{
  "189": {
    "case_id": 189,
    "title": "Thymom",
    "section": "Chest imaging",
    "age": "50",
    "gender": "female",
    "diagnosis": "Malignant Thymoma",
    "history": "Chest pain",
    "image_finding": "Right sided pleuritic chest pain",
    "discussion": "8 \u2013 15% of patients with Myasthemia gravis have a thymoma \n 50% of these are malignant.\n Usually found in the anterior mediastinum.\n\n\nRADIOLOGICAL INVESTIGATIONS :\n -Plain radiographs: frontal and lateral views.\n -CT\n -MRI\n \nThe tumour can be very large (1 \u2013 10cm in diameter), and \nusually replaces the normal thymus.\nVariable density from fat to soft tissue; calcification often visible.  Cystic components may be present.\nCan be benign / malignant.\n\nFeatures of malignancy:\nCertain CT / MR findings are strongly suggestive:- Definite extension / spread of tumour into the mediastinum\tor lung parenchyma through breach in the capsule.\n-Pleural deposits from transpleural seeding of the tumour (especially posteriorly and in the costo-phrenic angles).\n-Irregular pericardial thickening from pericardial implants. \n\nBenign thymoma - No reliable radiological signs of benignity.\n\t-A low-density plane of cleavage, representing fat between tumour and mediastinal structures (debatable).\n\t-Size of tumour does not assist in diagnosing benignity.\n\t-Calcification, although suggestive, but not sine qua non that thymoma is benign.\n\nConditions associated with thymomas:\n\t-Myasthenia gravis\n\t-Red blood cell aplasia\n\t-Hypogammaglobulinaemia\n\t-Mega oesophagus\n\t-Collagen vascular disease\n\nOther thymic tumours (difficult to differentiate)\n\t-Hodgkin\u2019s disease\n\t-Teratomas\n\t-Germinal tumours\n\t-Primary carcinoid tumours\n\t-Congenital cysts.",
    "differential_diagnosis": "Malignant, Thymoma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000189/000001.jpg?itok=cHbwUnKX",
            "caption": "PA  views shows subtle increase in soft tissue on the right side in superior mediastinum. Note pleural reaction at right base."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000189/000002.jpg?itok=1W8W3mrl",
            "caption": "Soft tissue mass is seen as anterior mediastinal shadow on lateral radiograph."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000189/000003.jpg?itok=TWz4ZUcz",
            "caption": "Unenhancing soft tissue density mass is seen in the anterior mediastinum on the right side."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000189/000004.jpg?itok=0k1lwsyd",
            "caption": "Discrete mass isointense to soft tissue is seen on T1-weighted coronal scan."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000189/000005.jpg?itok=Rew17HvM",
            "caption": "Sagittal image demonstrates anterior mediastinal location of mass."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000189/000006.jpg?itok=lhXD4jHf",
            "caption": "T1-weighted axial scan clearly demonstrates soft tissue mass breaching pericardium, indicating its invasive nature."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT",
      "MR"
    ],
    "link": "https://www.eurorad.org/case/189",
    "time": "18.05.2000"
  },
  "201": {
    "case_id": 201,
    "title": "Pulmonary embolism",
    "section": "Chest imaging",
    "age": "29",
    "gender": "female",
    "diagnosis": "MASSIVE PULMONARY EMBOLISM",
    "history": "Collapse",
    "image_finding": "32/40 pregnant\n\nCollapse",
    "discussion": "Plain chest radiograph\n- Signs are non-specific and sensitivity poor.\n- Can be normal even in patients with life-threatening \n  pulmonary embolism.\n- Major role is to exclude other diagnoses that might mimic \n  pulmonary embolism. \n- Helps in interpreting the radionuclide scans \n- But it can suggest the diagnosis.\n\n\nAcute pulmonary embolism without infarction:\n- Westermark sign: oligemia of the lung beyond the occluded \n  vessel.\n- Increase of size of main pulmonary artery (\"knuckle sign\", \n  \"plumping\")\n- Elevation of the hemidiaphragm\n- Discoid atelectasis (linear or disc-shaped densities) \n  secondary to elevation of hemidiaphragm\n- hyperventilation\n- depletion of surfactant\n- recurrent emboli may cause pulmonary arterial hypertension.\n\nAcute pulmonary embolism with infarction:\n- Gives rise to radiographically detectable consolidation; \n  multifocal in distribution and predominantly in lower lung \n  fields.  A \"Hampton\u2019s hump\" (pleurally based triangular \n  opacity) may rarely be seen. \n- Infarcts take several months to clear and frequently leave \n  permanent linear scars.\n- As they resolve, they may melt like an ice cube (cf.acute \n  pneumonia disappears in a patchy fashion).\n- An air bronchogram is rarely seen.\n- Cavitation within infarct is rare \u2013 thin-walled.  (Usually \n  secondarily infected or result from septic emboli.)\n- Pleural effusions common (50%); often bloody.  Usually \n  small and unilateral.\n\nSpiral CT and ECG-gated MRI:\n- Infarcts in the lung may be shown as pleural-based \n  wedge-shaped opacities on CT (non-specific).\n\nRadionuclide imaging:\n- Mismatched perfusion defect is the hallmark.\n- If embolism results in infection \u2013 matched defects appear: \n  defect of ventilation, corresponding to the perfusion \n  defect.\n\nPulmonary angiography:\n- Intraluminal filling defect is the hallmark.\n- Occlusion of a pulmonary artery branch.\n- Done when - V/Q scan is significantly at variance with the \n  clinical probability of pulmonary embolism\n- when thrombolytic therapy is contemplated\n- before embolectomy, vena caval interruption, or filter \n  insertion.",
    "differential_diagnosis": "MASSIVE, PULMONARY, EMBOLISM",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000201/000001.jpg?itok=hlbb_Wyw",
            "caption": "Chest radiograph showing hyper-transradiant left  upper zone with attenuation of vascular markings."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000201/000002.jpg?itok=sG2MjqCC",
            "caption": "CECT: Multiple large filling defects in the left  main pulmonary artery with oligaemic left lung."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000201/000003.jpg?itok=SHYcRl81",
            "caption": "CECT: similar appearances to Figure 2a"
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000201/000004.jpg?itok=BreJTecW",
            "caption": "CECT: Smaller filling defects are seen within the  right lower lobe artery with thin rim of contrast  around thrombus - the \"polo mint\" sign"
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000201/000005.jpg?itok=ki0p1SrT",
            "caption": "CECT: at a lower level with partly occluded lower  lobe pulmonary artery on right"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/201",
    "time": "18.01.2002"
  },
  "528": {
    "case_id": 528,
    "title": "Sarcoma of the pulmonary artery",
    "section": "Chest imaging",
    "age": "38",
    "gender": "female",
    "diagnosis": "Pulmonary angiosarcoma",
    "history": "Recurrent right chest pain and dyspnea.",
    "image_finding": "First admitted with cough and right sided chest pain worse on inspiration. Chest radiograph and perfusion scan are shown. Spiral CT showed a filling defect in the lower and middle lobe vessels. The clinical condition did not improve. Thrombolysis was attempted with no success. Six months from the first admission the patient was readmitted with dyspnea, chest pain and hemoptysis. On examination there was a right pleural effusion and a pulmonary outflow murmur. Chest radiograph, lung perfusion scan and CT angiogram (shown) demonstrated a mass filling the lumen of the right main pulamonary artery and no perfusion of the right lung. Embolectomy was peformed in a specialist institution.",
    "discussion": "Primary pulmonary angiosarcoma is very rare with only some 200 cases reported.\nHowever angiosarcomas remain the most common primary tumours of the heart and great vessels. The majority arise from the right atrium or pulmonary vessels.\nThe associated clinical symptoms are varied and non-specific. Infiltration of the pulmonary arteries can mimic pulmonary embolism as in our case.\nEarly diagnosis is therefore difficult but improves survival.\nApproximately 80% of the tumours behave as aggressive intra-luminal neoplasms arising from the intimal cells . They are characterised histologically by staining with factor VIII related antigen.\nDespite the increasing availability of echocardiography , spiral CT and MR studies distinction from chronic pulmonary embolism remains difficult with 50% of diagnoses made at thoracotomy/cytology.\nRecent interest has focused on dynamic contrast enhanced MR to obtain 2D multiplanar and ultrafast 3D sequences with some success.",
    "differential_diagnosis": "Pulmonary, angiosarcoma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000528/000001.jpg?itok=eMVgva9d",
            "caption": "On first admission, chest radiograph showed blunting of the right costophrenic angle and reduced vascular markings of the right base (not well seen on digital image)."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000528/000002.jpg?itok=fw3AeKqc",
            "caption": "On the second admission there was  a raised right hemidiaphragm and a riht pleural effusion."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000528/000003.jpg?itok=DFt1zqP5",
            "caption": "On first admission there was reduced perfusion in the lower and middle lobes."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000528/000004.jpg?itok=xQQoRh92",
            "caption": "On second admission there was absent perfusion of the entire right lung."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000528/000005.jpg?itok=on9QkUYU",
            "caption": "Iv contrast. Section at the aorto-pulmonary window."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000528/000006.jpg?itok=z5cJyo-F",
            "caption": "Iv contrast.Large filling defect in the pulmonary outflow tract."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000528/000007.jpg?itok=XCkCeGOQ",
            "caption": "Iv contrast.Large filling defect in the pulmonary outflow tract."
          },
          {
            "number": "Figure 3d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000528/000008.jpg?itok=v8yAUWVe",
            "caption": "Iv contrast.Large filling defect in the pulmonary outflow tract."
          },
          {
            "number": "Figure 3e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000528/000009.jpg?itok=sr5o17YL",
            "caption": "Iv contrast.Large filling defect in the pulmonary outflow tract."
          },
          {
            "number": "Figure 3f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000528/000010.jpg?itok=Du-58itp",
            "caption": "Iv contrast.Section just caudal to the filling defect in the pulmonary outflow tract."
          },
          {
            "number": "Figure 3g",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000528/000011.jpg?itok=AaGR8d-u",
            "caption": "Iv contrast.Note the infarct in the right base which followed the obstruction of the pulmonary outflow tract."
          },
          {
            "number": "Figure 3h",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000528/000012.jpg?itok=FJoA9eZf",
            "caption": ""
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT",
      "MR"
    ],
    "link": "https://www.eurorad.org/case/528",
    "time": "24.10.2000"
  },
  "543": {
    "case_id": 543,
    "title": "Blunt traumatic sternal and chondrosternal fractures",
    "section": "Chest imaging",
    "age": "64",
    "gender": "male",
    "diagnosis": "Blunt traumatic sternal and chondrosternal fractures as part of a seatbelt syndrome",
    "history": "Head-on car crash",
    "image_finding": "Belted 64-year-old male driver involved in a head-on car accident",
    "discussion": "Fractures of the sternum are encountered in up to 4% of blunt chest trauma patients, as part of steering-wheel or seatbelt syndromes. Most often tranverse, they may involve the sternal body (70%) or the manubrio-sternal joint (18%). Dislocation of rib cartilages from the sternum are sometimes met, especially in children. When sternal fractures are associated with costo-chondral dislocations or rib fractures, they may lead to an anterior or lateral flail chest.",
    "differential_diagnosis": "Blunt, traumatic, sternal, and, chondrosternal, fractures, as, part, of, a, seatbelt, syndrome",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000543/000001.jpg?itok=kwVvIJio",
            "caption": "Spiral CT section (3-mm) depicts fractures of the calcified first rib cartilages (white arrows) (From Wintermark M, Schnyder P (2000) Trauma of the chest wall. In Schnyder P, Wintermark M. Radiology of blunt trauma of the chest. Springer, Berlin Heidelberg New York, pp 9-27)"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000543/000002.jpg?itok=pTUqh1HA",
            "caption": "Spiral CT section (3-mm) displays a comminutive fracture of the sternal body (black arrow), which is responsible for an anterior hemomediastinum (From Wintermark M, Schnyder P (2000) Trauma of the chest wall. In Schnyder P, Wintermark M. Radiology of blunt trauma of the chest. Springer, Berlin Heidelberg New York, pp 9-27)"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/543",
    "time": "24.10.2000"
  },
  "544": {
    "case_id": 544,
    "title": "Costal hook sign as a radiological pattern of flail chest",
    "section": "Chest imaging",
    "age": "45",
    "gender": "male",
    "diagnosis": "Right flail chest featuring a costal hook sign on the plain film",
    "history": "Traffic accident",
    "image_finding": "45-year-old male patient run over by a truck",
    "discussion": "Three or more adjacent fractured ribs, when broken at least on two different sites, result in a chest wall area isolated from the rest of the thoracic bone cage. This isolated chest wall flap, called a \"flail chest\", allows for paradoxical motion during breathing and may be responsible for ventilatory failure. Flail chests are encountered in less than 10% of blunt chest trauma patients. They are associated with an elevated mortality rate (up to 40%).\nThe \u201ccostal hook\u201d sign indicates posterior flail chest. Rotational displacement of posterior rib segments gives a characteristic hook-like configuration to the sites of successive rib fractures.",
    "differential_diagnosis": "Right, flail, chest, featuring, a, costal, hook, sign, on, the, plain, film",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000544/000001.jpg?itok=vYdKFi1H",
            "caption": "Admission plain film of the chest discloses a \"costal hook\" sign (arrow) as a typical pattern of flail chest. The ipsilateral hemithorax is partially blurred due to concomittant presence of a hemothorax. Subcutaneous and muscular emphysema is also portrayed (From Wintermark M, Schnyder P (2000) Trauma of the chest wall. In Schnyder P, Wintermark M. Radiology of blunt trauma of the chest. Springer, Berlin Heidelberg New York, pp 9-27)"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000544/000002.jpg?itok=O7N7SCYa",
            "caption": "Spiral CT sections (3-mm) portray the flail chest as striking serial double rib fractures. The hemothorax results in a right lung collapse and justified chest tube insertion"
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000544/000003.jpg?itok=QpcT5NKh",
            "caption": "Spiral CT sections (3-mm) portray the flail chest as striking serial double rib fractures. The hemothorax results in a right lung collapse and justified chest tube insertion"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/544",
    "time": "24.10.2000"
  },
  "545": {
    "case_id": 545,
    "title": "Blunt traumatic anterior flail chest",
    "section": "Chest imaging",
    "age": "71",
    "gender": "female",
    "diagnosis": "Blunt traumatic anterior flail chest",
    "history": "Anterior paradoxical chest wall motion as part of a high-speed car accident",
    "image_finding": "Belted 71-year-old female driver involved in a high-speed car crash and with an anterior paradoxical chest wall motion as part of her clinical presentation",
    "discussion": "Flail chests usually affect one single hemithorax, but may exceptionally involve both hemithoraces when sternal and/or bilateral anterior chondro-costal fractures result in a complete disruption of the anterior thoracic wall",
    "differential_diagnosis": "Blunt, traumatic, anterior, flail, chest",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000545/000001.jpg?itok=1Wo6_4SN",
            "caption": "Spiral CT section (5-mm) displays an unusual anterior flail chest consecutive to left and right lateral chondro-costal dislocations (black arrows) and rib fractures (white arrows). A mediastinal hematoma and bilateral hemothoraces are also present."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/545",
    "time": "24.10.2000"
  },
  "546": {
    "case_id": 546,
    "title": "Z-shaped rib fractures",
    "section": "Chest imaging",
    "age": "26",
    "gender": "female",
    "diagnosis": "Blunt traumatic Z-shaped rib fractures",
    "history": "Car accident with a seatbelt syndrome",
    "image_finding": "Belted 26-year-old female car passenger involved in a traffic accident",
    "discussion": "Rib fractures are the most common injuries in blunt chest trauma. They are present in up to 81% of blunt chest trauma patients. The are encountered especially in motor vehicle crashes.\nIn blunt trauma patients, rib fractures are multiple in 84% of cases and unique in the remaining 16%. Rib fractures most often hit the same site on several adjacent ribs or rib cartilages, thus resulting in a focal alignement called bridging rib fractures.\nSixty percent of rib fractures, whatever their location, are overlooked by admission chest roentgenograms. Digitized radiology,through window setting modifications and reconstruction algorithms, is more sensitive.",
    "differential_diagnosis": "Blunt, traumatic, Z-shaped, rib, fractures",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000546/000001.jpg?itok=k-2GlQlp",
            "caption": "Admission chest X-ray displays a right clavicle fracture, as well as a right pneumothorax, persisting despite drainage, but does not depict any rib fracture (From Wintermark M, Schnyder P (2000) Trauma of the chest wall. In Schnyder P, Wintermark M. Radiology of blunt trauma of the chest. Springer, Berlin Heidelberg New York, pp  9-27)"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000546/000002.jpg?itok=JOU7yMjO",
            "caption": "Spiral CT sections (3-mm) dislcose serial \"Z-shaped\" right anterior rib fractures, which were not recognizable on the chest roentgenogram"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/546",
    "time": "24.10.2000"
  },
  "547": {
    "case_id": 547,
    "title": "Blunt traumatic sternal fracture",
    "section": "Chest imaging",
    "age": "63",
    "gender": "male",
    "diagnosis": "Blunt traumatic manubrio-sternal dislocation and fracture of the sternal body",
    "history": "Fall from a height",
    "image_finding": "63-year-old male patient involved in a fall from a 7-m height. Palpation of a sternal stairstep justified realization of a lateral chest X-ray, which was exceptionnally obtained in this trauma patient.",
    "discussion": "Sternal fractures are most often tranverse. Seventy percent of them hit the sternal body, whereas 18% involve the manubrio-sternal joint. When concomitant with rib fractures or costo-chondral dislocations, sternal fractures may be part of an anterior or lateral flail chest.\nPlain films remain silent in 84% of patients with sternal fracture (Fig. 2.13). In 16% of cases, sternal fractures are prone to injure the internal mammary vessels or their branches, leading to retrosternal hematomas.The lateral chest radiograph is a useful diagnostic test for sternal fractures, but is no longer obtained in blunt chest trauma patients since, in many institutions, CT has become the diagnostic survey modality of choice for chest trauma patients. CT advantageously demonstrates most fracture lines, even when transverse, sternal displacements, retrosternal hematomas and internal thoracic vessel injuries.",
    "differential_diagnosis": "Blunt, traumatic, manubrio-sternal, dislocation, and, fracture, of, the, sternal, body",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000547/000001.jpg?itok=7MqiulK2",
            "caption": "Lateral chest film displaying a fracture of the sternal body (black arrow)  and a manubrio-sternal dislocation (white arrow) (From Wintermark M, Schnyder P (2000) Trauma of the chest wall. In Schnyder P, Wintermark M. Radiology of blunt trauma of the chest. Springer, Berlin Heidelberg New York, pp 9-27)"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/547",
    "time": "27.12.2000"
  },
  "548": {
    "case_id": 548,
    "title": "Blunt traumatic sternal fracture and tear of the left internal mammary artery",
    "section": "Chest imaging",
    "age": "47",
    "gender": "female",
    "diagnosis": "Blunt traumatic sternal fracture with lesion of the left internal mammary artery and subsequent hemomediastinum",
    "history": "Fall from a height",
    "image_finding": "47-year-old female patient who tried to commit suicide and fell from a 20-m bridge",
    "discussion": "In 16% of cases, sternal fractures are associated with lesions of the internal mammary vessels or their branches and thus result in retrosternal hematomas. But, even in such cases, as long as sternal fractures are isolated, they rarely induce enough bleeding to widen the mediastinum on chest X-ray. Thus, mediastinal widening in presence of a sternal fracture necessitate to rule out an aortic or great vessel lesion. This is performed by chest CT, which is the diagnostic survey modality of choice for chest trauma patients. Moreover, chest CT advantageously demonstrates most sternal fracture lines, even when transverse, sternal displacements, retrosternal hematomas and internal thoracic vessel injuries. Chest CT has completely replaced lateral chest radiograph, which is no longer obtained in blunt chest trauma patients",
    "differential_diagnosis": "Blunt, traumatic, sternal, fracture, with, lesion, of, the, left, internal, mammary, artery, and, subsequent, hemomediastinum",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000548/000001.jpg?itok=SPRZSay2",
            "caption": "Spiral CT sections (3-mm) on T2 and T3 levels disclose a traumatic lesion of the left internal mammary artery consecutive to an oblique fracture of the sternal manubrium (arrows). This vascular lesion induces in turn an extensive anterior mediastinal hematoma. A left hemothorax, as well as a left anterior soft tissue hematoma are also portrayed."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000548/000002.jpg?itok=cjSgJ6qf",
            "caption": "Spiral CT sections (3-mm) on T2 and T3 levels disclose a traumatic lesion of the left internal mammary artery consecutive to an oblique fracture of the sternal manubrium (arrows). This vascular lesion induces in turn an extensive anterior mediastinal hematoma. A left hemothorax, as well as a left anterior soft tissue hematoma are also portrayed."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/548",
    "time": "22.07.2001"
  },
  "549": {
    "case_id": 549,
    "title": "Lateral scapular displacement in a blunt traumatic scapulo-thoracic dissociation",
    "section": "Chest imaging",
    "age": "24",
    "gender": "male",
    "diagnosis": "Blunt traumatic scapulo-thoracic dissociation with lateral scapular displacement",
    "history": "Motorcycle accident with a close forequarter amputation",
    "image_finding": "24-year-old male patient involved in a high-speed deceleration motorcycle accident",
    "discussion": "Scapulo-thoracic dissociation is an uncommon condition encountered in high-energy trauma and most often relate to motorcycle accidents. They occur as a result of a severe abduction of the upper limb, which induces a lateral displacement of the scapula, a massive disruption of the rotator muscular cuff and an extensive subscapular hematoma. Associated neuro-vascular damage is present in 90% of cases.",
    "differential_diagnosis": "Blunt, traumatic, scapulo-thoracic, dissociation, with, lateral, scapular, displacement",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000549/000001.jpg?itok=wkCUrN0j",
            "caption": "Striking lateral displacement of the left scapula as part of a scapulo-thoracic dissociation in a motorcycle driver (From Wintermark M, Schnyder P (2000) Trauma of the chest wall. In Schnyder P, Wintermark M. Radiology of blunt trauma of the chest. Springer, Berlin Heidelberg New York, pp 9-27)"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/549",
    "time": "24.10.2000"
  },
  "550": {
    "case_id": 550,
    "title": "Blunt traumatic avulsion of the left brachial plexus",
    "section": "Chest imaging",
    "age": "23",
    "gender": "male",
    "diagnosis": "Blunt traumatic avulsion of the left brachial plexus as part of a scapulo-thoracic dissociation",
    "history": "Motorcycle accident with a close forequarter amputation",
    "image_finding": "23-year-old male motorcycle driver involved in a traffic accident and whose neurological examination in the emergency room demonstrated a complete left brachial plexus palsy.",
    "discussion": "In 90% of cases, scapulo-thoracic dissociation is associated with severe neuro-vascular damage: brachial plexus avulsion is encountered in 94% of cases and lesions of the subclavian or vertebral vessels in 80%. Brachial plexus avulsions may also induce an ipsilateral diaphragmatic paralysis, since the brachial plexus and phrenic nerve origins are near each other: whereas the brachial plexus originates in the C5-T1 nerve roots, the phrenic nerve refers to a large root from the C4 ventral ramus, with small contributions from the C3 and C5 ventral rami.",
    "differential_diagnosis": "Blunt, traumatic, avulsion, of, the, left, brachial, plexus, as, part, of, a, scapulo-thoracic, dissociation",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000550/000001.jpg?itok=wgnVb2_i",
            "caption": "A myelography and a myelo-CT performed ten days later after the trauma display a complete avulsion of the left branchial plexus, with extensive intra- and extra-canalar contrast material leak from C5 to T2. The spinal cord is shifted rightwards by an intradural hematoma (From Wintermark M, Schnyder P (2000) Trauma of the chest wall. In Schnyder P, Wintermark M. Radiology of blunt trauma of the chest. Springer, Berlin Heidelberg New York, pp 9-27)"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000550/000002.jpg?itok=hyUWfJYg",
            "caption": "A myelography and a myelo-CT performed ten days later after the trauma display a complete avulsion of the left branchial plexus, with extensive intra- and extra-canalar contrast material leak from C5 to T2. The spinal cord is shifted rightwards by an intradural hematoma (From Wintermark M, Schnyder P (2000) Trauma of the chest wall. In Schnyder P, Wintermark M. Radiology of blunt trauma of the chest. Springer, Berlin Heidelberg New York, pp 9-27)"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/550",
    "time": "06.11.2000"
  },
  "552": {
    "case_id": 552,
    "title": "Concomitant pericardial and left diaphragmatic rupture, with intrathoracic herniation of the stomach and of the spleen",
    "section": "Chest imaging",
    "age": "71",
    "gender": "female",
    "diagnosis": "Concomitant blunt traumatic pericardial and left diaphragmatic rupture, with intrathoracic herniation of the stomach and of the spleen",
    "history": "High-speed car accident",
    "image_finding": "71-year-old female car passenger involved in a high-speed traffic accident",
    "discussion": "Diaphragm usually ruptures into the pleural cavity. In less than 1% of cases, rupture of the diaphragmatic pericardium occurs concomittantly with a tear of the diaphragmatic central tendon. This sometimes allows for herniation of the stomach, transverse colon or omentum into the pericardium.",
    "differential_diagnosis": "Concomitant, blunt, traumatic, pericardial, and, left, diaphragmatic, rupture,, with, intrathoracic, herniation, of, the, stomach, and, of, the, spleen",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000552/000001.jpg?itok=Fs9bR_c8",
            "caption": "Spiral CT section (5-mm) on T10 level demonstrates concomitant pericardial rupture (arrow) and left diaphragmatic rupture, with intrathoracic herniation of the stomach and of the spleen (From Wintermark M, Schnyder P (2000) Trauma of the diaphragm. In Schnyder P, Wintermark M. Radiology of blunt trauma of the chest. Springer, Berlin Heidelberg New York, pp 29-43)"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/552",
    "time": "24.10.2000"
  },
  "553": {
    "case_id": 553,
    "title": "Blunt left diaphragmatic rupture with stomach herniation",
    "section": "Chest imaging",
    "age": "62",
    "gender": "female",
    "diagnosis": "Blunt left diaphragmatic rupture with stomach herniation",
    "history": "High-speed car accident",
    "image_finding": "Unbelted 62-year-old female car driver involved in a high-speed traffic accident",
    "discussion": "Clinical series report a predominance of left diaphragmatic ruptures (90%), whereas autopsy series show nearly equal prevalence of left- and right-sided diaphragmatic lesions. Indeed, because of the presence of the liver, right diaphragmatic ruptures are more difficult to diagnose clinically and radiologically. Furthermore, left diaphragmatic ruptures are more likely to occur because of the diaphragmatic anatomy and the biomechanics of trauma. The only unprotected diaphragmatic portion, where ruptures most often lie, relates to the postero-lateral aspect of the left diaphragmatic dome, at the junction of the peripheral muscular portion and the central tendon. The other diaphragmatic areas are supported above and below by adjacent organs: the right diaphragm is protected by the liver, which acts as a shock absorber, whereas the posterior portions are shielded by the kidneys and lumbar muscles and the central tendinous portion by the heart.",
    "differential_diagnosis": "Blunt, left, diaphragmatic, rupture, with, stomach, herniation",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000553/000001.jpg?itok=046A1s9Q",
            "caption": "Admission plain film displays a discontinuous left diaphragm, with a buldge of its mid segment, relating possibly to a diaphragmatic lesion. Serial left rib fractures, a left pneumothorax and a pneumopericardium are also present"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000553/000002.jpg?itok=IRHvoETm",
            "caption": "Spiral CT section (3-mm) demonstrates a  diaphragmatic defect (arrows), filled with abdominal fat. An extensive hemoperitoneum arising from laceration of the spleen and the splenic artery is also depicted"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/553",
    "time": "24.10.2000"
  },
  "556": {
    "case_id": 556,
    "title": "Blunt left diaphragmatic rupture with stomach and bowel loop herniation",
    "section": "Chest imaging",
    "age": "37",
    "gender": "male",
    "diagnosis": "Blunt left diaphragmatic rupture with stomach and bowel loop herniation",
    "history": "High-speed truck accident",
    "image_finding": "Seatbelted 37-year-old male patient involved in a high-speed truck accident",
    "discussion": "Diaphragmatic ruptures have irregular and bloody edges. They are linear rather than star-shaped. They range from 1 to 30 centimeters in length.\nBecause of the cyclical tension and motion associated with breathing, diaphragmatic lesions do not heal spontaneously, but rather enlarge with time. This results in partial or complete, delayed intrathoracic herniation of one or several abdominal viscera. The stomach is the most frequently implicated viscus.",
    "differential_diagnosis": "Blunt, left, diaphragmatic, rupture, with, stomach, and, bowel, loop, herniation",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000556/000001.jpg?itok=jPzI4jhV",
            "caption": "Admission front CT scout view displays a blurred, elevated left diaphragm. A wide band pulmonary atelectasis and a right subpulmonary pneumothorax are also depicted"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000556/000002.jpg?itok=P9aYEdOF",
            "caption": "Intrathoracic herniation of the stomach and bowel loops consecutive to left diaphragmatic rupture - Spiral CT section (3-mm) on T12 level demonstrates an intrathoracic herniation of the stomach (star) and bowel loops (arrows), thus confirming the diagnosis of diaphragmatic rupture"
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000556/000003.jpg?itok=Mud7EWqL",
            "caption": "Two-dimensional coronal-oblique reconstruction of a left diaphragmatic rupture with gastric herniation - A two-dimensional coronal-oblique reconstruction allows for the identification of an abrupt diaphragmatic interruption (arrows), with herniation of the stomach (star) through it"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/556",
    "time": "24.10.2000"
  },
  "557": {
    "case_id": 557,
    "title": "Splenosis consecutive to blunt traum",
    "section": "Chest imaging",
    "age": "44",
    "gender": "male",
    "diagnosis": "Intrathoracic and abdominal splenosis consecutive to blunt traumatic rupture of diaphragm and spleen",
    "history": "Left diaphragmatic rupture and splenic fracture consecutive to a fall from a height",
    "image_finding": "44-year-old male patient who fell from a 5-m bridge and with subsequent left diaphragmatic rupture and splenic fracture",
    "discussion": "Either as a result of the impact or of direct laceration by a fractured rib, splenic lesions occur in about 50% of splenic herniation through a diaphragmatic rupture. Autotransplantation of fragments of splenic tissue onto the pleura may occur after a diaphragmatic injury associated with splenic rupture. These fragments may be identified on computed tomography or magnetic resonance imaging. This condition is termed \"intrathoracic splenosis\".",
    "differential_diagnosis": "Intrathoracic, and, abdominal, splenosis, consecutive, to, blunt, traumatic, rupture, of, diaphragm, and, spleen",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000557/000001.jpg?itok=-3GtMV4p",
            "caption": "Thoracic and abdominal spiral CT (3-mm) obtained 15 months after the trauma demonstrates three well-defined, round, 1- to 2-cm, contrast-enhanced nodules (arrows), featuring intrathoracic and abdominal splenosis (From Wintermark M, Schnyder P (2000) Trauma of the diaphragm. In Schnyder P, Wintermark M. Radiology of blunt trauma of the chest. Springer, Berlin Heidelberg New York, pp 29-43)"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000557/000002.jpg?itok=zAwSCVx-",
            "caption": "Thoracic and abdominal spiral CT (3-mm) obtained 15 months after the trauma demonstrates three well-defined, round, 1- to 2-cm, contrast-enhanced nodules (arrows), featuring intrathoracic and abdominal splenosis (From Wintermark M, Schnyder P (2000) Trauma of the diaphragm. In Schnyder P, Wintermark M. Radiology of blunt trauma of the chest. Springer, Berlin Heidelberg New York, pp 29-43)"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/557",
    "time": "06.11.2000"
  },
  "558": {
    "case_id": 558,
    "title": "Unusual pattern of blunt traumatic pulmonary lacerations",
    "section": "Chest imaging",
    "age": "65",
    "gender": "female",
    "diagnosis": "Blunt traumatic pulmonary lacerations devoid of surrounding pulmonary contusions",
    "history": "Traffic accident",
    "image_finding": "Alcoholized 65-year-old female patient involved in a high-speed traffic accident. Admission radiological survey included a spiral chest CT, performed because of the accident deceleration biomechanics.",
    "discussion": "Pulmonary lacerations designate severe lung tissue damage, with extensive alveolar ruptures. They may either relate to blood-filled pulmonary hematomas or, especially in young people, to air-filled pneumatoceles or pseudo-cysts. The elastic recoil forces of the surrounding intact pulmonary tissue are responsible for the round or ovoid shape of these intrapulmonary cavities.\nMost of pulmonary lacerations are totally blurred by large areas of lung contusion that surround them, and thus not depicted on initial plain films. They are progressively exposed due to the resolution of the surrounding contusions, a few days after trauma.",
    "differential_diagnosis": "Blunt, traumatic, pulmonary, lacerations, devoid, of, surrounding, pulmonary, contusions",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000558/000001.jpg?itok=qB6GkIbs",
            "caption": "Spiral CT sections (3-mm) displays two left pulmonary lacerations, filled with blood (arrows) or with air and blood (arrowheads). These pulmonary lacerations are surrounded by hazy areas related to pulmonary contusions. A left anterior pneumothorax and subcutaneous emphysema are also present, as a result of rib fractures, not depicted on these CT sections."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000558/000002.jpg?itok=TQXMFKJz",
            "caption": "Spiral CT sections (3-mm) displays two left pulmonary lacerations, filled with blood (arrows) or with air and blood (arrowheads). These pulmonary lacerations are surrounded by hazy areas related to pulmonary contusions. A left anterior pneumothorax and subcutaneous emphysema are also present, as a result of rib fractures, not depicted on these CT sections."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/558",
    "time": "24.07.2001"
  },
  "560": {
    "case_id": 560,
    "title": "Macklin effect in blunt chest traum",
    "section": "Chest imaging",
    "age": "43",
    "gender": "female",
    "diagnosis": "Blunt traumatic Macklin effect extending into the mediastinum as a pneumopericardium",
    "history": "Fall from a height",
    "image_finding": "43-year-old female patient who jumped through a window and fell from a 9-m height to commit suicide",
    "discussion": "Pneumomediastinum, also known as mediastinal emphysema, stands for free air collections surrounding mediastinal structures . It occurs in up to 10% of blunt chest trauma. In over 95% of cases, pneumomediastinum results either from extension of a subcutaneous emphysema or from alveolar rupture related to primary lung trauma or positive--pressure mechanical ventilation. Alveolar rupture is followed by centripetal dissection of the released alveolar air through the pulmonary interstitium and along the peribroncho-vascular sheaths into the mediastinum, this pathophysiological process being classically described as the \u201cMacklin effect\u201d. In the remaining cases, pneumomediastinum results from lesions of the trachea, bronchi or esophagus",
    "differential_diagnosis": "Blunt, traumatic, Macklin, effect, extending, into, the, mediastinum, as, a, pneumopericardium",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000560/000001.jpg?itok=fqIBK7dy",
            "caption": "The Macklin effect features a pulmonary interstitial emphysema, i.e. numerous aeric lucencies (arrows) contiguous to small pulmonary vessels on both lung fields"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000560/000002.jpg?itok=L3Vyueiz",
            "caption": "A Macklin effect can definitely be diagnosed only when the chest CT allows for the identification of a triad bronchus-pulmonary vessel-surrounding air collection (arrows)"
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000560/000003.jpg?itok=5emE1HpE",
            "caption": "Pneumomediastinum induces in turn a pneumopericardium, because of an air leak through a pericardial defect"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/560",
    "time": "24.10.2000"
  },
  "561": {
    "case_id": 561,
    "title": "Blunt traumatic pneumomediastinum and subcutaneous emphysem",
    "section": "Chest imaging",
    "age": "32",
    "gender": "male",
    "diagnosis": "Blunt traumatic pneumomediastinum and subcutaneous emphysema consecutive to rib fractures",
    "history": "Fall from a height",
    "image_finding": "32-year-old male patient involved in a fall from a 7-m bridge. This deceleration mechnism justified chest CT survey and, consecutive to identifying subcutaneous emphysema and pneumothorax on the latter, bronchoscopy to rule out a tracheo-bronchial injury.",
    "discussion": "Pneumomediastinum relates to free air collections around mediastinal structures. It is encountered in up to 10% of blunt chest trauma. In over 95% of cases, pneumomediastinum either is associated with a subcutaneous emphysema or results from alveolar rupture. In the remaining cases, pneumomediastinum is induced by lesions of the trachea, bronchi or esophagus.\nSubcutaneous emphysema is most often associated with rib fractures and sometimes with a pneumothorax. It can extend far away from the chest, to the face, abdomen, scrotum, limbs, mediastinum and retroperitoneum. It may sometimes be responsible for thoracic restriction and ventilatory impairment.\nAlveolar rupture may result from primary lung trauma or positive-pressure mechanical ventilation. It is followed by centripetal dissection of the released alveolar air through the pulmonary interstitium and along the peribroncho-vascular sheaths into the mediastinum. This pathophysiological process is described as the \u201cMacklin effect\u201d. \nIn the submitted case, pneumomediastinum was associated with subcutaneous emphysema and pneumothorax, all consecutive to rib fractures. Tracheo-bronchoscopy ruled out a tracheo-bronchial injury.",
    "differential_diagnosis": "Blunt, traumatic, pneumomediastinum, and, subcutaneous, emphysema, consecutive, to, rib, fractures",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000561/000001.jpg?itok=OCZlx8J5",
            "caption": "Admission chest X-ray displays extensive subcutaneous cervical and thoracic emphysema, as well as muscular emphysema casting both pectoral muscles. An air collection in the aorto-pulmonic window is extending along the inferior aspect of the aortic arch and the superior border of the left pulmonary artery. A Levin\u2019s \u201c continuous diaphragm\u201d sign (black arrows) and a Naclerio\u2019s \u201cV\u201d sign (white arrows) are also present. The Naclerio's \"V\" sign relates to air collections located along the descending aorta, on one hand, and between the pleura and the left hemidiaphragm, on the other hand (From Wintermark M, Wicky S, Bettex D, et al (2000) Trauma of the mediastinum. In Schnyder P, Wintermark M. Radiology of blunt trauma of the chest. Springer, Berlin Heidelberg New York, pp 71-134)."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000561/000002.jpg?itok=Q3woh-Mc",
            "caption": "Spiral CT section (3-mm) displays the extent of the subcutaneous and muscular emphysema. A left antero-medial pneumothorax and a pneumomediastinum are also depicted (From Wintermark M, Wicky S, Bettex D, et al (2000) Trauma of the mediastinum. In Schnyder P, Wintermark M. Radiology of blunt trauma of the chest. Springer, Berlin Heidelberg New York, pp 71-134)"
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000561/000003.jpg?itok=zOeHld7L",
            "caption": "Air collections outline the left subclavian and carotid arteries, the right innominate vein and the right superior intercostal vein (white arrow) (From Wintermark M, Wicky S, Bettex D, et al (2000) Trauma of the mediastinum. In Schnyder P, Wintermark M. Radiology of blunt trauma of the chest. Springer, Berlin Heidelberg New York, pp 71-134)"
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000561/000004.jpg?itok=xgd7qcIH",
            "caption": "Air collections surround the thymic remnants (white arrow), as well as both aspects of the aortic arch and branching of the right superior intercostal vein. The anterior border of the innominate vein confluence is highlighted by another free air collection, which relates to the \"V\" sign of plain films (From Wintermark M, Wicky S, Bettex D, et al (2000) Trauma of the mediastinum. In Schnyder P, Wintermark M. Radiology of blunt trauma of the chest. Springer, Berlin Heidelberg New York, pp 71-134)"
          },
          {
            "number": "Figure 1e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000561/000005.jpg?itok=CLnY23lW",
            "caption": "An air collection highlights the azygos arch (From Wintermark M, Wicky S, Bettex D, et al (2000) Trauma of the mediastinum. In Schnyder P, Wintermark M. Radiology of blunt trauma of the chest. Springer, Berlin Heidelberg New York, pp 71-134)"
          },
          {
            "number": "Figure 1f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000561/000006.jpg?itok=5cj8Rays",
            "caption": "The pneumomediastinum extends along the descending thoracic aorta. It follows the course of the spinal nerve root, goes through the right T8 intervertebral foramen and dissects into the epidural space (black arrow) (From Wintermark M, Wicky S, Bettex D, et al (2000) Trauma of the mediastinum. In Schnyder P, Wintermark M. Radiology of blunt trauma of the chest. Springer, Berlin Heidelberg New York, pp 71-134)"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/561",
    "time": "06.11.2000"
  },
  "562": {
    "case_id": 562,
    "title": "Blunt tracheal rupture with extensive pneumomediastinum",
    "section": "Chest imaging",
    "age": "61",
    "gender": "male",
    "diagnosis": "Blunt tracheal rupture with subsequent pneumomediastinum, pneumoperitoneum, as well as subcutaneous and muscular emphysema",
    "history": "Traffic accident",
    "image_finding": "61-year-old male patient involved in a high-speed deceleration traffic accident. This deceleration mechanism justified chest CT survey.",
    "discussion": "Tracheo-bronchial injuries are reported in 0.03% to 2.8% of blunt chest trauma. They occur in very severe trauma and are associated with a 85% mortality. Tracheo-bronchial lesions are most often located in the membraneous portion, mainly at its junction with the cartilages. In 80% of cases, they lie within 2.5 cm of the carina.\nAdmission chest X--ray may demonstrate indirect features, such as tracheal shift, widened mediastinum, pneumomediastinum, pneumopericardium, (tension) pneumothorax persisting despite adequate chest tube drainage, or possibly hemothorax, as well as subcutaneous and muscular or cervical emphysema. Direct radiological signs are rarely present: interruption of the radiolucent lumen, sharp angulation and Kumpe\u2019s \u201cfallen lung\u201d sign, which relates to disrupted lung hilar attachments, with subsequent fall of the lung in the most dependent part of the chest.\nComputed tomography identifies the same indirect signs of tracheo-bronchial lesions as plain films. CT rarely depicts the tracheo-bronchial injuries directly.",
    "differential_diagnosis": "Blunt, tracheal, rupture, with, subsequent, pneumomediastinum,, pneumoperitoneum,, as, well, as, subcutaneous, and, muscular, emphysema",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000562/000001.jpg?itok=YfzR9L0W",
            "caption": "Front chest X-ray demonstrates severe cervical, subcutaneous and muscular emphysema casting pectoral muscles. A pneumopericardium (arrows) and bilateral pulmonary contusions are also present (From Wintermark M, Wicky S, Bettex D, et al (2000) Trauma of the mediastinum. In Schnyder P, Wintermark M. Radiology of blunt trauma of the chest. Springer, Berlin Heidelberg New York, pp 71-134)"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000562/000002.jpg?itok=q_mhUKio",
            "caption": "Lateral plain film discloses subcutaneous emphysema (white arrows). An anterior pneumomediastinum (black arrows)  and a pneumoperitoneum (arrowheads) are clearly delineated from each other by the xiphoid attachment of the diaphragm (From Wintermark M, Wicky S, Bettex D, et al (2000) Trauma of the mediastinum. In Schnyder P, Wintermark M. Radiology of blunt trauma of the chest. Springer, Berlin Heidelberg New York, pp 71-134)"
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000562/000003.jpg?itok=zZZQlbyO",
            "caption": "Spiral CT section (3-mm) above the carina depicts an avulsion of the tracheal membraneous part (arrows) on its right attachment (From Wintermark M, Wicky S, Bettex D, et al (2000) Trauma of the mediastinum. In Schnyder P, Wintermark M. Radiology of blunt trauma of the chest. Springer, Berlin Heidelberg New York, pp 71-134)"
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000562/000004.jpg?itok=W1UkLXl5",
            "caption": "The air leak consecutive to the tracheal lesion generates air collections surrounding the the trachea and extending around the aortic arch, innominate veins, superior vena cava, and fatty thymic remnants (stars) (From Wintermark M, Wicky S, Bettex D, et al (2000) Trauma of the mediastinum. In Schnyder P, Wintermark M. Radiology of blunt trauma of the chest. Springer, Berlin Heidelberg New York, pp 71-134)"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/562",
    "time": "06.11.2000"
  },
  "563": {
    "case_id": 563,
    "title": "Combined blunt tracheal and esophageal ruptures",
    "section": "Chest imaging",
    "age": "44",
    "gender": "male",
    "diagnosis": "Combined blunt tracheal and esophageal ruptures at the cervical level, with subsequent cervical emphysema",
    "history": "Traffic accident",
    "image_finding": "44-year-old male car driver involved in a high-speed deceleration crash",
    "discussion": "Blunt esophageal lesions are encountered in less than 0.01% of cases. They occur in violent traffic accidents, as part of a crushing mechanism, and are associated with a 57% mortality, consecutive to associated lesions or to delayed mediastinitis and subsequent sepsis.\nEsophageal injuries include mucosal dissections, intramural hematomas, lacerations and ruptures. They are often associated with other visceral lesions, such as tracheo-bronchial ones, due to the mechanism and severity of trauma.",
    "differential_diagnosis": "Combined, blunt, tracheal, and, esophageal, ruptures, at, the, cervical, level,, with, subsequent, cervical, emphysema",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000563/000001.jpg?itok=1ESrymTK",
            "caption": "Air bubble in cervical subcutaneous tissues - Coned-view of the admission plain film displays a cervical round air collection (arrows) leftwards located with respect to the trachea (From Wintermark M, Wicky S, Bettex D, et al (2000) Trauma of the mediastinum. In Schnyder P, Wintermark M. Radiology of blunt trauma of the chest. Springer, Berlin Heidelberg New York, pp 71-134)"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000563/000002.jpg?itok=VwLwbm6X",
            "caption": "Spiral CT section (3-mm) depicts a large gap in the left antero-lateral tracheal wall (white arrow). This gap is occluded by the endotracheal tube balloon cuff . A hypodensity (black arrows) located on the right side of the esophagus (made visible by an opaque naso-gastric tube) was identified as a possible soft tissue air collection and raised suspicion about an esophageal tear. The latter was demonstrated during esophagoscopy and surgery (From Wintermark M, Wicky S, Bettex D, et al (2000) Trauma of the mediastinum. In Schnyder P, Wintermark M. Radiology of blunt trauma of the chest. Springer, Berlin Heidelberg New York, pp 71-134)."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/563",
    "time": "06.11.2000"
  },
  "564": {
    "case_id": 564,
    "title": "Mediastinal widening consecutive to arterial hemorrhage",
    "section": "Chest imaging",
    "age": "31",
    "gender": "male",
    "diagnosis": "Compressive hemomediastinum with an unidentified arterial origin",
    "history": "High-speed motorcycle accident",
    "image_finding": "31-year-old male driver ejected from his motorcycle",
    "discussion": "Mediastinal widening is diagnosed when the mediastinum width to chest width ratio, at the level of the aortic arch, is superior to 0.25. It is related with an aortic lesion in about 20% of cases, but may also result from other major mediastinal vessel injuries or from small vessel lesions consecutive to clavicular, sternal, rib or vertebral fractures. Finally, widened mediastunum in trauma patients may be secondary to abundant fluid perfusion with superior vena cava distension or to patient\u2019s supine position. Spiral chest CT and/or transesophageal echography are sensitive screening imaging modalities to rule out life-threatening aortic injuries. Rarely, a thoracic aortography is needed to complete this screening survey.",
    "differential_diagnosis": "Compressive, hemomediastinum, with, an, unidentified, arterial, origin",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000564/000001.jpg?itok=92xEjpc-",
            "caption": "Admission plain film displays a striking widening of the superior mediastinum (From Wintermark M, Wicky S, Bettex D, et al (2000) Trauma of the mediastinum. In Schnyder P, Wintermark M. Radiology of blunt trauma of the chest. Springer, Berlin Heidelberg New York, pp 71-134)"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000564/000002.jpg?itok=46JZ2Dda",
            "caption": "Spiral CT sections (3-mm) dislcose a large hemomediastinum, which compresses the right innominate vein and superior vena cava (white arrows), inducing a superior vena cava syndrome. The trachea and bronchi (black arrows) are also compressed and posteriorly displaced. Such compressive pattern demonstrates the arterial origin of this hemomediastinum, even if no arterial lesion could be identified by Spiral CT and thoracic aortography. Complete radiographic resolution of the hemomediastinum occurred within one week after the admission"
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000564/000003.jpg?itok=70VZtdap",
            "caption": "Spiral CT sections (3-mm) dislcose a large hemomediastinum, which compresses the right innominate vein and superior vena cava (white arrows), inducing a superior vena cava syndrome. The trachea and bronchi (black arrows) are also compressed and posteriorly displaced. Such compressive pattern demonstrates the arterial origin of this hemomediastinum, even if no arterial lesion could be identified by Spiral CT and thoracic aortography. Complete radiographic resolution of the hemomediastinum occurred within one week after the admission"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/564",
    "time": "06.11.2000"
  },
  "565": {
    "case_id": 565,
    "title": "Blunt traumatic intramural aortic hematom",
    "section": "Chest imaging",
    "age": "47",
    "gender": "male",
    "diagnosis": "Blunt traumatic aortic intramural hematoma",
    "history": "High-speed truck accident",
    "image_finding": "47-year-old male truck driver involved in a high-speed traffic accident. After the admission plain film, the patient underwent chest CT. Since the latter demonstrated an abnormal shape of the aortic contour, a thoracic aortogram was obtained, which confirmed the presence of an aortic intramural hematoma. During surgery, the patient underwent transesophageal echography.",
    "discussion": "In most blunt aortic lesions, only the intima and media are injured. The adventitia is the strongest layer and remains intact. Bleeding from the aorta or from intramural vasa vasora results in a pseudo-aneurysm, featuring an saccular pulsatile outpouching of the aortic lumen limited by a thin layer of adventitia and by neighbouring tissues and usually outlined by a hemomediastinum. In less than 5% of cases, traumatic aortic injuries may relate only to intimal tear, with aortic dissection and/or intramural hematoma. Ninety percent of blunt traumatic aortic lesions lie on the antero-medial aspect of the aortic isthmus.\nAortography can demonstrate blunt traumatic lesions within the aortic walls as  a sightly abnormal contour. However, it shows little sensitivity in the detection of such lesions, unless coupled with intravascular ultrasound imaging. On the other hand, they are easily depicted by transesophageal echography and spiral CT, as well as, in the future, MR. CT, which is performed in hemodynamically stable patients, features intimal flaps as low-attenuation curvilinear filling defects within the aortic lumen and intramural hematomas as aortic contour deformities or focal biconvex wall thickenings. On TEE images, obtained in the operating room in hemodynamically unstable patients, intramural hematomas are responsible for a double contour of the aortic wall.",
    "differential_diagnosis": "Blunt, traumatic, aortic, intramural, hematoma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000565/000001.jpg?itok=udPh-sxF",
            "caption": "Admission plain film displays a widened mediastinum and a blurring of the aortic knob and descending thoracic aorta. A rightward displacement of the trachea and of a naso-gastric tube to the right, a lowering of the left mainstem bronchus and bilateral apical caps are also present (From Wintermark M, Wicky S, Bettex D, et al (2000) Trauma of the mediastinum. In Schnyder P, Wintermark M. Radiology of blunt trauma of the chest. Springer, Berlin Heidelberg New York, pp 71-134)"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000565/000002.jpg?itok=l9YMVhi-",
            "caption": "Spiral CT section (3-mm-thick sections acquired with a pitch of 1.5:1) discloses a hemomediastinum surrounding the aortic arch and the azygos arch. Bilateral hemothoraces are also portrayed."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000565/000003.jpg?itok=FHU8FvKa",
            "caption": "Spiral CT section on T9 level depicts a filling defect (arrows) within the anterior lumen of the descending thoracic aorta. This pattern was related to a possible intramural hematoma"
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000565/000004.jpg?itok=H681e7gk",
            "caption": "5-MHz trans-esophageal echography, obtained in the operating room, demonstrates the aortic intramural hematoma (arrow) (From Wintermark M, Wicky S, Bettex D, et al (2000) Trauma of the mediastinum. In Schnyder P, Wintermark M. Radiology of blunt trauma of the chest. Springer, Berlin Heidelberg New York, pp 71-134)"
          },
          {
            "number": "Figure 1e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000565/000005.jpg?itok=M722O-XB",
            "caption": "5-MHz trans-esophageal echography also depicts an intimal flap (arrow) within the aortic lumen at the level of the isthmus - Blunt traumatic aortic rupture with intimal tear was diagnosed (From Wintermark M, Wicky S, Bettex D, et al (2000) Trauma of the mediastinum. In Schnyder P, Wintermark M. Radiology of blunt trauma of the chest. Springer, Berlin Heidelberg New York, pp 71-134)."
          },
          {
            "number": "Figure 1f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000565/000006.jpg?itok=EX9JfKa8",
            "caption": "Retrospectively, the aortic intramural hematoma was identified on the thoracic aortogram as an indentation of the aortic contour (arrows) on the antero-lateral aspect of the descending thoracic aortic lumen (From Wintermark M, Wicky S, Bettex D, et al (2000) Trauma of the mediastinum. In Schnyder P, Wintermark M. Radiology of blunt trauma of the chest. Springer, Berlin Heidelberg New York, pp 71-134)."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT",
      "Ultrasound"
    ],
    "link": "https://www.eurorad.org/case/565",
    "time": "12.01.2002"
  },
  "566": {
    "case_id": 566,
    "title": "Blunt traumatic dissection and thrombosis of the celiac artery extending from a diaphragmatic aortic lesion",
    "section": "Chest imaging",
    "age": "26",
    "gender": "male",
    "diagnosis": "Blunt traumatic dissection and thrombosis of the celiac artery extending from a diaphragmatic aortic lesion",
    "history": "High-speed motorcycle accident",
    "image_finding": "26-year-old male driver involved in a high-speed motorcycle accident",
    "discussion": "In 90% of cases, blunt traumatic aortic lesions lie at the level of the aortic isthmus. In less than 10% of cases, they involve the ascending aorta, just above the aortic valve, and may then be associated with cardiac injuries and/or coronary artery lesions, with subsequent hemopericardium and cardiac tamponade. Finally, in 2% to 3%, blunt aortic injuries are located at the level of the diaphragm. They are then associated with lesions of the diaphragm and the celiac and/or superior mesenteric artery.",
    "differential_diagnosis": "Blunt, traumatic, dissection, and, thrombosis, of, the, celiac, artery, extending, from, a, diaphragmatic, aortic, lesion",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000566/000001.jpg?itok=7huBzSUs",
            "caption": "Spiral CT section (10-mm) on T12 level depicts an abnormal oval shape of the aortic lumen, the anterior border of which is blurred. The aorta is surrounded by a hematoma, which is anteriorly delineated by the diaphragmatic cruces. This radiological pattern lets a blunt aortic lesion be suspected (From Wintermark M, Wicky S, Bettex D, et al (2000) Trauma of the mediastinum. In Schnyder P, Wintermark M. Radiology of blunt trauma of the chest. Springer, Berlin Heidelberg New York, pp 71-134)"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000566/000002.jpg?itok=QlZL5xZY",
            "caption": "Spiral CT section (10-mm) on L2 level discloses irregularities and intraluminal filling defects and irregularities within the celiac artery (arrow), relating to an extension of the blunt aortic injury (From Wintermark M, Wicky S, Bettex D, et al (2000) Trauma of the mediastinum. In Schnyder P, Wintermark M. Radiology of blunt trauma of the chest. Springer, Berlin Heidelberg New York, pp 71-134)"
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000566/000003.jpg?itok=W0gQ_AsP",
            "caption": "An abdominal aortogram discloses a dissection of the celiac artery (white arrow), extending to the hepatic artery (black arrow) (star = splenic artery). The aortic lesion is not depicted (From Wintermark M, Wicky S, Bettex D, et al (2000) Trauma of the mediastinum. In Schnyder P, Wintermark M. Radiology of blunt trauma of the chest. Springer, Berlin Heidelberg New York, pp 71-134)"
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000566/000004.jpg?itok=VbFqq3Jo",
            "caption": "Sliding thin-slab maximum intensity projection depicts displays a thrombus within the celiac artery(white arrows) and its extension as a dissection within the hepatic artery (black arrow) (From Wintermark M, Wicky S, Bettex D, et al (2000) Trauma of the mediastinum. In Schnyder P, Wintermark M. Radiology of blunt trauma of the chest. Springer, Berlin Heidelberg New York, pp 71-134)"
          },
          {
            "number": "Figure 1e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000566/000005.jpg?itok=wyv6Vxln",
            "caption": "Sliding thin-slab maximum intensity projection depicts displays a thrombus within the celiac artery(white arrows) and its extension as a dissection within the hepatic artery (black arrow) (From Wintermark M, Wicky S, Bettex D, et al (2000) Trauma of the mediastinum. In Schnyder P, Wintermark M. Radiology of blunt trauma of the chest. Springer, Berlin Heidelberg New York, pp 71-134)"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT",
      "Digital radiography"
    ],
    "link": "https://www.eurorad.org/case/566",
    "time": "24.10.2000"
  },
  "567": {
    "case_id": 567,
    "title": "Blunt traumatic pneumomediastinum outlining thymic remnants",
    "section": "Chest imaging",
    "age": "12",
    "gender": "male",
    "diagnosis": "Blunt traumatic pneumomediastinum outlining thymic remnants in child blunt trauma",
    "history": "Blunt trauma in a child",
    "image_finding": "12-year-old male child involved in a blunt trauma (traffic accident)",
    "discussion": "Radiological patterns of blunt traumatic pneumomediastinums are similar in children and in adults. Two specifics patterns are allowed by the presence of thymic remnants in children. Anterior air collections elevating the thymic lobes on front chest X--rays create a crescent-shaped configuration mimicking a spinnaker sail (\u201cthymic spinnaker-sail\u201d sign), whereas perithymic air collections associated with small bilateral pneumothoraces feature a soft-tissue density simulating the rockers of an infant\u2019s cradle (\u201crocker--bottom thymus\u201c sign).",
    "differential_diagnosis": "Blunt, traumatic, pneumomediastinum, outlining, thymic, remnants, in, child, blunt, trauma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000567/000001.jpg?itok=7wdb9YGh",
            "caption": "Front and lateral plain films disclose an anterior pneumomediastinum, which surrounds both thymic lobes (white arrows). Besides, the lateral film displays a \u201ccontinuous left hemidiaphragm\u201d sign (black arrows), and posterior air collections outlining the descending thoracic aorta (From Wintermark M, Gudinchet F, Schnyder P (2000) Pediatric chest trauma. In Schnyder P, Wintermark M. Radiology of blunt trauma of the chest. Springer, Berlin Heidelberg New York, pp 135-146)"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000567/000002.jpg?itok=C74dI61S",
            "caption": "Front and lateral plain films disclose an anterior pneumomediastinum, which surrounds both thymic lobes (white arrows). Besides, the lateral film displays a \u201ccontinuous left hemidiaphragm\u201d sign (black arrows), and posterior air collections outlining the descending thoracic aorta (From Wintermark M, Gudinchet F, Schnyder P (2000) Pediatric chest trauma. In Schnyder P, Wintermark M. Radiology of blunt trauma of the chest. Springer, Berlin Heidelberg New York, pp 135-146)"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/567",
    "time": "06.11.2000"
  },
  "568": {
    "case_id": 568,
    "title": "Blunt traumatic aortic injury in a traumatized chil",
    "section": "Chest imaging",
    "age": "16",
    "gender": "female",
    "diagnosis": "Blunt aortic lesion at the level of the isthmus in a crushed child",
    "history": "Crush accident in a child",
    "image_finding": "16-year-old female child run over and crushed by a small truck",
    "discussion": "Blunt aortic injuries are encountered in less than 0.5% of blunt chest trauma. They occur in high-speed traffic accidents and are thus associated with severe cranial, intrathoracic and intra-abdominal lesions. They usually lie at the aortic isthmus. Plain film patterns, notably mediastinal widening, may be difficult to interprete, due to thymic presence. As in adults, spiral computed tomography and trans-esophageal echography most often replace time-consuming and invasive aortography.",
    "differential_diagnosis": "Blunt, aortic, lesion, at, the, level, of, the, isthmus, in, a, crushed, child",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000568/000001.jpg?itok=q7ZIspJG",
            "caption": "Admission chest X-ray demonstrates a mediastinal widening and bilateral subpulmonary pneumothoraces (From Wintermark M, Gudinchet F, Schnyder P (2000) Pediatric chest trauma. In Schnyder P, Wintermark M. Radiology of blunt trauma of the chest. Springer, Berlin Heidelberg New York, pp 135-146)"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000568/000002.jpg?itok=NsPxWcTH",
            "caption": "Spiral CT section (3-mm) on T4 level displays an extensive hemomediastinum. This hemomediastinal realtes to an aortic rupture, featuring intimal flaps (black arrows) within the aortic lumen, which are delineating an aortic pseudo-aneurysm (white arrows) (From Wintermark M, Gudinchet F, Schnyder P (2000) Pediatric chest trauma. In Schnyder P, Wintermark M. Radiology of blunt trauma of the chest. Springer, Berlin Heidelberg New York, pp 135-146)"
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000568/000003.jpg?itok=VmAIc5HX",
            "caption": "Thoracic aortography confirms the aortic lesion at the level of the isthmus (arrow) (From Wintermark M, Gudinchet F, Schnyder P (2000) Pediatric chest trauma. In Schnyder P, Wintermark M. Radiology of blunt trauma of the chest. Springer, Berlin Heidelberg New York, pp 135-146)"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT",
      "Digital radiography"
    ],
    "link": "https://www.eurorad.org/case/568",
    "time": "06.11.2000"
  },
  "572": {
    "case_id": 572,
    "title": "Intrapulmonary lymph nodes",
    "section": "Chest imaging",
    "age": "3",
    "gender": "female",
    "diagnosis": "Intrapulmonary lymph nodes",
    "history": "Three years old girl with suspicion of pulmonary metastases",
    "image_finding": "The child was followed for\n a malignant sacrococcygeal \nteratoma discovered by US during \npregnancy treated initially by \nsurgery and chemotherapy. Because \nof a  recent increase in alpha-foeto protein level, a chest CT \nwas performed to rule out \nmetastases (Fig 1). Four micronodules were\ndisclosed. A mini thoracotomy was\nperformed, and the four nodules were\nanalysed. No evidence of metastases was found\nat histology.",
    "discussion": "Lymph nodes are located in the mediastinum, around the main bronchi and within the lung to the level of the third or fourth order branches of the bronchi. The lymph nodes located more distally are considered abnormal and termed intrapulmonary lymph nodes (IPLN).\nThe prevalence of these nodes is not well evaluated.  Trapnell, using plain film radiographs techniques, demonstrated intrapulmonary lymph nodes distal to the fourth-order bronchi in six of 92 post-mortem lungs by injection of contrast medium into pleural lymphatic vessels (1). Bankoff have reported that the nodules in 17 of 96 patients (18%) who underwent minithoracotomy for resection of well-circumscribed peripheral pulmonary nodules were found to be benign IPLN (2).\nMost patients with IPLN are men, heavy smokers of long duration and older than 50 years. Rare paediatric cases have been reported. Tanaka has reported three paediatric cases (3). Two were associated with osteosarcoma and one with juvenile granulosa cell tumor. Lung metastasis were also present in the first two cases. No radiological differential diagnosis was performed before pathology.\n\nPathologically, evidence of lymphoid follicles, ectatic lymphatic channels, anthracotic pigmentation and partial encapsulation are seen in most IPLN.\nRadiographically (4,5), most IPLN are located under the level of the carina especially in the lower lobes. In two third of the cases the node is unique. They are usually smaller than 12 mm in diameter, and therefore more frequently diagnosed at CT than on chest radiogragrams. They are well defined, homogeneous, round or ovoid and located within 20 mm of visceral pleural surface.  The borders may sometimes be rough like that of lung cancer. Pleural indentations or convergence of peripheral vessels may sometimes occur. A peripheral pulmonary vein can be seen adjacent to the IPLN.\nReports of IPLN with rapid growth and high serum carcinoembryonic antigen levels (CEA) have been documented.\nIPLN can be associated with tumors or metastases.\nCT features of IPLN, lung cancer and metastases may sometimes overlap. The subpleural location in the lower lobes is also favored for metastases. No critera permit to distinguish benign versus malign nodule. The diagnosis of benign IPLN is still a pathologic diagnosis.\nWith the improvement in the image quality of CT, more pulmonary nodes are likely to be identified, such as in our case, and a higher proportion of these small peripheral nodules may ultimately be proven to be benign IPLN at percutaneous biopsy or after surgery.",
    "differential_diagnosis": "Intrapulmonary, lymph, nodes",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000572/000001.jpg?itok=dQvGwp4f",
            "caption": "Chest CT demonstrates an intrapulmonary nodule located in the left scissure (yellow arrow) and another one, immediatly subpleural,located in the inferior right lobe (green arrow). Both nodules measure less than 2 mm. Notice also the presence of a nodular image similar to the previous one, located more anteriorly (red arrow), which corresponds to a pulmonary vessel."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/572",
    "time": "24.10.2000"
  },
  "590": {
    "case_id": 590,
    "title": "Pneumothorax in a preterm",
    "section": "Chest imaging",
    "age": "1",
    "gender": "female",
    "diagnosis": "Pneumothorax",
    "history": "Respiratory distress syndrome at birth. Pneumothorax at day 2.",
    "image_finding": "At birth the weight was 1,1 kilos. She was reanimated by means of physical stimulation and oxygen mask. On the first day presented reduced oxygen blood saturation and chest x-ray demonstrated a respiratory distress syndrome. The second day she was intubated and chest x-Ray showed a left pneumothorax and a drainage was initiated. Pneumothorax completely resolved after two weeks.",
    "discussion": "Chest radiograms revealed in our case the onset of a pneumothorax in a preterm with distress respiratory syndrome that non uniformly involved the lung fields; the collapse of the left lung with the complete absence of the pulmonary plan were also observed. Pneumothorax corresponds to the extravasation of air in the pleural cavity and produces a partial or complete collapse of the adjacent lung. Pneumothorax is defined spontaneous when no traumatic or iatrogenic factors are involved. Respiratory distress syndrome or hyaline membrane disease are caused  by surfactant deficiency and these are the conditions in which a pneumothorax occurs in spontaneously breathing so this is not primarily a complication of mechanical ventilation. Respiratory distress syndrome requiring ventilatory support is a common condition among small premature infants. Recently pneumothorax and other air leaks have been attributed to high ventilatory pressure (barotrauma) or volumes ( volutrauma). High ventilatory volumes induce pneumothorax in atelectasic lungs because inflated air is forced only into the expanded areas of the lung that result in volumetric overload. In the present case it is impossible to establish if the pneumothorax was spontaneous or iatrogenic.",
    "differential_diagnosis": "Pneumothorax",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000590/000001.jpg?itok=qrKgGAT-",
            "caption": "Plain chest radiograph in this newborn shows caracteristically small, and granular lungs with air broncograms."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000590/000002.jpg?itok=y29lALO-",
            "caption": "Pneumothorax is evident on the left side associated with a partial  collapse of the adjacent lung. Mediastinum structure is also  dislocated on the right side."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000590/000003.jpg?itok=Sb3QwEct",
            "caption": "Drainage was applied at the level  of the seventh intercostal space and  mediastinum returned normal."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000590/000004.jpg?itok=RUs5u7YN",
            "caption": "Pneumothorax resolved but respiratory distress syndrome  persisted."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/590",
    "time": "24.07.2001"
  },
  "606": {
    "case_id": 606,
    "title": "Hemorrhagic bilateral pleural effusion as first sign of IgG myelom",
    "section": "Chest imaging",
    "age": "51",
    "gender": "female",
    "diagnosis": "IgG Lambda multiple myeloma",
    "history": "A 51 year-old woman presented with dyspnea due to a bilateral pleural effusion. The pleural fluid was hemorrhagic. The CT scan of the thorax delineated a soft-density tumor encircling the sternum, an intact cortex of the sternal body, mild compression and displacement of the heart by the mass, and a bilateral pleural effusion with no discernible pleural nodules.",
    "image_finding": "A 51 year-old woman presented with progressive dyspnea on exertion that led to hospital admission 20 days later. On physical examination, a soft, ill-delimited, and barely visible mass was overlying the sternal manubrium, and there was a suggestion of bilateral pleural effusion; no other abnormal signs were found. The blood hemoglobin concentration was 11.9 g/dL, the leukocyte count was 9.4 x 109/L with an unremarkable differential, and the platelet count was 312 x 109/L. The erythrocyte sedimentation rate was 42 mm in the first hour. Biochemical measurements in the serum revealed the following: urea 32 mg/dL, creatinine 0.69 mg/dL, glucose 120 mg/dL, urates 5.4 mg/dL, total protein 5.56 g/dL, and beta-2-microglobulin 3.8 micrograms/mL (reference range 0-3). The urine contained 75 mg/dL of proteins, and was otherwise normal.\n\tThe chest X-ray showed only a bilateral pleural effusion. No bone lesions were seen on serial radiographs of the ribs, spine, pelvis, sternum and cranium. The CT scan of the thorax delineated a soft-density tumor encircling the sternum, an intact cortex of the sternal body, mild compression and displacement of the heart by the mass, and a bilateral pleural effusion with no discernible pleural nodules.\n\tOn left thoracentesis, hemorrhagic pleural fluid was obtained.. This pleural fluid contained 5.1 g/dL of protein, 99 mg/dL of glucose, a red blood cell count of 1.1 x 1012/L, a leukocyte count of 11.9 x109/L (70% mononucleated, 30% polinucleated), and an adenosine deaminase activity of 37.7 U/L. The cytologic study of the pleural fluid disclosed neoplastic cells with a plasmacytoid appearance.\n\tSerum electrophoresis showed a small monoclonal band, and immunofixation of the serum revealed IgG Lambda monoclonality. Immunoglobulin concentrations in the serum were: IgG 613 mg/dL, IgM 42.6 mg/dL, and IgA 49.3 mg/dL. In the urine, 85.2 mg/dL (reference range 0-0.5 mg/dL) of Lambda light chains were found. A needle biopsy of the presternal mass obtained a sample entirely made up of IgG Lambda myeloma tissue. A bone marrow aspirate and biopsy contained 30% of atypical plasma cells that stained with IgG Lambda antibody.",
    "discussion": "Myeloma is not among the causes usually considered in the differential diagnosis of pleural effusions [1]. There have been a number of case reports of myelomatous pleural effusions either at presentation or late in the course of multiple myeloma [2], but in most cases the diagnosis of myeloma was previously known. We report a case of IgG Lambda multiple myeloma presenting as a hemorrhagic bilateral pleural effusion.\n      Hemorrhagic pleural effusions are uncommon and mostly secondary to a pleural based malignancy [3], but we are not aware of any published case of myelomatous hemorrhagic pleural effusion.\n\tPleural effusions develop rarely in the course of multiple myeloma. In a consecutive series of 54 cases of multiple myeloma, only 1 was found to have pleural involvement [4]. There are single case reports of multiple myeloma or even plasmacytoma presenting as pleural effusion, usually unilateral.\n\tThe adenosine deaminase activity in the pleural fluid has been reported to be elevated in some cases of myelomatous pleural effusion [5], but in our case it was below the discriminant value of 45 U/L.\n\tIn contrast to our case of IgG Lambda myeloma, the majority of myelomatous pleural effusions have been described in IgA myelomas, apparently because they have a greater propensity for extramedullary involvement [5].\n\tThe prognosis of cases with pleural involvement in multiple myeloma is dismal, with survival in reported cases usually less than one year [2,5]. In our case, bilateral talc pleurodesis performed at the beginning of treatment appeared to be effective in the long term, as she did not develop further dyspnea attributable to pleural effusion. The survival of our patient almost 3 years from the time of diagnosis was longer than anticipated.\n\tIn conclusion, undiagnosed myeloma should be included in the differential diagnosis of unilateral or bilateral pleural effusions, even if they are hemorrhagic.",
    "differential_diagnosis": "IgG, Lambda, multiple, myeloma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000606/000001.jpg?itok=1cwHTtIE",
            "caption": "Bilateral pleural effusion without heart enlargement. A soft mass encircling the sternal body spares the sternal cortex and displaces the heart."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000606/000002.jpg?itok=QTBGkmW0",
            "caption": "Atypical cells with a plasmacytoid appearance and frequently binucleated can be seen over a hematic background (Papanicolaou stain 400x)."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/606",
    "time": "24.10.2000"
  },
  "612": {
    "case_id": 612,
    "title": "Pulmonary arteriovenous malformation in Rendu-Osler-Weber disease.",
    "section": "Chest imaging",
    "age": "64",
    "gender": "male",
    "diagnosis": "Pulmonary arteriovenous malformation with hemothorax",
    "history": "Acute dyspnea and rapid occurrence of anaemia",
    "image_finding": "The patient, affected by the Rendu-Osler-Weber disease,  complained of dyspnea. Laboratory findings: rapid occurence of anaemia (Hb:9,4mg/dl).\nA standard chest radiography revealed pleural effusion at the left hemithorax ; a polylobate nodule (3 cm in diameter) was also detected at the left lung base (see images 1a and 1b). After 2 days the symptoms worsened (increase in dyspnea, Hb: 7,9mg/dl, pO2: 49mmHg, pCO2: 32,3mmHg); for this reason a further standard chest radiography was performed: it  revealed complete opacity of the left lung associated to right dislocation of the mediastinum (see image 1c). In addition a contrast enhanced CT of the thorax was performed (see image 2). Few hours later the patient died.",
    "discussion": "The Rendu-Osler-Weber (RWO) disease  or hereditary hemorrhagic telangiectasia is a rare (about 1-2/100000 in European population) autosomal dominant inherited disorder which may give rise to arteriovenous malformations localized in the microcircle of the derm, in telangiectasic shape. Frequently they involve the nose, lips, conjunctivae, mucosal surface, nailbed and the distal portion of the limbs. Sometimes the RWO disease is associated with vascular anomalies in other organs, particularly in the pulmonary, hepatic and cerebral circulations.\nGastrointestinal bleeding and epistaxis represent the most common clinical features.  Dyspnea, cyanosis, digital clubbing and rarely cardiac failure may occur particularly in case of pulmonary arteriovenous fistula with high flow or right to left shunt. Because of paradoxical emboli, various central nervous system complications have been described, including stroke and brain abscess. A pulmonary arteriovenous malformation can also bleed and results in hemoptysis and hemothorax. \nAt standard chest  radiography arteriovenous malformations appear as lobulated nodular lesions, located at central or peripherical lung area with linear stria connecting to homolateral pulmonary hilum. This linear stria represents the tortuous feeding arteries and draining veins.\nOn CT scan it is possible to reveal a nodular lesion with sharp edges, parenchymatous density and homogeneous enhancement. Afferent vessels originating from bronchial artery can be found, as well as  ectasic efferent vessels coming from arteriovenous malformations and flowing into a pulmonary vein.",
    "differential_diagnosis": "Pulmonary, arteriovenous, malformation, with, hemothorax",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000612/000001.jpg?itok=v17qd9LT",
            "caption": "Pleural effusion at the left hemithorax is evident; a polylobate nodule (3 cm in diameter) also can be seen at the left lung base."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000612/000002.jpg?itok=2e-V878q",
            "caption": "Close-up of the left lower thorax."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000612/000003.jpg?itok=zfOi3dir",
            "caption": "Two days after: diffuse opacity of the left lung assiociated to right dislocation of the mediastinum."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000612/000004.jpg?itok=hfLy13Bm",
            "caption": "At the left hemithorax a nodular lesion with homogeneous enhancement, connected to an ectasic efferent vessel flowing into the inferior vena cava, is evident."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000612/000005.jpg?itok=T1pyRR9_",
            "caption": "A massive pleural effusion with collapse of the left lung and dislocation of the mediastinum is present. This scan shows that the upper portion of the arteriovenous malformation originates from the lower part of the collapsed lung."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000612/000006.jpg?itok=Y9VrNUdU",
            "caption": "At the left hemithorax a massive pleural effusion ( with collapse of the left lung and dislocation of the mediastinum) is present."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000612/000007.jpg?itok=bi6qGyb_",
            "caption": "The high HU density (35-40) of the pleural effusion is suggestive of hemothorax."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT",
      "MR"
    ],
    "link": "https://www.eurorad.org/case/612",
    "time": "24.07.2001"
  },
  "617": {
    "case_id": 617,
    "title": "Intralobar sequestration",
    "section": "Chest imaging",
    "age": "49",
    "gender": "male",
    "diagnosis": "Intralobar sequestration",
    "history": "Pneumonia, productive cough and fever",
    "image_finding": "A 49 year old male, smoker since 15 years of age, with history of chronic pneumonia, productive cough and fever. The patient obtained benefits from the antibiotic therapy with substantial reduction of severity of symptoms. Recently he had a single episode of fever (37,5\u00b0C) associated with non productive cough. Chest CT was performed and revealed a parenchymal consolidation in the right lower lobe.The nature of this consolidation was better characterized by MR imaging and Angiography, that confirmed an intralobar sequestration.",
    "discussion": "Pulmonary sequestration has been classically described in two forms: intralobar and extralobar sequestration. Intralobar sequestration has been suggested by several authors to be a congenital malformation consisting of non functional embryonic lung tissue lying within normal pulmonary visceral pleura, with no communication with normal bronchial system, supplied by aberrant systemic artery.The arterial supply is usually from the descending thoracic aorta (73%)but occasionally by upper abdominal aorta, celiac or splenic arteries (21%)(3). In decreasing order of frequency the intercostal, subclavian,internal thoracic may be supplying arteries(5).  The venous drainage is provided by pulmonary veins.The intralobar sequestration is located in lower lobes (98%), occurring on the left side in the majority of cases (58%). Extralobar sequestration is characterized by the complete separation of the embryonic tissue that is enclosed in its own pleural investment and it presents a greater left side preponderance (over 80%).The venous drainage of extralobar sequestration is usually systemic (80% of cases)through the azygos and hemiazygos system or superior vena cava in the right atrium. Clinical manifestations consist of chronic and recurrent pneumonia, productive cough, fever and haemoptysis. In presence of a large systemic arterial venous shunt, the patients may have exercise intolerance. This anomaly is rarely detected in infancy (usually associated with other anomalies). The diagnosis of pulmonary sequestration traditionally requires arteriography (1)to identify abnormal systemic vessels feeding the abnormal portion of the lung. CT and MRI are useful for locating sequestered parenchyma and large vascular supply (2), while angiography can delineate small arterial supplying vessels. Recent advances in MR angiography (4)based on to multiplanar imaging suggest the capability of this technique to recognize small vessels and also multi row detector CT permits the demonstration of both arterial supply from the descending aorta and venous drainage to hemiazygos vein.Therefore actually angiography remains an essential tool in the diagnosis of pulmonary sequestration, notwithstanding the great potentials of multi row detector CT and MR angiography.  Differential diagnosis includes bronchiectasis, lung abscess, artero-venous shunt in Rendu-Osler-Weber disease, and Bochdalek hernia.",
    "differential_diagnosis": "Intralobar, sequestration",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000617/000001.jpg?itok=8Wsr6QjW",
            "caption": "Parenchymal consolidation at the lower right lobe (lung window setting)"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000617/000002.jpg?itok=KnLGaR-S",
            "caption": "At the same level blood vessels are evident within the parenchymal lesion (mediastinum window setting)"
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000617/000003.jpg?itok=yMQP3qO6",
            "caption": "A parenchymal consolidation  with an arterial branch within the lesion can be seen at a lower level"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000617/000004.jpg?itok=rBnFBVxm",
            "caption": "Contrast enhancement MR angiography confirmed the presence of a parenchimal consolidation with an arterial feeder inside"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000617/000005.jpg?itok=VeBXOKs2",
            "caption": "Volume rendered MR angiography shows the origin of the feeder from the celiac artery"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000617/000006.jpg?itok=1ebFQnMl",
            "caption": "DSA - artherial  phase shows the feeding artery"
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000617/000007.jpg?itok=Hp1TQqqc",
            "caption": "DSA- venous fase shows the venous drainage of the pulmonary sequestration"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT",
      "MR-Angiography",
      "MR",
      "MR"
    ],
    "link": "https://www.eurorad.org/case/617",
    "time": "15.10.2002"
  },
  "658": {
    "case_id": 658,
    "title": "Contrast-enhanced three-dimensional MRA in the evaluation of  multiple pulmonary arteriovenous malformations: MIP reconstruction.",
    "section": "Chest imaging",
    "age": "25",
    "gender": "female",
    "diagnosis": "Rendu-Osler-Weber disease",
    "history": "Recurrent episodes of hemoptysis, blood desaturation and with familiar history of  Osler-Weber-Rendu disease.",
    "image_finding": "A 25 y.o. woman with recurrent episodes of hemoptysis, blood desaturation and with familiar history of  Osler-Weber-Rendu disease.\nPhysical examination of the thorax showed bilateral, diffuse bruits; she underwent ce MRA to rule out possible vascular pulmonary involvement of O-W-R disease.",
    "discussion": "Pulmonary arteriovenous fistulas (PAVFs) are rare vascular malformations of the\nlung and are most frequently congenital, usually associated with familiar hemorrhagic\ntelangectasia (Rendu-Osler-Weber disease).  Although most patients are asymptomatic, PAVFs can cause dyspnea due to right-to-left shunt. They can also bleed and result in hemoptysis and hemothorax. Because of paradoxical emboli, various central nervous system complications have been described including stroke, and brain abscess.\nSpiral CT scan (SCT) may allow to detect pulmonary arteriovenous malformations, with a sensitivity (3) superior to that of  digital angiography. CEMRA, a non-invasive procedure, has high sensitivity (4) and specificity for the diagnosis of clinically relevant PAVFs.\nTherapeutic options include angiographic embolization with metal coils or balloon occlusion and surgical excision. Angiographic treatment has become the mainstay of therapy for most patients during the last decade. It is minimally invasive and can be easily repeated.\nContrast-enhanced three-dimensional MRA provide the interventional radiologist with a pre-embolization road map from which information regarding the number and size of feeding and draining vessels can be obtained accurately and noninvasively.",
    "differential_diagnosis": "Rendu-Osler-Weber, disease",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000658/000001.jpg?itok=B-URegh8",
            "caption": "MRAngiography using MIP reconstruction shows the presence of multiple, bilateral arteriovenous malformations of pulmonary vessels"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "MR-Angiography"
    ],
    "link": "https://www.eurorad.org/case/658",
    "time": "06.11.2000"
  },
  "659": {
    "case_id": 659,
    "title": "Relapsing polychondritis",
    "section": "Chest imaging",
    "age": "58",
    "gender": "female",
    "diagnosis": "Relapsing polychondritis.",
    "history": "A 58-year-old greek woman presented with a long history of respiratory symptoms and ocular, auricular and nasal inflammation, which she had been suffering from since 1981.",
    "image_finding": "A 58-year-old greek woman had a long history of respiratory symptoms and ocular, auricular and nasal inflammation since 1981. Initially, she had recurrent cough, conjuctivitis, episcleritis, and\nincreased C- reactive protein. Later, she had recurrent inflammation of the pinnae and nose deformity. In 1989 the diagnosis of relapsing polychondritis was made and was treated with steroids. Soon\nafter, the cough became intense and more frequent. A chemotherapeutic treatment with Endoxan (Cyclophosphamide) was initiated. The year before, the patient was admitted to our hospital with\npersistent wheezing and inspiratory dyspnea. She was suggested to undergo a CT scan of the thorax, in order to evaluate the tracheobronchial tree. The results showed an alteration of the normal\nmorphology and marked stenosis of the distal trachea and main bronchi (Figs. 1a, 2a, 3a). A CT scan of the paranasal (Fig. 4a) sinuses was also performed, which showed a collapse of the nasal\ncartilage. The last CT scan of the thorax (Fig. 5a) showed infiltration of the right lung due to food aspiration.",
    "discussion": "Relapsing polychondritis (RPC) is a rare, chronic, multisystem inflammatory disorder, which mainly affects the cartilaginous tissues, and which is difficult to be diagnosed at an early stage. It is\nfrequently associated with rheumatoid arthritis, systemic vasculitis, connective tissue diseases, and haematologic disorders. The tissues involved are the ears, joints, nose, larynx, trachea, eyes,\nheart valves, kidneys,and the skin. Airway complications\u2013tracheobronchial narrowing and obstruction\u2013are the most serious manifestations and can be fatal. The diagnosis of RPC is made on\nthe basis of Damiani's criteria and imaging findings [1], [2]. CT is the most useful imaging modality to identify laryngeal, tracheal, bronchial and nasal cartilage involvement. CT findings include\ntracheobronchial wall thickening, lumen stenosis (due to oedema and inflammatory granulomas) and wall calcification, and, later, collapse of the lumen (caused by the destruction of the cartilage and\nby fibrous scarring of the tracheal walls). Collapse of the cartilage of the nose and calcification in the cartilages of the ears can also be clearly demonstrated by CT [4], [5]. The early diagnosis\nof RPC is crucial, as appropriate pharmacological treatment may prevent life-threatening airway obstruction. Expandable metallic stents can be placed using a flexible bronchoscope at a later stage,\nof tracheobronchial stenosis [1], [3].",
    "differential_diagnosis": "Relapsing, polychondritis.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000659/000001.jpg?itok=a4pkdxcn",
            "caption": "A spiral CT scan, soft tissue window, taken at the level of the upper mediastinum reveals deformation of the normal contour of the trachea due to the destruction of cartilage (indicated by an arrow)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000659/000002.jpg?itok=hCQtQPGO",
            "caption": "A spiral CT scan, soft tissue window, taken at the level of the distal trachea reveals  narrowing of the tracheal lumen (indicated by an arrow)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000659/000003.jpg?itok=sOfWQpL-",
            "caption": "A spiral CT scan, soft tissue window, taken at the level of the carina reveals a  marked narrowing of the two main bronchi (indicated by arrows)."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000659/000004.jpg?itok=-_kSRq14",
            "caption": "A spiral CT scan, axial view, soft tissue window, taken at the level of the nasal cavity confirms the collapse of the nasal cartilage (indicated by an arrow), resulting in a flattened nose."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000659/000005.jpg?itok=ocZr4YhZ",
            "caption": "A HRCT scan, lung window, taken at the lower part of the lung reveals infiltration in the middle lobe of the right lung (indicated by an arrow), due to food aspiration."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/659",
    "time": "03.04.2002"
  },
  "667": {
    "case_id": 667,
    "title": "Missed lung micronodule",
    "section": "Chest imaging",
    "age": "66",
    "gender": "male",
    "diagnosis": "Metastatic pulmonary nodule from lung carcinoma missed at first CT examination.",
    "history": "Examined twice with CT of the thorax at four months interval .",
    "image_finding": "A 66 year old male, cigarette smoker, presented with hystory of cough, and recent appareance of bloody sputum.\nChest radiograms showed an opacity of the right upper lung lobe and bronchoscopy and biopsy revealed a primary squamo-cellular carcinoma.\nConventional chest and abdominal CT were performed at our institution for tumour staging.\nCT scans confirmed the tumoral lesion of the right upper lobe associated with perifocal satellite nodules and thickening of the postero-lateral parietal pleura; no thoracic or abdominal metastases were detected.\nThe patient refused surgery and underwent antiblastic chemotherapy.\nConventional chest and abdominal CT were repeated four months later and revealed the enlargement of the neoplastic mass lesion as well as the appareance of a metastatic nodule, 6 mm in diameter, located in the medial segment of the right lower lobe.\nWe evaluated the CT scans obtained four month earlier and we retrospectively detected a micronodule located at the same site.",
    "discussion": "Lung cancer represents the leading cause of cancer related death in western world; for these reasons there is an urgent need for improvement in diagnosis and management. Chest CT is considered more sensitive than chest radiography for the detection of nodules of lung cancer, but the potential for missing minute cancerous lesions is the major shortcoming of chest CT.Spiral CT improves the detection rates of small lung nodules but the most appropriate diagnostic criteria for minute lung cancers should be still established.Small pulmonary nodules, (less than 1 cm in diameter), represent a relevant diagnostic challenge because the accuracy of available diagnostic procedures is often unsatisfactory owing to their small size (4).\nSmall lung cancer nodules can be missed in prospect but easily seen in retrospect, and we must realize that a cancer lesion can be clearly recognized when the location is known, but go totally undetected in a prospective search (2).\nQUESTIONS RELATED TO MISS DETECTION:\nDetection failures are probably due to: the low resolution of the imaging technique, the lesions growth that allows nodules detection at following examinations and the different ability of the observers to detect subtle nodules or in differentiating from other structures as pulmonary vessels (3). An aid to reduce the number of detection failures is given by the use of spiral CT that allows to detect all nodules noted at conventional CT, as well as additional small nodules, but we believe that actually the most important tool to prevent the misdiagnosis of small lung nodules is based onto the careful examination of CT images by expert radiologists (1)(5). Small nodules can be metastases or primary tumours: a second primary lung cancer can also occour synchronously or metachronously and must be differentiate from metastases because of a second primary lung cancer can be surgically treated .\nUNDERSTAGING\nAnother question is related  to the understaging of primary lung cancers. Mediastinal adenopathy are currently evaluated on chest CT but there is a relevant percentage of misdiagnosis that prevents to establish the correct patient's prognosis. Actually PET associated with CT is significantly more accurate than CT alone in the N staging of non small cells lung cancer.",
    "differential_diagnosis": "Metastatic, pulmonary, nodule, from, lung, carcinoma, missed, at, first, CT, examination.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000667/000001.jpg?itok=g10xvv_N",
            "caption": "Tumoral mass lesion, of the right upper lobe, with irregular borders and contrast enhancement."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000667/000002.jpg?itok=1QfJMkri",
            "caption": "The same tumoral lesion appears enlarged four months after the first examination."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000667/000003.jpg?itok=3V1-pMb2",
            "caption": "A small lung nodule is evident in the medial segment of the right lower lobe."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000667/000004.jpg?itok=U_gPKCVu",
            "caption": "The small metastatic nodule is retrospectively visible in the same location in CT images obtained at the first examination. The small nodule was missed at first examination and its growth allowed an easy detection at second examination."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/667",
    "time": "27.05.2001"
  },
  "682": {
    "case_id": 682,
    "title": "Right aortic arch and agenesia of left pulmonary artery",
    "section": "Chest imaging",
    "age": "56",
    "gender": "male",
    "diagnosis": "right aortic arch with agenesia of left pulmonary artery",
    "history": "56 years old patient with long standing abnormalities of the left hemithorax including volume reduction, irregular pleural interface, pleural thickening, right aortic arch and atypical shape of the left pulmonary hilum",
    "image_finding": "Clinical History : This is a 56-year-old white male with coronary heart disease and a history of a myocardial infarction two years ago. He underwent PTCA of the LCA and received a coronary stent several weeks after myocardial infarction. His medical history is further remarkable for a rejection from the army when he was drafted at age of 19 years. He was first rejected because of an \u201einsufficient physical development\u201c. He was redrafted one year later and was again rejected, this time because of an abnormal chest X-ray that led subsequently to further investigations. The patient has no pulmonary complaints and he has never smoked. He missed once school for several weeks because of a prolonged lower respiratory infection during his childhood, but he has never since suffered from recurrent or prolonged bronchitis. The physical exam is remarkable for decreased breath sounds on the left side. There is a systolic murmur over the right anterior chest. The chest appears normal on inspection. Pulmonary function testing reveals a mild restrictive defect (TLC 78% predicted), no obstruction and a normal diffusing capacity for CO. An ECG was normal and a recent echocardiography failed to demonstrate signs of pulmonary hypertension. Imaging procedures : Chest X ray and CT were performed to evaluate the anatomy of the mediastinum and lungs in preparation of a planned coronary bypass surgery. The actual chest X-ray showed an remarkable volume reduction of the left lung with consecutive mediastinal shift. An right aortic arch is seen. The pleura of the left lung is irregular and thickened. The right lung is of normal appearance. CT images (pulmonary artery angio-CT protocol, 4x1 mm, RI 1.25 mm, Increment 1 mm, 150 ml contrast media, 3 ml/sec, delay 30 sec) shows the absence of the left pulmonary artery. The pulmonary veins are hypoplastic compared to the contralateral side but both left pulmonary veins are present. The pleural fat plane in the left hemithorax is thickened . Multiple widened intercostal arteries are seen. The pleuro-pulmonary interface shows multiple wedge-shaped pleural abnormalities which extend into thin intrapulmonary septa. Viewing of the entire image stack on CT workstation revealed multiple intercostal arteries crossing the pleura at these locations and entering the lung parenchyma.",
    "discussion": "Conventional X-ray of the thorax showed an volume reduction of the left hemithorax. Differential diagnosis of unilateral volume reduction included \n1. congenital abnormalities of the pulmonary artery such as unilateral hypoplasia, aplasia, coarctation or atypical origin (ring sling etc.)  \n2. Swyer-James Syndrome \n3. volume loss due to chronic pneumonia (less probable: no opacification)\n4. volume loss doe to pleural changes such as fibrosis or mesothelioma (less probable: no effusion, probably long standing changes)\n5. \nThe CT findings showed clearly the absence of the left pulmonary artery. Many different congenital abnormalities with and without associated cardiac abnormalities may affect the pulmonary arteries. The typical radiologic features of unilateral agenesis of the pulmonary artery include a small hemithorax, ipsilateral displacement of the mediastinum, absence of the pulmonary artery and reticular abnormalities along the pleura due to systemic collateral blood supply to the affected lung. Absence of the pulmonary artery is an result of misdevelopment of the proximal portions of the right or the left sixth arch of embryonal circulation and can, consequently, be associated with congenital heart disease, especially tetralogy of Fallot. In the present case, however, no congenital heart disease is present.",
    "differential_diagnosis": "right, aortic, arch, with, agenesia, of, left, pulmonary, artery",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000682/000001.jpg?itok=e2mmWOag",
            "caption": "Conventional X-ray of the chest  (1971)showing an volume reduction of the left hemithorax with mediastinal displacement to the left. The aortic arch is located on the right side. The left hilum is superimposed by the left contour of the heart. Slight thickening of the pleura on the left side is seen. The pleuro-pulmonary interface is irregular."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000682/000002.jpg?itok=3uYoy6t-",
            "caption": "Conventional X-ray of the chest  (1982)showing no changes in comparison with the findings from 1991"
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000682/000003.jpg?itok=yxaB8yne",
            "caption": "Conventional X-ray of the chest  (2000)showing no changes in comparison with 1971 and 1982"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000682/000004.jpg?itok=AbLuN3Ck",
            "caption": "CT images (MDCT, 4x2.5 mm) at the level of the pulmonary artery trunc showing the absence of the left pulmonary artery. The left upper pulmonary vein (*) is hypoplastic but normally located. The pleura shows an increased fat interposition with multiple enlarged intercostal arteries."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000682/000005.jpg?itok=XRN-cQzn",
            "caption": "CT image at the level of the left atrium shows an hypoplastic left pulmonary vein (*)."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000682/000006.jpg?itok=iBlrwT4j",
            "caption": "CT image (pulmonary window settings) shows an irregular pleuro-pulmonary interface with multiple wedge-shaped extensions of the pleura into the lung. Stack viewing of the images at the workstation showed small vessels entering the lung at these locations crossing the pleura."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/682",
    "time": "27.05.2001"
  },
  "690": {
    "case_id": 690,
    "title": "Paget s disease and extramedullary hematopoiesis: A case report",
    "section": "Chest imaging",
    "age": "75",
    "gender": "male",
    "diagnosis": "Paget s disease and extramedullary hematopoiesis",
    "history": "20 year-history of Paget s Disease.Since few weeks cough and fever",
    "image_finding": "A 75 year-old man with a 20 year-history of Paget s Disease, insufficiency of the aortic valve and mild systolic hypertension. Since few weeks cough and fever. No other symptoms or biological alterations were associated.\nThe hemoglobin level was normal as the red and white  blood cell count as well as the serum level of acid phosphatase and calcium.",
    "discussion": "Paget's disease is a progressive bone disease, monostotic or polyostotic, characterized by hypertrophy of affected bones and accelerated disorganized bone remodeling. It results in bone deformities and pain, with a risk for articular and neurological complications, and fractures. Paget s diseases has unknown etiology (probable viral etiology). It occurs predominantly in males and may involve almost any bone of the body (most frequently skull, vertebrae, hip, femur, knee, ribs and shoulder). The risk of complications, and thus the therapeutic decision, are age related. Bisphosphonates are first-line therapy for Paget's disease . The altered architecture of the bone leads to a softening of the bone itself which commonly results in pathologic fractures. These fractures are usually incomplete and may occur without trauma mainly during the lytic phase of the disease. Prolonged weight bearing can produce loss of height of the vertebral bodies or a compression fracture (maily at the thoraco-lumbar spine).\nThe patient performed a CT scan of the lungs for his pulmonary symptoms. CT showed total involvement of the bones of the thorax by Paget s disease. As an additional finding a mass was found in the right paraspinal region next to the bones. The density of the mass revealed fat content. That probably was a locus of extramedullary hematopoiesis, but the diagnosis is largely presumptive because we haven't got the biopsy proof . In fact softening of bone and the occurrence pathologic fractures may result in extrusion of hematopoietic marrow into paraspinal region, later developing into a locus of active extramedullary hematopoiesis.",
    "differential_diagnosis": "Paget, s, disease, and, extramedullary, hematopoiesis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000690/000001.jpg?itok=X0C_1wXb",
            "caption": "complete involvement of chest wall bone"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000690/000002.jpg?itok=3YD8oNey",
            "caption": "Focus of extramedullary hematopoiesis in the right paraspinal space"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000690/000003.jpg?itok=Zi8DIzE8",
            "caption": "the same paravertebral focus of extramedullary hematopoiesis after iniection of contrast media"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/690",
    "time": "16.08.2001"
  },
  "722": {
    "case_id": 722,
    "title": "Yellow nail syndrome",
    "section": "Chest imaging",
    "age": "74",
    "gender": "male",
    "diagnosis": "Yellow nail syndrome",
    "history": "Patient presenting with yellowish discoloured nails in the hands and feet and long-standing respiratory disorders with recurrent bronchitis and pneumonias",
    "image_finding": "This is a previously healthy 74-years-old man who stopped smoking 15 years ago. He noticed a yellow discoloration of his finger nails and toe nails during the past 2 years. At the same time he started to suffer from chronic rhinorrhea and a chronic productive cough. He experienced two episodes of fever that promptly responded to antibiotics. \nPhysical examination :\nPhysical examination was remarkable for a yellow discoloration with trophic changes of the finger nails and the toe nails. Breath sounds were normal. No peripheral edema was noted. \nPulmonary function tests were normal for dynamic and static lung volumes and for CO diffusion capacity. In sputum cultures did not grow acid fast bacilli, Nocardia or Gram-negative bacteria.  \nImaging findings :\nA recent chest X-ray examination performed by the referring physician was of only intermediate quality and showed no pathology. Chest CT (4x2.5 mm collimation, pitch 5, 120 ml contrast media, 2 ml/ sec flow, delay 45 sec, VolumeZoom, Siemens, Erlangen, Germany)  including HR-CT (4x1mm, single slice, 20 mm slice distance) were performed to exclude bronchiectasis as a reason for the recurrent bronchitic episodes. \nCT showed bronchiectasis in the left lower lobe with adjacent patchy consolidations. Mild bronchiectasis and tree-in-bud phenomenon were seen in the lingula. A small consolidation or subsegmental atelectasis was present in the right medial middle lobe.\nNo pleural effusion and no lymphedema were present to date.\nYellow nail syndrome was diagnosed based on the dystrophic changes of the nails and the extensive manifestation of bronchiectasis with consecutive bronchial mucus impaction.",
    "discussion": "Yellow nail syndrome is a rare disorder featuring the classical trias yellow nails, lymphedema, pleural effusion. It was first discribed in 1964 by Samman and White(5). However, first clinical reports without considering it a \"syndrome\" were published much earlier beginning in 1894 (for complete history see Ref. 4).\nRecently a further diagnostic criterium has been added : bronchiectasis (2,4). \nNordkild et. al give an extensive overview over the history and the 97 case reports until 1986. The etiology of the syndrome is still unknown. The diagnosis is justified if 2 of the 4 criteria are fulfilled (4,1). Symptoms may appear not simultaneously but in different order and severity. Yellow nails are the most stable symptom observed in 89% of the patients (4). Most frequent age of presentation is middle or older age. In the present case bronchiectasis and yellow nails were present whereas no pleural effusion or lymphedema were detected. Tree in bud sign represent the imaging manifestation of peripheral bronchial mucus impaction. Moore proximal mucus impaction resulted in small atelectasis. \nClinical course as well as physical examination and imaging findings together suggested Yellow nail syndrome as a reason for the patients complaints. Differential diagnosis would be bronchiectasis of other origin such as chronic endobronchial infection (M. avium etc.). Hence, bronchoscopy did not reveal such clinical condition.",
    "differential_diagnosis": "Yellow, nail, syndrome",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000722/000001.jpg?itok=mHyF6d5-",
            "caption": "fotography of the fingers of the right hand showing dystrophic nails of yellowish color"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000722/000002.jpg?itok=evcZOZHS",
            "caption": "Enlarged View of the nails of the indicating and middle fingers of the right hand"
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000722/000003.jpg?itok=iSzL7SeN",
            "caption": "Fotography showing the dystrophic changes of the nails of the left foot"
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000722/000004.jpg?itok=YSlDBUeQ",
            "caption": "Fotography showing the dystrophic changes of the nails of the right foot"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000722/000005.jpg?itok=R2tAVbMZ",
            "caption": "CT image showing a consolidation  or subsegmental atelectasis in the medial segment of the middle lobe"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000722/000006.jpg?itok=LVnOHFhz",
            "caption": "Enlarged HR-CT image image showing bronchiectasis in the basolateral segment of the left lower lobe and peripheral mucus impaction (\"tree in bud\" sign)"
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000722/000007.jpg?itok=D_q3Wi_t",
            "caption": "MPR showing the bronchiectasis and adjacent consolidation in the left lower lobe as well as a consolidation in the middle lobe"
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000722/000008.jpg?itok=euNL1fPs",
            "caption": "\"Tree in bud\" sign in the lingula"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/722",
    "time": "16.08.2001"
  },
  "724": {
    "case_id": 724,
    "title": "NHL of the pleural cavity",
    "section": "Chest imaging",
    "age": "74",
    "gender": "male",
    "diagnosis": "Non - Hodgkin lymphoma of the pleural cavity",
    "history": "74-years old male showing severe chest pain and dyspnoe, weight loss and low grade fever over the last month.",
    "image_finding": "A 74-year-old male underwent therapeutic pneumothorax for right pulmonary tuberculosis 43 years ago. Few month ago the patient developed severe chest pain and dyspnoe, weight loss and low grade fever. The patient had quit smoking more than 25 years ago. \nConventional X-ray showed a large mass in the right apex. The shape of the pleural interface was indeterminate in a.p. projection due to the overlaying pacemaker device. However, side projection showed clearly the pleural origin of the mass. Computed tomography revealed a large tumor in the posterior aspect of the right upper hemithorax measuring 9 x 6.5 x 7 cm. The tumor showed an extensive pleural involvement. Several coarse calcifications were seen, mostly lining the visceral pleura but also located more centrally in the tumor. Both dorsal upper as well as apical lower lobe of the right lung were affected. The fourth dorsal rib showed a periostal reaction without osteolysis which was interpreted as a sign of beginning chest wall invasion. No lymph node enlagement was seen.",
    "discussion": "The patient had quit smoking more than 25 years ago, however, he was clinically diagnosed of peripheral lung cancer and scheduled for surgery. Diagnosis of a malignant process was made on surgical examination, where the whitish soft lesion presented with invasion of the parietal and visceral pleura. The Tumor was completely resected by upper right lobectomy. The tumor cells were positive for CD45, CD43, CD30 and EBV (EBER), but negative for B, T and NK markers(Figure 3). MIB-1 proliferation fraction was 50% (Figure 3). Sothern blot analysis of the IgH gene showed B-cell clonality and confirmed the diagnosis of pyothorax associated B-cell lymphoma. This type of lymphoma occurs in patients with normal immune system and is characterized by the presence of EBV infection. An EBV-mediated growth promotion together with genetic lesions (including p53 gene) and contribution of inflammatory cytokines are described as possible factors causing malignant transformation (1). A review of literature showed that malignant lymphomas arising in the lung or pleura constituted only about 0.3% of all non-Hodgkin\u2019s lymphoma. A wide range of radiologic presentations of NHL of the lung has been described including ground glass pattern, reticulo-nodular pattern, pulmonary nodules with and without cavitation, pulmonary masses and widespread alveolar consolidations. Primary NHL of the lung can be divided into : 1. BALT lymphomas (B-cell), 2. malignant neoplastic endotheliosis (B-cell), 3. lymphomatoid granulomatosis (T-cell), 4. angioimmunoblastic lymphadenopathy (T-cell). Subpleural lymphomatoid tissue, located just beneath the visceral pleura, is a common presentation of NHL. Shuman et al found pleural and subpleural manifestations of lymphoma in 31% of patients with advanced or recurrent lymphoma (2). CT showed either subpleural nodules or pleural plaques. However, no histopathologic correlation was performed to clearly distinguish the pleural from supleural (pulmonary) form of disease. Pleural and subpleural lymphoma presented as solid lesions without calcifications and cystic changes at initial presentation. Calcifications and areas of necrosis may occur as a result of treatment. However, all this findings were made in patients with advanced disease and involvement of the pleura and subpleural lung was secondary to pulmonary lymphoma or lymphoma of the ribs. There was no case of primary pleural lymphoma in this large series. Primary NHL of the pleural cavity is very rare and has been described in association with a long-standing chronic tuberculous pyothorax. The cases were reported almost exclusively from Japan (3). Case-control studies however suggest that artificial pneumothorax for the treatment of pulmonary tuberculosis or tuberculous pleuritis leading to chronic non-healing inflammation in the pleural cavity may result in a significant increased risk for the development of pleural lymphoma (1, 4). Without these predisposing factors primary pleural lymphoma without other organ involvement is extremely rare. Additional pleural involvement in patients with NHL of the lung is much more common (2). Furthermore, cases of Aids-related primary lymphoma of the pleural cavity have been described(5). Our patient did not reveal any other manifestations of his lymphoma. Bone marrow was not infiltrated.",
    "differential_diagnosis": "Non, -, Hodgkin, lymphoma, of, the, pleural, cavity",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000724/000001.jpg?itok=rNgaAM3N",
            "caption": "Large tumor in the right apex. The caudo-lateral part including the caudal lung-chest wall interface is obscured by a cardiac pacemaker device."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000724/000002.jpg?itok=imfdD1Yq",
            "caption": "Side projection demonstrates the pleural origin of the tumor clearly."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000724/000003.jpg?itok=8nqnKqSe",
            "caption": "Axial CT image showing a large homogeneous tumor with coarse calcifications lining the pleura visceralis and extensive pleural extension."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000724/000004.jpg?itok=u_WWN1MC",
            "caption": "Sagittal MPR showing both subpleural calcifications as well as an intratumoral calcification locatet in the cranial pleural extension of the tumor."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000724/000005.jpg?itok=42jlLw5U",
            "caption": "Microphotograph showing HE, CD43, EBER, CD3, MIB-1 and CD30 staining (see text)"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/724",
    "time": "29.09.2002"
  },
  "725": {
    "case_id": 725,
    "title": "Kartagener's syndrome.",
    "section": "Chest imaging",
    "age": "67",
    "gender": "female",
    "diagnosis": "Kartagener's syndrome.",
    "history": "Situs viscerum inversus. Chronic rhinosinusitis and recurrent bronchitis.",
    "image_finding": "The patient affected by situs viscerum inversus (previously diagnosed) complained of recurrent pulmonary infections and chronic rhinosinusitis. She was referred to our Institute to undergo a high resolution computerized tomography (HRCT) of the chest which revealed  bronchiectasis and a CT study of the sinuses which confirmed local signs of inflammation.",
    "discussion": "Kartagener\u2019s syndrome is a rare autosomal recessive inherited disease characterised by the clinical triad of bronchiectasis, sinusitis and situs viscerum inversus. \nThe pathogenesis of this condition is a defect in ciliary motility, associated with structural abnormalities of cilia; males with this condition tend to be infertile, owing to ineffective mobility of the sperm tail.\nAbout half the patients with defective cilia don't have situs inversus; it is assumed that during early embryonic life ciliary beats determine the type of laterality: when ciliary movements are absent laterality may develop fortuitously, thus effecting a situs inversus in about half the affected cases.\nThe lack of ciliary activity results in impaired mucociliary clearance, predisposing sinuses and bronchi to infection. Bronchiectasis are caused by chronic necrotizing infection of the bronchi leading to abnormal permanent dilatation of these airways. The clinical manifestations consist of cough, fever and expectoration of copious purulent, sometimes bloody sputum. In severe cases obstructive ventilatory insufficiency may occur and leads to marked dyspnea and cyanosis.\nThe HRCT of the chest can demonstrate the dilatation of the airways; these dilatations may produce long, tubelike enlargements (\u201ccylindrical bronchiectasis\u201d) or in other cases may cause saccular(\u201ccystic bronchiectasis) or varicose-like aspect of bronchi (\u201cvaricose bronchiectasis\u201d).",
    "differential_diagnosis": "Kartagener's, syndrome.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000725/000001.jpg?itok=LUWqdV4Y",
            "caption": "Bronchiectasis are evident at the posterior segment of the upper lobe of the right lung (which in patients with situs inversus has the characteristic segmentation of the left lung)."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000725/000002.jpg?itok=XIXg32QK",
            "caption": "In the HRCT section cylindrical bronchiectasis can be seen in addition to centrilobular nodules representing bronchioles distended by secretions."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000725/000003.jpg?itok=yx5RquCk",
            "caption": "Situs inversus of the thoracic structures."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000725/000004.jpg?itok=7LmgTAuA",
            "caption": "Upper abdomen: situs inversus of all the abdominal organs."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000725/000005.jpg?itok=0ibl8iRB",
            "caption": "The maxillary sinuses are replete with soft tissue: it is suggestive for rhinosinusitis."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000725/000006.jpg?itok=2f9b3M-q",
            "caption": "The sphenoidal sinuses also show local signs of inflammation."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT",
      "CT",
      "CT",
      "MR"
    ],
    "link": "https://www.eurorad.org/case/725",
    "time": "09.12.2001"
  },
  "727": {
    "case_id": 727,
    "title": "xtralobar pulmonary sequestration",
    "section": "Chest imaging",
    "age": "33",
    "gender": "male",
    "diagnosis": "extralobar pulmonary sequestration",
    "history": "33 Years old patient (smoker) with progressive pain in the left lateral chest wall. The patient reported similar problems four years ago.",
    "image_finding": "A 33-year-old patient was admitted to the hospital with progressive pain in the left lateral chest wall. He was a smoker (one package a day) until one and a half year ago. The symptoms were augmented by deep breathing and by moving. Four years ago he had similar problems. A CT-scan of the thorax was done four years ago. A paravertebral mass was found above the diaphragm on the left hemithorax, which was suspected to be a lung sequestration. No specific treatment was offered to him. In the last few months the pain was permanently present which required intermittent Paracetamol or Mefenamin Acid treatment. Additionally, the patient suffered from reflux symptoms approximately once a month since several years. X-ray of the thorax and CT were performed. The X-ray showed a paravertebrally and retrocardially located mass on the left side in a. p.- projection. In Side projection no abnormalities were seen. CT (Somatom VolumeZoom, Siemens, Erlangen, Germany, collimation 4x2.5 mm, 120 ml contrast media, 2 ml/sec flow, 55 sec delay), revealed an centrally hypodense lesion in paravertebral location on the left side. Two arties originating from the descending aorta were located : One smaller artery originating ventrally and one larger originating laterally on the left side. Venous drainage was shown to take place via an accessory hemiacygos vein into the left subclavian vein. In lung window settings the extrapleural location of the lung sequestration was evident showing additionally an accessory interlobar fissure seen in the lower lobe. Video-assisted thoracoscopic exploration was performed showing an extralobar lung sequester. There were two arteries originating directly from the descending aorta. These arteries were clipped and the sequestration was completely resected thoracoscopically. The patient was discharged on the fifth postoperative day after an uneventful course. The histopathological assessment showed a lung sequestration without evidence of malignancy.",
    "discussion": "A pulmonary sequestration is a rare acquired (mostly intralobar) or congenital (intralobar or extralobar) abnormality characterized by the presence of pulmonary tissue that does not communicate with the normal tracheo-bronchial tree. Pulmonary sequestrations can be divided into two types : the more common intralobar and the rare extralobar type. Both types of sequesters receive its arterial supply from an anomalous systemic artery, most common from the thoracic aorta or its branches (3). Intralobar sequesters are located within the normal lung and its pleural cover. A pulmonary venous drainage is typical. The most common clinical manifestation is infection. There is no sex predelection. Intralobar sequesters are in 60-70% of cases located on the left side. 98% occur in the lower lobes. They appearance on plain chest radiographs as consolidations. They are have more  often ill-defined margins. Uncomplicated lesions are uniformly dense in chest radiographs. Overlaying infection may cause focal changes in density including fluid-gas levels as a consequence of fistula formation with adjacent bronchi. In CT both intralobar as well as extralobar sequestrations show typically tissue inhomogenity. Extralobar sequesters are located extrapleurally and are characterized by a venous drainage via thoracic or abdominal systemic veins. Atypical types of drainage such as drainage to the portal vein have been reported (4). Extralobar sequestrations are more often associated with other congenital malformations (congenital diaphragmatic hernia, congenital heart disease, etc.) (4). They are mostly diagnosed as incidental findings. Male patients are more often affected (M:F=4:1). They are in 90% of cases located on the left side. Clinical manifestations as a result of recurrent infection (current case) or hemorrhage (1) are less common. Presentation of extralobar sequesters in chest radiography differs from intralobar sequesters by better defined outer marigins and a greater variety in location. They may occur in a variety locations in- and outside the lung such as pericardial space, mediastinum or retroperitoneum. In paramediastinal location they show a well-defined outer margin (due to the pleural cover) and abut the the mediastinum medially such that they are radiographically difficult to differentiate from mediastinal masses (present case). Multiple imaging modalities including chest X-ray, bronchoscopy, CT and MRI was recently proposed for preoperative assessment of pulmonary sequestration (5). However, the present case shows that MDCT alone may provide full diagnostic information necessary for planning surgery. Vascular supply was in the present case correctly assessed by CT. Multiplanar reconstruction may be helpful in demonstration of the vascular supply showing the entire course of anomalous vessels in one secondary image.",
    "differential_diagnosis": "extralobar, pulmonary, sequestration",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000727/000001.jpg?itok=TAfEzfSI",
            "caption": "Chest x-ray in ap projection showing a left-sided, well defined  paraverrebral mass in retrocardial projection. The cranial pleuro-vertrebral interface suggests an extrapleural location of the lesion."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000727/000002.jpg?itok=FDHDDuE7",
            "caption": "Chest X-ray in lateral projection is normal."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000727/000003.jpg?itok=zgpCZUX5",
            "caption": "CT image showing an centrally hypodense lesion in paravertebral location with a supplying artery origiating from the left lateral aspect of the aorta descendens."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000727/000004.jpg?itok=F0OTLAzC",
            "caption": "CT image showing a second supplying arterial vessel originating from the Aorta descendens ventrally."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000727/000005.jpg?itok=Mozy0NWV",
            "caption": "CT image in lung window settings showing the wedge-shaped configuration of the sequester with an accessory interlobar fissure originating from the tip of the sequestration."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000727/000006.jpg?itok=eJ3o82m8",
            "caption": "MIP performed over the entire stack of axial images showing the sequester. Both supplying ateries are seen."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000727/000007.jpg?itok=9UdVOHtl",
            "caption": "MPR showing the complete venous drainage via an accessory hemiacygos vein into the left subclavian vein."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000727/000008.jpg?itok=SwUpFnDF",
            "caption": "Intraoperative view taken during laparoscopic resection showing the diaphragma (1), the collapsed lower lobe of the lung (2), the chest wall (3) and the extralobar pulmonary sequestration."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000727/000009.jpg?itok=jqrwwqmm",
            "caption": "Intraoperative view during laparoscopic resection showing the diaphragma (1), the collapsed lower lobe of the lung (2), the chest wall (3) and the extralobar pulmonary sequestration."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "Digital radiography",
      "CT",
      "CT",
      "MR"
    ],
    "link": "https://www.eurorad.org/case/727",
    "time": "11.11.2001"
  },
  "734": {
    "case_id": 734,
    "title": "Cryptogenic organizing pneumonia (COP)",
    "section": "Chest imaging",
    "age": "53",
    "gender": "female",
    "diagnosis": "Idiopathic cryptogenic organizing pneumonia (COP)",
    "history": "A 53-year-old woman admitted to the hospital with a two-month history of intermittent pyrexia.",
    "image_finding": "A 53-years-old woman, was admitted to the hospital with a two-month history of intermittent pyrexia, malaise and dry cough. She had received repeated courses of antibiotics as outpatient with no clinical improvement. On examination, she was febrile 38.2 oC  with end-inspiratory crackles on auscultation. Haematological and usual biochemistry profiles were normal except from an elevated erythrocyte sedimentation rate (110 mm/h). Serolory for viral agents, blood and sputum cultures, immunological profile and tumor markers were all within normal range. The pulmonary function tests showed a moderate restrictive defect .\nA chest radiograph showed areas of consolidation at the periphery of both middle and lower lung zones (FIG 1). Comparison with previous radiographs showed worsening of radiological abnormalities.HRCT revealed a mixed pattern consisting of bilateral patchy areas of ground glass attenuation and consolidations, in a peripheral and peribronchovascular distribution, in all three lung fields. However the lesions predominated in the middle and lower lung fields. Dilated bronchi were occasionally observed through the consolidations (FIG 2a, 2b). Centrilobular nodules and a few parenchymal bands were also seen almost exclusively in the upper lung fields (FIG 2b). Video-assistant thoracoscopic biopsy of the lung was performed.",
    "discussion": "Idiopathic cryptogenic organizing pneumonia (COP) also known as bronchiolitis obliterans organizing pneumonia (BOOP) is characterised histologically by the presence of plugs of granulation tissue in the lumen of the distal air spaces -respiratory and terminal bronchioles, alveoli and alveolar ducts- associated with a variable degree of interstitial and air space infiltration with mononuclear cells and foamy macrophages. A typical clinical presentation characterised by subacute onset, dry cough, dyspnea, fever and flu-like symptoms occurs in over half of the patients. Although COP is sometimes associated with other pathologic conditions including collagen vascular diseases, ulcerative colitis, tumors, in the majority of patients is idiopathic. Lung function tests typically show a restrictive pattern (1).\nThe most frequent findings on chest radiograph consists of multiple, patchy, bilateral areas of consolidation, which may show spontaneous regression as well as progression on follow up films. The most common HRCT appearance of COP consists of bilateral patchy areas of consolidation or a combination of consolidation and ground glass attenuation in a predominately subpleural and peribronchovascular distribution. Nodules usually occur as part of a mixed pattern (2). Many atypical radiological presentations have been reported including multiple linear (3) or ring shape opacities (4) and multiple large nodules or masses (5).\nAlthough the CT findings of COP are not specific for the disease, a combination of patchy, bilateral areas of ground glass opacities and air space consolidation in a peripheral and peribronchovascular distribution, should arouse the suspicion of COP, in the appropriate clinical settings.",
    "differential_diagnosis": "Idiopathic, cryptogenic, organizing, pneumonia, (COP)",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000734/000001.jpg?itok=hmhfwIxL",
            "caption": "Posteroanterior chest radiograph shows areas of airspace consolidation at the periphery of both middle and lower lung zones."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000734/000002.jpg?itok=gALctGyA",
            "caption": "HRCT at the middle lung fields shows multiple patchy areas of ground-glass attenuation and consolidations in a peripheral and peribronchovascular distribution."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000734/000003.jpg?itok=1Hwonibx",
            "caption": "HRCT at the carina level reveals patchy, peribronchovascular, airspace consolidations intermixed with an area of ground-glass attenuation at the periphery of the anterior segment of the left upper lobe. Some dilated bronchi are seen within the consolidations. Centrilobular nodules and a few parenchymal bands are also seen, particularly on the right."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/734",
    "time": "21.06.2001"
  },
  "740": {
    "case_id": 740,
    "title": "Pulmonary alveolar microlithiasis",
    "section": "Chest imaging",
    "age": "58",
    "gender": "female",
    "diagnosis": "Pulmonary alveolar microlithiasis",
    "history": "A 58 year old female admitted for cholecystectomy. Preoperative chest radiograph was abnormal but no respiratory complaints were referred.",
    "image_finding": "A 58 year old female was admitted for cholecystectomy. The preoperative chest radiograph showed diffuse parenchymal opacification in both middle and lower lung fields and discrete deposits of calcific density at the periphery of lung bases. A zone of increased lucency between the lung parenchyma and the ribs was observed (FIG 1). The patient denied any respiratory symptoms. Pulmonary function tests revealed a mild restrictive defect with reduced total lung capacity. A chest HRCT revealed confluent calcific densities throughout all lung fields, more prominent in the middle and lower ones (FIG 2a, 2b). Discrete calcified micronodules were depicted subpleurally in the less involved upper lung fields as well as multiple, tiny subpleural cysts with a ribbon-like appearance. (FIG 2c).",
    "discussion": "Pulmonary alveolar microlithiasis  is a rare disease characterized by the presence of innumerable tiny calculi, composed of calcium phosphate, within alveolar air-spaces. The aetiology and pathogenesis are unknown. A familial occurrence has been noted in approximately half of the reported cases. The severity of the x-ray imaging is not usually associated with the patients clinical condition which may be without symptoms (1). \nThe radiographic pattern consists of very fine micronodulation involving both lungs, more severe over the lower than the upper zones. Although the opacities often coalesce and a normally exposed chest radiograph shows the lungs uniformly white, individual deposits are usually identifiable. A zone of increased lucency between the lung and the ribs known as \"black pleura line\" has been attributed to subpleural emphysema or a fatty layer in HRCT studies (1,2,3). HRCT also reveals high concentration of microliths in the subpleural parenchyma and along bronchovascular bundles (4).\nThe diagnosis of pulmonary alveolar microlithiasis usually can be made with confidence from the classic radiographic pattern and the striking radiological-clinical dissociation. Microliths can be identified in sputum, bronchoalveolar lavage fluid, and transbronchial biopsy specimens (1).",
    "differential_diagnosis": "Pulmonary, alveolar, microlithiasis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000740/000001.jpg?itok=WNbBZo97",
            "caption": "Posteroanterior chest radiograph shows diffuse parenchymal opacification in both middle and lower lung fields, obscuring the mediastinal and diaphragmatic borders and a reticular pattern in the upper lung fields. Tiny discrete deposits of calcific density are depicted at the periphery of lung bases. A zone of increased lucency between the lung parenchyma and the ribs is also depicted, more prominent on the right (arrows)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000740/000002.jpg?itok=gtcOwfBa",
            "caption": "HRCT in the lower lung fields shows extensive calcific densities replacing almost completely the normally aerated airspaces."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000740/000003.jpg?itok=YoADBVrH",
            "caption": "HRCT in the middle lung fields shows calcific areas of attenuation involving the left lung and to a lesser degree the right. Discrete calcific nodules are seen on the pleural surface."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000740/000004.jpg?itok=sztp8Mgi",
            "caption": "HRCT in the upper lung fields, depicts areas of high attenuation and discrete calcified foci in the ventral aspects of upper lobes bilaterally and subpleurally as well. Multiple subpleural cysts arranged along the mediastinal and costal surface of the pleura are seen."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/740",
    "time": "21.06.2001"
  },
  "757": {
    "case_id": 757,
    "title": "Tracheal rupture during intubation for surgical operation",
    "section": "Chest imaging",
    "age": "50",
    "gender": "male",
    "diagnosis": "Iatrogenic tracheal rupture",
    "history": "This patient was admitted to our hospital for a lombar laminectomy. After surgery, he complained about having retrosternal pain and dyspnea. Physical examination revealed subcutaneous emphysema extended to face, chest and neck. Auscultation evidenced crepitation synchronous with pulse and respiration. Suddenly performed spiral CT showed subcutaneous and mediastinal emphysema and revealed a tracheal rupture.",
    "image_finding": "Iatrogenic tracheal perforation is a rare complication of intubation that occurs when it is performed  without having a visual control of a fiberscope.\nSymptoms and signs involve thoracic pain (80-90% of the patients), sensation of oppression, dyspnea, cough, dysphagia, hemoptysis, inspiratory sounds, subcutaneous emphysema, modification in voice tone. \nThe most frequent complications are edema of the larynx, ulcerations of the pharynx and larynx, oesophago-tracheal fistula, laryngeal or tracheal stenosis, paralysis and synechia of vocal cords, paralysis of the tongue, pneumothorax.\nX-ray, chest CT and fiberscopy are conventional diagnostic steps made in order to perform an accurate diagnosis and to obtain successfull emergency surgery. Spiral CT reveals the rupture of trachea with further possibility to characterize the exact position of the tracheal wall injury. Moreover, involvement of oesophagus and other mediastinal structures are characterized as well as subcutaneous emphysema. Nevertheless, fiberscopy is the present gold standard in order to confirm the diagnosis.\nThe wall injury should be repaired as soon as possible through a right thoracotomy or a collar incision using resolvable sutures. A conservative treatment may be used in case of small lesion. Overall, tracheal injuries prognosis is good.",
    "discussion": "Iatrogenic tracheal rupture",
    "differential_diagnosis": "Iatrogenic, tracheal, rupture",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000757/000001.jpg?itok=95RqIqmO",
            "caption": "Image shows the subcutaneous emphysema at the level of the neck"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000757/000002.jpg?itok=8dpv6RAs",
            "caption": "Mediastinal emphysema and the right posterior tracheal interruption are evident"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/757",
    "time": "11.11.2001"
  },
  "766": {
    "case_id": 766,
    "title": "Mature mediastinal teratom",
    "section": "Chest imaging",
    "age": "27",
    "gender": "female",
    "diagnosis": "Mature mediastinal teratoma",
    "history": "High dorsalgia",
    "image_finding": "The clinical presentation consisted in isolated high dorsalgia, without respiratory discomfort. Blood tests were normal and the tumor markers like beta-HCG and alpha-foetoprotein were not elevated. A front chest radiograph revealed a left paramedian mediastinal mass, sharply outlined by the adjacent lung, containing an ill-defined lucency.\nA chest CT demonstrated a well-defined antero-superior mediastinal mass with attenuation areas consistent with a fat-fluid level.",
    "discussion": "Mature mediastinal teratomas relate to spherical, encapsulated, cystic and multi-loculated tumors, which mostly arise in the anterior mediastinum. Teeth, bone and cartilaginous elements are frequently recognizable. Adjacent mediastinal structures are classically not involved by this benign condition. In 3-8% of cases, these tumors can develop in the posterior mediastinum; pericardiac, intracardiac and esophageal localizations are also described. On histology, mediastinal teratomas typically contain mature cells derived from at least one of the three embryonic layers (1,2).\nIt is postulated that extragonadal mediastinal teratomas arise from dislocated germ cells that are misplaced along midline structures during their migration from the yolk sac endoderm to the gonad during early embryogenesis (1-2). \nThe frequency in male and female is approximately equal; most teratomas are diagnosed between 15 and 30 years old with a median age of 28 years old. Apparent predisposing risk factors for the development of these tumors are the Klinefelter's syndrome and hemopathies (1,2).\nClinical presentation: In 50-60% of cases, this tumor is discovered incidentally on chest radiographs obtained for other reasons. Large tumors may produce dyspnea, chest pain, cough and recurrent respiratory infections. Rarely, pneumothorax, pleural or pericardial effusions, superior vena cava syndrome are reported (1-2). Blood tumor markers (alpha-foetoprotein, beta-HCG) are negative whereas they are positive in other tumors arising from germ cells (yolk sac tumor, choriocarcinoma, embryonal carcinoma). \nRadiographic findings: When sufficiently large, mediastinal teratomas appear on chest radiographs as a well defined space occupying lesion of the anterior mediastinum, round, sometimes lobulated, more commonly on the left side. The tumor margins are sharply outlined against the adjacent lung. Calcifications are identified in 20 to 40% of cases (1-2). They can be present along the cyst walls, in the tumor capsule or in solid tumoral tissue. CT examinations reveal a contrast enhanced well-defined capsule, which circumscribes a heterogeneous mass containing fat, fluid and soft-tissues of intermediate attenuation and frequent calcifications. The fat-fluid level, called the Phemister's line, is highly suggestive if not pathognomonic for the assessment of the diagnosis (1,2). Magnetic resonance may be useful to precise the surgical approach but is not mandatory (3).\nSurgery is the treatment of choice. After complete resection, the prognosis is excellent with a 5 years survival of 100%. Local recurrences from residual tissue are exceptional. Malignant transformation has not been confirmed (1).",
    "differential_diagnosis": "Mature, mediastinal, teratoma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000766/000001.jpg?itok=YeBqZAco",
            "caption": "Front chest radiograph showing a 5cm left anterior mediastinal mass which erases the pulmonary arch."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000766/000002.jpg?itok=ppRJacf_",
            "caption": "Contrast-enhanced chest CT demonstrates a 5,5cm well delineated heterogeneous spherical mass in close contact with the pulmonary trunk. 2a: the tumor is well defined by a capsule. It consists in fat and tissue densities which mean attenuation value is 25 HU."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000766/000003.jpg?itok=2XEzEtbH",
            "caption": "2b :A characteristic fat-fluid level is displayed, which is considered as specific for the diagnosis of mediastinal teratoma."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000766/000004.jpg?itok=7wTbTgte",
            "caption": "Cut section of the surgical specimen  relates to a capsulated unilocular mass containing solid nodules, oily fluid and hairs. Normal thymic parenchyma is recognized on the top of the specimen."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000766/000005.jpg?itok=K6Q_WJx1",
            "caption": "Microscopic close examination shows that  the mature teratoma is composed by cutaneous elements such as stratified squamous keratinized epithelial tissues, hair follicles, sebaceous and sweat glands derivated from the ectoderma, by a pseudostratified ciliated columnar respiratory epithelium (endodermal origin), by smooth muscular tissue and adipose tissue (mesodermal origin)."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000766/000006.jpg?itok=uIxDRi3R",
            "caption": "Microscopic close examination shows that  the mature teratoma is composed by cutaneous elements such as stratified squamous keratinized epithelial tissues, hair follicles, sebaceous and sweat glands derivated from the ectoderma, by a pseudostratified ciliated columnar respiratory epithelium (endodermal origin), by smooth muscular tissue and adipose tissue (mesodermal origin)."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT",
      "MR"
    ],
    "link": "https://www.eurorad.org/case/766",
    "time": "11.11.2001"
  },
  "793": {
    "case_id": 793,
    "title": "Necrotizing sarcoidosis presenting with hemoptysis",
    "section": "Chest imaging",
    "age": "43",
    "gender": "male",
    "diagnosis": "Necrotizing sarcoidosis presenting with hemoptysis",
    "history": "43-year-old non-smoker presenting with acute hemoptysis in the emergency department.",
    "image_finding": "A 43-year-old social worker presented with minor hemoptysis of two months duration. He denied other respiratory symptoms, fever, night sweats or weight loss. Four years ago he had been diagnosed having sarcoidosis with bihilar lymphadenopathy and parenchymal opacification. A Chest X-ray from 1997 showed reticulo-nodular pattern with predominantly perihilar distribution and only faint bihilar lymphadenopathy (Figure 1a). Because of a troublesome cough at that time he had been treated successfully with systemic corticosteroids for a year. The physical examination at the current presentation was unremarkable. Pulmonary function tests and the laboratory findings (hematogram, liver enzymes, calcium) were normal. The actual chest X-ray showed severe bilateral lymphadenopathy and parenchymal opacification, most pronounced in the right upper lobe, where cavitation was suspected. The CT scan of the thorax confirmed cavitation as well as bilateral hilar and mediastinal lymphadenopathy with calcification. HR-CT showed micronoduli with peribronchovasvular distribution. Bronchoscopy revealed no abnormalities. Neither microorganisms nor malignant cells were found in the bronchoalveolar lavage. A systemic corticosteroid therapy was started. Promptly hemoptysis stopped and bilateral opacification decreased.",
    "discussion": "Hemoptysis allows a wide range of differential diagnosis: Infection, including tuberculosis, chronic bronchitis, bronchiectasis and aspergilloma. Vascular disorders including arterio-venous malformations, venous hypertension, pulmonary embolism, bronchial wall injury including foreign body erosion and bronchoscopy / biopsy, tumors including carcinoma and benign tumors. Additionally, rare causes of hemoptysis should be taken into account such as Wegener\u2019s granulomatosis and sarcoidosis. The presence of severe bihilar lymphadenopathy with calcifications, bilateral pulmonary consolidations and the presence of interstitial nodules with peribronchovascular distribution together with the absence of microorganisms and malignant cells in the broncho-alveolar lavage  suggested necrotizing sarcoidosis as the cause of hemoptysis in the present case. Bleeding rarely occurs in sarcoidosis and can present as diffuse alveolar hemorrhage (1, 3) with or without hemoptysis (2-4). Alveolar hemorrhage may occur even in absence of severe pulmonary involvement by sarcoidosis (1) whereas hemoptysis is mostly seen in cases with massive pulmonary fibrosis and cavitation (2-4 ). In these cases bronchopulmonary aspergillosis or aspergilloma may be associated with sarcoidosis and cause hemorrhage (4). No endobronchial aspergillus infection was detected during bronchoscopy / BAL in the present case. Hemoptysis in sarcoidosis is often a sign of end stage disease and may end fatal. In severe cases of hemorrhage bronchial artery embolization or even surgery may be necessary for treatment(5). However, the clinical course in the present case was benign with rapid clinical recovery and improvement of the imaging findings after starting corticosteroid therapy.",
    "differential_diagnosis": "Necrotizing, sarcoidosis, presenting, with, hemoptysis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000793/000001.jpg?itok=lDfusVQ-",
            "caption": "Earliest available chest X-ray from 1997 shows diffuse reticulonodular pattern in both lungs predominating the perihilar regions."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000793/000002.jpg?itok=h7VvXUF4",
            "caption": "Chest X-ray at time of presentation with hemoptysis in November 2000 showing massive bilateral consolidations with perihilar distribution. Cavitation was suspected on the right and later confirmed by CT."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000793/000003.jpg?itok=PYWuBoNm",
            "caption": "Axial CT image in soft tissue window settings showing bihilar lymph nodes and bilateral perihilar consolidations with cavitation on the right side."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000793/000004.jpg?itok=NJfI7cYv",
            "caption": "Axial CT image in same location as 2a in lung window settings confirming cavitation."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000793/000005.jpg?itok=_O2Wbo8-",
            "caption": "Axial CT image in soft tissue window settings at the level of the carina showing calcified subcarinal and hilar lymph nodes"
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000793/000006.jpg?itok=9Bbk-HVU",
            "caption": "HR-CT image at the level of the cavitating consolidation  showing massive perihilar fibrotic changes"
          },
          {
            "number": "Figure 2e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000793/000007.jpg?itok=dMx_s4WD",
            "caption": "Enlarged part of an HR-CT image showing noduli in peribronchovasvular distribution"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000793/000008.jpg?itok=-yrrX5wB",
            "caption": "Maximum intensity showing massive bilateral calcifying lymphadenopathy and parenchymal opacification"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000793/000009.jpg?itok=kmvQvCti",
            "caption": "Chest X-ray after 2 month of systemic corticosteroid therapy showing partial regression of  pulmonary opacification"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "Digital radiography",
      "CT",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/793",
    "time": "19.05.2002"
  },
  "794": {
    "case_id": 794,
    "title": "Pulmonary edema due to aortic valve prosthesis dislocation in endocarditis",
    "section": "Chest imaging",
    "age": "49",
    "gender": "male",
    "diagnosis": "Pulmonary edema due to aortic valve prothesis dislocation in endocarditis",
    "history": "49 years old patient presenting with severe dyspnoea / orthopnoea in the emergency department. Dyspnea and fever over the last 6 weeks were reported.",
    "image_finding": "Dear Reviewer,\n\nplease note that the author has no possibility to make changes in presentation of image numbers. The numbers are assigned automatically. After last revision I wrote a mail containing the same statement to the subject editor. Unfortunately the information was not forwarded to you. Recently I informed the webmaster of Eurorad about the problem and asked him to inform you about the technical restrictions. Unfortunately I did not get an answer. Therefore, I included the message now into the text of the case.\n\nSincerely\n\nauthor\n\n\nA 49-year-old man presented in the emergency department with severe dyspnea / orthopnea. The patient had a mechanical aortic valve prosthesis implanted 2 years ago with the diagnosis of aortic valve insufficiency due to congenital bicuspid valve. A cardiac pacemaker was implanted 1 year ago due to AV-Block II Type Mobitz. \nThe patient showed increasing dyspnea and fever over the last 6 weeks. Increased body temperature was initially subfebrile but increased recently up to septical temperatures. Dyspnea increased suddenly over the last hours.\nChest X-ray, computed tomography (CT) and transesophageal echocardiography (TTE) were performed in the emergency room. The X-ray (Figure 1a)showed severe bilateral alveolar pulmonary consolidations. Furthermore, bilateral pleural effusions were present. The atypical position of the aortic valve prosthesis was overlooked initially. CT showed severe bilateral alveolar consolidations with pleural effusions(Figure 2a-d). Alveolar pulmonary edema was diagnosed. The atypical position of the aortic valve prosthesis was seen in retrospect in the x-ray and acute incomplete dislocation of the prosthesis was supposed. Coronal Maximum Intensity Projection (MIP, Figure 2e) showing the atypical valve position further substantiated the diagnosis.\nTEE (images not shown) revealed an severe paravalvular leck leading to end-diastolic pressure balance between aorta and the left ventricle, massive dilatation of the left ventricle (end diastolic diameter=7.9 cm) and pulmonary hypertension. Ejection fraction was 30% at a heart rate of 130 beats per minute. Peracute cardiac decompensation due to aortic valve prosthesis dislocation was diagnosed and the patient was immediately transferred into the emergency operating room. Severe encdocarditis with abscesses of the annulus was found. Debridement and reconstruction of the annulus were performed and a new mechanical prosthesis was implanted. The postoperative course was uneventful.\nA Chest X-ray 24 hours after surgery showed a complete regression of the edema.",
    "discussion": "Valvular ring abscesses in acute endocarditis have a low, though not insignificant, prevalence (4). Nevertheless, incomplete or complete valve prosthesis dislocation due to such abscesses may complicate the clinical course in patients previously treated with prosthesis implantations (4). Complete prosthesis dislocations to the abdominal aorta were reported and are often fatal (1). However, even in cases of total dislocation single cases of survival were reported (2). Beside dislocation valve fracture may give cause to an identical clinical presentation, also often with fatal outcome (3)\nIn the present case the dislocation was incomplete but a severe paravalvular leck resulted in acute respiratory insufficiency due to alveolar pulmonary edema and pleural effusions. The diagnosis was made based on conventional x-ray of the thorax and CT. CT showed the typical features : perihilar consolidation (\u201cbat wing alveolar edema\u201d), septal thickening and effusion. Bat wing edema is seen in less than 10% of pulmonary edema and generally occurs in rapidly developing cardiac failure (5). The lung periphery is free of interstitial or alveolar edema whereas the perihilar region shows alveolar consolidation. Increased pulmonary capillary wedge pressure of about 12-17 mmHg leads to cephalization of  pulmonary vessels. If the wedge pressure increases further up to 17-20 mmHg Kerley lines occur (5). With increasing pressure of more than 25 mm Hg fluid drainage from the extravascular compartment is at maximum capacity which causes flooding of the alveolar space. These changes occur under chronic conditions first at the subsegmental and segmental levels and migrate centrally. However, under acute conditions the interstitial phase may go undetected radiographically and perihilar alveolar (\u201cbat wing\u201d) consolidation may be the initial presentation (current case). There are several theories which try to explain the pathophysiology of bat wing edema : 1. Changes of extracellular mucopolisacharid matrix occurring under the condition of high hydrostatic pressure may allow the water to be drained easily in central direction. 2. Peripheral respiratory motion may cause better drainage of the peripheral lung  compared to the central parts. 3. Contractile properties of the alveolar septa may facilitate central drainage (5).",
    "differential_diagnosis": "Pulmonary, edema, due, to, aortic, valve, prothesis, dislocation, in, endocarditis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000794/000001.jpg?itok=Dnum03Pb",
            "caption": "The initial chest X-ray showed bilateral perihilar alveolar consolidations and bilateral (right < left) pleural effusions. The atypical position of the valve prothesis showing the full prothesis ring in a.p. projection was initialy overlooked."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000794/000002.jpg?itok=18I9Ar7V",
            "caption": "CT image in lung window setting showing extensive alveolar consolidations at the level of the carina."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000794/000003.jpg?itok=RzyCm7sx",
            "caption": "CT image in soft tissue window settings showing extensive alveolar consolidations."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000794/000004.jpg?itok=s_CnJxV6",
            "caption": "CT image in soft tissue window settings showing perihilar consolidations as well as pleural effusions (right>left)and an enlarged left atrium."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000794/000005.jpg?itok=w3en4yjk",
            "caption": "Coronal multiplanar reconstruction showing an apical predominance of the alveolar edema."
          },
          {
            "number": "Figure 2e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000794/000006.jpg?itok=dqlum7Pg",
            "caption": "Coronal maximum intensity projection showing the cardiac pacemaker and the atypical projection of the displaced ring of the valvular prothesis"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000794/000007.jpg?itok=Vuuu78Z6",
            "caption": "Complete regression of the pulmonary edema 2 days after surgery. The newly implanted aortic valve prothesis is now shown in typical projection."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "Digital radiography",
      "CT",
      "Digital radiography"
    ],
    "link": "https://www.eurorad.org/case/794",
    "time": "16.08.2001"
  },
  "795": {
    "case_id": 795,
    "title": "Intrapulmonary cyst crossed by a dilated pumonary vein",
    "section": "Chest imaging",
    "age": "60",
    "gender": "female",
    "diagnosis": "Slowly growing intrapulmonary  cyst crossed by a dilated pulmonary vein",
    "history": "60-year-old female patient with chest pain presented herself in the emergency department.",
    "image_finding": "A 60-year-old female patient presented with chest pain irradiating into the left arm in the emergency department. Arterial blood pressure was increased (190/130 mm Hg). A chest X-ray was performed showing a cystic lesion of 7 cm diameter in the right lower lobe of the lung. The patient reported that the lesion was first detected 1988. The chest X-ray from 1988 (Figure 1b) showed a cystic lesion measuring 3.1 cm in diameter. A previous X-ray from 1986 (Image 1a) was normal. No severe trauma or pneumonia had taken place in the meantime. Follow-up chest X-ray examinations were done in a 2-3 years interval showing a slow growth of the cyst. The actual X-ray showed a cystic lesion with a thin but well defined border fitting well the imaging characteristics of a lung cyst. In a.p. projection a band-like structure was seen in projection at the upper third of the cyst. In the lateral view, however, no clearly corresponding structure was found. A CT including HR-CT was performed for further lesion characterization. The CT showed a cyst with a centrally located band-like lesion that followed first the medial wall of the cyst (Fig. 2a), turned than cranially and laterally (Figure 2b)passing through the cysts center and following then the cranial wall (Figure 2c). HR-CT images showed that the band-like structure extended beyond the borders of the cyst. Based on the mentioned imaging features the band-like structure was suspected to be a blood vessel or a cord of connective tissue. However, no larger supplying vessel was found. The lesion was examined before (figure 4a) and after (figure 5a)contrast media application and density measurements were performed placing ROI\u00b4s in the supposed vessel, in the lower pulmonary vein and in the descending aorta. Based on the enhancement characteristics the structure could be identified as a dilated blood vessel.",
    "discussion": "A lung cyst is defined as a round space with a well defined wall, usually air-containing without associated pulmonary emphysema. The presentation in X-ray and CT corresponds to this definition. However, the term is usually reserved for enlarged air spaces in end stage fibrotic lung disease, Langerhans cell histiocytosis and lymphangiomyomatosis. None of the typical features of these diseases (multiple cysts) is present here. Intrapulmonary located bronchogenic cysts may also contain air. Bronchogenic cysts are located preferentially in the mediastinum (80%) and are typically fluid filled (1). In 20% they are located inside the lung and may get temporarily or constantly connected to the bronchial tree, which results in drainage of the fluid. The etiology of the presented lesion is difficult to define only from imaging features. An intrapulmonary slowly growing bronchogenic cyst (not visible in 1986 because it was too small) is possible. The imaging features are very similar to an reported case of a bronchogenic cyst containing air which was also crossed by a dilated blood vessel (2). The presence of an intracystic vessels an important diagnostic feature that has to be addressed clearly in the report. Rupture of vessels in air-containing cysts may lead to severe air embolism with fatal outcome (3). Even barotrauma due to pressure changes in a starting or landing air plane may be sufficient to cause rupture of the vessel with consecutive air embolism. Cabin pressure in modern airplanes is maintained at an pressure equivalent of 8000 Ft altitude. Therefore, the cabin pressure drops during the climb of the aircraft to its cruising altitude from 760mm Hg at see level to 560 mm Hg at cruising altitude (4). If the bronchial tree drainage is temporarily closed these pressure changes may cause a cyst rupture. In case of a intracystic vein air embolism may result. The same mechanism may cause barotrauma during diving (5) or during a cable car ascents. In the present case a thoracoscopic resection of the cyst was performed and an intrapulmonary cyst containing a dilated pulmonary vein was histopathologically confirmed.",
    "differential_diagnosis": "Slowly, growing, intrapulmonary, cyst, crossed, by, a, dilated, pulmonary, vein",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000795/000001.jpg?itok=6GEsa9Gj",
            "caption": "Oldest availlable chest X-ray (enlarged view) from 1986 showing no pathologic changes."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000795/000002.jpg?itok=dRkN4YZ8",
            "caption": "Chest X-ray from 1988 (enlarged view) showing a cystic lesion in the right lung measuring 3.2 cm (arrows)."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000795/000003.jpg?itok=7dB_JeDC",
            "caption": "Recent chest X-ray from October 2000(enlarged view)in p.a. projection showing the cyst measuring now 7 cm in diameter. In the upper third of the lesion a band-like structure is seen which was later identified to be an intracystic vessel (arrows)"
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000795/000004.jpg?itok=MrOxs_fM",
            "caption": "Lateral projection (10/2000, enlarged view) showing the cyst located in the apical lower lobe but failing to show the intracystic vessel."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000795/000005.jpg?itok=tPj9WfWc",
            "caption": "Coronal MPR showing the the cyst with the intracystic vessel in medial position"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000795/000006.jpg?itok=tjJaoOa6",
            "caption": "Coronal MPR showing the vessel's course leading cranially and laterally"
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000795/000007.jpg?itok=3GpY7co6",
            "caption": "Sagittal MPR showing the vessel in contact with the top wall of the cyst"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000795/000008.jpg?itok=_jHjQ857",
            "caption": "HR-CT image showing the intracystic vessel crossing the wall of the cyst laterally"
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000795/000009.jpg?itok=lXeGTgpD",
            "caption": "HR-CT image showing the intracystic vessel branching in the medial part"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000795/000010.jpg?itok=7a-6EnqH",
            "caption": "Lower right pulmonary vein and Aorta descendens showing 30-35 HE"
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000795/000011.jpg?itok=AkeU9F8x",
            "caption": "Intracystic vessel showing 45-55 HE"
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000795/000012.jpg?itok=FzHRKG1M",
            "caption": "Lower right pulmonary vein and Aorta descendens showing 110-150 HE"
          },
          {
            "number": "Figure 5b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000795/000013.jpg?itok=k6qz4ZyV",
            "caption": "Intracystic vessel showing 165-177 HE"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "Digital radiography",
      "CT",
      "CT",
      "MR",
      "CT",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/795",
    "time": "09.12.2001"
  },
  "797": {
    "case_id": 797,
    "title": "Chronic pulmonary embolism",
    "section": "Chest imaging",
    "age": "52",
    "gender": "male",
    "diagnosis": "chronic pulmonary embolism",
    "history": "A 52 years old previously healthy patient presented with worsening exertional dyspnea over the preceding year.",
    "image_finding": "A 52-year-old previously healthy patient presented with worsening exertional dyspnea over the preceding year. Chest X-ray was performed by the referring physician and was not conclusive. CT (Siemens VolumeZoom, collimation 4 x 2.5 mm, 140 kV, 120 mAs) showed all signs of severe pulmonary arterial hypertension : enlarged pulmonary artery trunc (3.88 cm !), enlarged right and left pulmonary artery, enlarged right ventricle, horizonal displacement of the interventricular septum and remarkable pericardial effusion.\nThe lumen of the pulmonary artery itself was reduced bilaterally by partially recanalized, partially calcified organized thrombi. CT images in lung window settings showed the typical pattern of mosaic oligaemia with areas of hyper- and hypoattenuation. The vessel diameter was markedly smaller in areas of hypoattenuation.",
    "discussion": "In the present case all classical CT signs (5) of chronic thrombembolic pulmonary hypertension (CTEPH) are present : \n1. partially calcified, partially recanalized organized thrombi lining the pulmonary artery endothelium, \n2. signs of pulmonary hypertension\n3. mosaic oligaemia. \nThe terminus CTEPH suggests that the etiology of the disorder is well known. However, it is still disputable if recurrent pulmonary embolism alone can cause pulmonary hypertension (1). Pulmonary artery thrombosis is proposed to be a more probable mechanism causing CTEPH than recurrent pulmonary embolism (1).\nThe pathophysiology is characterized by a reduction in diameter due to thrombi adhesive to the inner wall of the pulmonary arteries (2). When a diameter reduction of 50% or more is present a severe increase in pulmonary arterial pressure occurs and the patients suffer from exertional dyspnoe. The only available therapy is thromboendarterectomy (PTE) (2). Still ten years ago PTE had a perioperative mortality of more than 20%. Now mortality rates are lower than 10%. PTE is indicated in all patients with central thrombi, even if the periphery is partially occluded. Hence, peripheral involvement makes the operation much more risky. Pulmonary angiography is still the method of choice to assess peripheral pulmonary artery involvement(2,3). Surgery should be performed in a early stage of CTEPH because higher pulmonary artery pressures worsens prognosis. Recently lung or combined heart-lung transplantation became an alternative for treatment of CTEPH (4).\nThe patient was referred to PTE.",
    "differential_diagnosis": "chronic, pulmonary, embolism",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000797/000001.jpg?itok=M7tPG31j",
            "caption": "Axial CT image at the level of the pulmonary artery trunc showing severe enlargement of the pulmonary artery (diameter 3.88 cm). A partially calcified thrombus along the dorsal wall of the left pulmonary artery causes partial obliteration of the vessel."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000797/000002.jpg?itok=iwzZ6MQF",
            "caption": "Axial CT image in a more caudal location showing partial obliteration of the left pulmonary artery trunc in the region of the lower lobe artery origin"
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000797/000003.jpg?itok=Xr2hP97R",
            "caption": "Axial CT image at the level of the right ventricle showing an enlarged right ventricle and horizontal interventricular septum as indirect signs of severe pulmonary artery hypertension. Note also the pericardial effusion as a further indirect sign of increased pulmonary artery pressure."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000797/000004.jpg?itok=In6srgl5",
            "caption": "Sagittal MPR showing the organized, partially recanalized and partially calcified thrombus lining the endothelium of the left pulmonary artery"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000797/000005.jpg?itok=2kfQ4976",
            "caption": "Axial CT images showing the typical pattern of mosaic oligaemia (=mosaic perfusion) in chronic pulmonary embolism. The \"normal\" areas are hyperdense (=normally perfused)in contrast to the hypoperfused (alterated by thrombi and secondary vessel wall fibrosis) areas. Note the typical smaller lumen of the pulmonary arteries in the hypoperfused regions of the lung."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT",
      "CT",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/797",
    "time": "09.10.2001"
  },
  "800": {
    "case_id": 800,
    "title": "Pulmonary hypertension and interstitial lung disease in systemic sclerosis",
    "section": "Chest imaging",
    "age": "60",
    "gender": "male",
    "diagnosis": "pulmonary hypertension and interstitial lung fibrosis in systemic sclerosis",
    "history": "A 60 years old patient presented in the outpatient department with worsening of a exertional dyspnoe.",
    "image_finding": "A 60-year-old patient presented himself to the outpatient department with exertional dyspnea . His everyday activities were actually limited by worsening dyspnea. The patient had a known systemic sclerosis, which caused only moderate symptoms. Pulmonary function tests showed a slight restrictive ventilation disorder and a severe reduction of diffusion capacity. CT and HR-CT were performed. Multidetector computed tomography (MD-CT) was performed in spiral mode in addition to a high-resolution CT. Imaging showed all signs of pulmonary artery hypertension, including small peripheral pulmonary arteries in contrast to large central arteries, enlarged right ventricle and atrium, pericardial effusion, and horizontally displaced interventricular septum. Vena cava and hepatic veins were enlarged due to right-heart insufficiency. Several enlarged mediastinal lymph nodes were present (Figure 1a). Apical HR-CT images showed only minor pathologic changes: Faint, peripherally located inter- and intralobular septal thickening was present. The same changes were detected in the lower lobes to a much greater degree, causing traction bronchiectasis and ground-glass opacities. The esophagus was dilated and fluid-filled as a consequence of typical organ involvement.",
    "discussion": "Systemic sclerosis is characterized by induration of the skin, Reynaud's phenomenon (in 80-90%), and musculoskeletal and visceral manifestations. The current patient shows the typical signs of lung involvement in systemic sclerosis. Pulmonary involvement is present in 70-90% of cases (2) and is now the major cause of death (1). Fibrotic changes occur predominantly in the lower lobes and are typically peripherally located. HR-CT findings include 1. ground glass opacification, 2. fine reticular pattern through to honeycombing, 3. lines of various types (septal, subseptal long parenchymal lines) and 4. subpleural and intralobular micronodulation (1). The intralobular thickening may reach the point that it causes ground-glass opacity. Pneumonia is a recognized complication of systemic sclerosis. It may be due to aspiration in cases of severe esophageal dysmotility. However, most authors consider that aspiration does not play a significant role in pathogenesis pulmonary fibrosis. Historically, the fibrosing alveolitis associated with systemic sclerosis was considered the same as cryptogenic fibrosing alveolitis. However, the much better prognosis of fibrosing alveolitis in systemic sclerosis compared to cryptogenic pulmonary fibrosis suggests a different pathogenesis (5). Exertional dyspnea is present in as much as 60% of patients with systemic sclerosis and is due to pulmonary hypertension (3). Pulmonary hypertension in systemic sclerosis, in contrast to pulmonary hypertension in other fibrosing lung diseases, is not strictly coupled to the grade of fibrosis. Both may develop independently. Its presence may be signaled by an isolated decrease in diffusing capacity. Pulmonary lymphadenopathy is present in 32-60% of cases (present case) (4).Findings in systemic sclerosis can be summarized as follows : 1. severe pulmonary hypertension (enlarged pulmonary artery, enlarged right ventricle, horizontal dislocation of the Septum interventriculare, pericardial effusion), 2. signs of basal / peripheral, slowly progressing  pulmonary fibrosis, often presenting as ground glass attenuation and intralobular septal thickening, 3. lymphadenopathy in 32-60%, 4. signs of esophageal dysmotility including widening of the esophagus and secondary aspiration pneumonias.",
    "differential_diagnosis": "pulmonary, hypertension, and, interstitial, lung, fibrosis, in, systemic, sclerosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000800/000001.jpg?itok=-32UviXc",
            "caption": "Post-contrast CT image showing slightly enlarged  right hilar and subcarinal lymph nodes."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000800/000002.jpg?itok=vSJ1b7tP",
            "caption": "Post-contrast CT image showing an enlarged pulmonary artery trunc as well as enlarged right and left pulmonary arteries"
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000800/000003.jpg?itok=Ymz4aLqI",
            "caption": "Post-contrast CT image shows an widened right atrium and ventricle and a pericardial effusion. A pleural effusion is seen on the right side."
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000800/000004.jpg?itok=Gub_iaf3",
            "caption": "Post-contrast CT image shows an enlarged right atrium and ventricle and a pericardial effusion. Note the horizontal displacement of the interventricular septum."
          },
          {
            "number": "Figure 1e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000800/000005.jpg?itok=p-0aTK45",
            "caption": "Contrast media regurgitation into the enlarged hepatic veins occurs due to right heart insufficiecy in cor pulmonale. Ascitis is present as a sign of chronic congestion."
          },
          {
            "number": "Figure 1f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000800/000006.jpg?itok=1vOGaQjI",
            "caption": "Coronal multiplanar reconstruction shows the enlarged right pulmonary artery as well as the the enlarged right atrium."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000800/000007.jpg?itok=NKjShDN4",
            "caption": "HR-CT image of the left upper lobe showing only faint subpleural intralobular and interlobular interstitial thickening."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000800/000008.jpg?itok=NU8RjXfI",
            "caption": "HR-CT image of the left upper lobe/lingula and apical lower lobe at the level of the carina showing subpleural intralobular and interlobular interstitial thickening as well as areas of ground glass opacity. Several small subpleural cysts (honeycombing) are seen."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000800/000009.jpg?itok=KjqBBiVQ",
            "caption": "HR-CT image at the level below the carina showing subpleural intralobular and interlobular interstitial thickening as well as areas of ground glass opacity. Several small subpleural cysts (honeycombing) are seen."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000800/000010.jpg?itok=u3uirXV7",
            "caption": "HR-CT image showing subpleural fibrosis in the lower lobe and inferior lingula segment on the left. Note the traction bronchiectasis in the lingula."
          },
          {
            "number": "Figure 2e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000800/000011.jpg?itok=H-5fzANB",
            "caption": "HR-CT image at the base of the left lung showing extensive fibrosis with subpleural predominance. Traction bronchiectasis are seen."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000800/000012.jpg?itok=wGBflOPO",
            "caption": "HR-CT image showing only faint subpleural intralobular and interlobular interstitial thickening in the right upper lobe."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000800/000013.jpg?itok=H0XXDvGz",
            "caption": "HR-CT image showing increasing subpleural intralobular and interlobular interstitial thickening in a slice located more caudally than 3a."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000800/000014.jpg?itok=ci3S0M5k",
            "caption": "HR-CT image of the left lung at the level of the carina showing intralobular and interlobular interstitial thickening as well as areas of ground glass opacity."
          },
          {
            "number": "Figure 3d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000800/000015.jpg?itok=wAw8-4ma",
            "caption": "HR-CT image of the lower lobe / middle lobe showing extensive intralobular interstitial thickening together with areas of ground glass opacity the lateral middle lobe and lower lobe with peripheral predominance."
          },
          {
            "number": "Figure 3e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000800/000016.jpg?itok=o2M9DO7o",
            "caption": "HR-CT image showing extensive fibrosis at the base of the right lung. Extensive intralobular thickening and bronchiectasis are seen. Only some small subpleural cysts (honeycombing) are detectable."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT",
      "CT",
      "CT",
      "MR"
    ],
    "link": "https://www.eurorad.org/case/800",
    "time": "09.10.2001"
  },
  "806": {
    "case_id": 806,
    "title": "Constrictive calcified pericarditis",
    "section": "Chest imaging",
    "age": "69",
    "gender": "female",
    "diagnosis": "Constrictive calcified pericarditis",
    "history": "Female 69-year old patient with a systolic heart rumor over the pulmonary valve.",
    "image_finding": "The patient was admitted for a change of the tip of her pacemaker, which was implanted because of bradycardia after ablation of an accessory conduction pathway in 1992. Family history revealed that the patient\u00b4s mother had died in the age of 43 because of non-ischemic heart disease. Clinical examination showed a systolic heart rumor over the pulmonary heart valve. Pre-interventional chest x-ray shows calcifications following the contour of the heart on the bottom of the right ventricle in the postero-anterior view and retrosternal in the lateral view. Echocardiography showed an enlarged left atrium and a thickened, partially calcified pericardium.",
    "discussion": "These imaging findings are typical for a calcified pericarditis, a clinical entity today mainly of idiopathic origin. Other causes are tuberculosis, viral infection, collagenosis, uremia, neoplasms and secondary to previous closed chest trauma, heart surgery and radiation therapy of the mediastinum. Scary adhesions of the pericardium and additional calcifications disturb diastolic relaxation as well as systolic contraction of the right heart and therefore cause elevated mean right-atrial and pulmonary wedge pressures. Possible symptoms include dyspnea, chest pain, fatigue and peripheral edema. Diagnosis is usually based on the finding of calcifications of the pericardium in chest x-ray or computed tomography (approximately one third to one-half of cases demonstrate calcifications), hemodynamical relevance is then evaluated by echocardiography.  The characteristic site of pericardial calcifications is over the right-sided cardiac chambers and in the atrioventricular grooves. A calcified former left ventricular aneurysm is the only radiological differential diagnosis, mainly presenting with calcifications in the apex of the left ventricle. Oral steroids have been reported to improve the clinical situation but the definitive form of therapy is pericardial stripping.",
    "differential_diagnosis": "Constrictive, calcified, pericarditis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000806/000001.jpg?itok=UIA1fJQG",
            "caption": "Pre-interventional chest x-ray shows calcifications following the contour of the heart over the bottom of the right ventricle. Typical projection of an unipolar pacemaker with its tip in the right ventricle (postero-anterior view)."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000806/000002.jpg?itok=J9dshjXK",
            "caption": "Calcifications over the bottom of the right ventricle and the anterior wall (retrosternal). Note: additional calcification of the mitral annulus (lateral view)."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/806",
    "time": "27.05.2001"
  },
  "813": {
    "case_id": 813,
    "title": "Intramural hematoma of the aortic wall due to blunt chest traum",
    "section": "Chest imaging",
    "age": "47",
    "gender": "male",
    "diagnosis": "Intramural hematoma of the aorta due to blunt chest trauma",
    "history": "An 47 years unconscious patient was admitted to the emergency department after suffering from blunt trauma in a car crash.",
    "image_finding": "A 47-year-old unconscious patient was referred to the hospitals emergency department after being involved in a high-speed car crash. X-ray of the pelvis showed a pelvic fracture. Chest X-ray performed in the emergency room showed a lung contusion and multiple rib fractures on the right side. No mediastinal pathology was seen. CT of the neurocranium revealed a small subarachnoidal hemorrhage. Transesophageal echocardiography showed an semicircular intramural hematoma of the left aortic wall at the origin of the left subclavian artery. Multislice helical CT (collimation 4 x 2.5 mm; pitch 1.25) confirmed the lung contusion on the right side and the rib fractures. In addition the semicircular intramural hematoma in the left lateral aortic wall at the origin of the left subclavian artery was visible. Sagittal and coronal multiplanar reformations demonstrated the band-like extension of the hematoma along the left lateral aortic wall of the aortic arch in caudal direction and along the proximal subclavian artery in cranial direction. To prevent further dissection an aortic stent graft was implanted 2 days after initial diagnosis of the intramural hematoma.",
    "discussion": "Traumatic aortic injury is a devastating and potentially lethal condition that should be diagnosed and treated immediately. Both CT as well as transesophageal echocardiography (TEE) have high sensitivity and specificity in diagnosis of traumatic aortic dissection. TEE shows even better results than angiography, which misses most minor (but potentially lethal) vessel wall injury. TEE has a sensitivity of 97% and a specificity of 100%, whereas angiography has a sensitivity of 83% and a specificity of 100% (1). Angiography fails to demonstrate minor changes like intramural hematoma and limited intimal flaps (1). CT-Angiography with single channel CT was reported to reach a sensitivity of 100% (3), and having a negative predictive value of 100% (2,3). However, gold standard for CT evaluation was angiography (1,3) with its known difficulties in detection of minor injury. Furthermore, all CT studies were performed prior to introduction of multislice helical CT into the clinical routine. Multiplanar reformations based on isotropic data sets are a powerful tool for diagnosis of even minor vessel injuries. Studies comparing the highly sensitive transesophageal echocardiography with multislice helical CT are still missing. Multislice helical CT may have good chances to reach the same sensitivity and specificity as TEE for the detection of even minor injuries of the thoracic aorta. In addition, multislice helical CT is providing additional information about pulmonary, mediastinal and upper abdominal injury. In the current case traumatic intramural hematoma in typical location was diagnosed by TEE and later seen in multislice CT. Clinical value of detection of minor aortic injury is still under investigation. Vilacosta et al. (4) could demonstrate that traumatic intramural hematoma resolved sponaneously in 3 of 6 patients. The other 3 patients died from multiorgan system failure and not from aortic rupture or dissection. A suitable therapeutic approach has to be established yet. In this case, the patient was treated by implantation of a aortic stent graft.",
    "differential_diagnosis": "Intramural, hematoma, of, the, aorta, due, to, blunt, chest, trauma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000813/000001.jpg?itok=cXH4lxIk",
            "caption": "Axial CT images showing a small hypodensity in the left wall of the aortic arch. The finding represents an intramural hematoma."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000813/000002.jpg?itok=ncxR_mNZ",
            "caption": "Axial CT images showing a small hypodensity in the left wall of the aortic arch. The finding represents an intramural hematoma."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000813/000003.jpg?itok=4Sao2Yp8",
            "caption": "Axial CT images showing a small hypodensity in the left wall of the aortic arch. The finding represents an intramural hematoma."
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000813/000004.jpg?itok=R7khmode",
            "caption": "Axial CT images showing a small hypodensity in the left wall of the aortic arch. The finding represents an intramural hematoma."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000813/000005.jpg?itok=NJ6Gn6rJ",
            "caption": "Coronal MPR showing the hematoma in the left aortic wall extending cranially in to the origin of the left subclavian artery"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000813/000006.jpg?itok=Nzxt9yy3",
            "caption": "The upper part of the hematoma which is located at the origin of the left subclavian artery is much better seen in sagittal multiplanar reconstruction."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000813/000007.jpg?itok=4RQDg5_1",
            "caption": "Enlarged coronal MPR image ot the origin of the left sublavian artery showing the hematoma extending along the left subclavian artery"
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000813/000008.jpg?itok=9lxGQO1c",
            "caption": "Enlarged sagittal MPR image of the origin of the left sublavian artery."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000813/000009.jpg?itok=NWUvztm9",
            "caption": "Dorsally of the origin of the left subclavian artery the hematoma involves the left aortic wall in the half of its circumference. The intimal tear was suspected in the lower part near to the insertion point of the Lig. arteriosum. However, this finding was not verified by any gold standard. echocardiography suspects the tear in be located equally."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000813/000010.jpg?itok=3tBJxwUo",
            "caption": "Video image taken in 90\u00b0 position showing the intramural hematoma (arrows)."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000813/000011.jpg?itok=Xo2lPmin",
            "caption": "Video images taken in 90\u00b0 (horizontal) position showing the intramural hematoma (arrows). Note the excellent depiction of the intimal flap."
          },
          {
            "number": "Figure 4c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000813/000012.jpg?itok=JcMfZjio",
            "caption": "Video images showing the hypothetic location of the intimal tear (arrow). This image corresponds well to image 3c (multiplanar reconstruction)."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT",
      "CT",
      "CT",
      "MR"
    ],
    "link": "https://www.eurorad.org/case/813",
    "time": "24.07.2001"
  },
  "816": {
    "case_id": 816,
    "title": "Cryptogenic organizing pneumonia (COP)",
    "section": "Chest imaging",
    "age": "60",
    "gender": "female",
    "diagnosis": "Cryptogenic organising pneumonia",
    "history": "A 60 years old patient complained of recent cough and fever. The chest X-ray showed an area of consolidation and she received antibiotics. Because no clinical improvement was observed, a new chest X-ray and a high resolution CT were performed two weeks later.",
    "image_finding": "The patient complained of recent cough and malaise. She also worried about nocturnal sweat and asthenia. She was febrile 38\u00b05, had crackles at auscultation of lung bases and an elevated erythrocyte sedimentation rate (90mm 1st hour). A chest X-ray was performed and showed an area of consolidation in the left lung (figure 1). A bacterial pneumonia was suspected and she received antibiotics without clinical improvement.\nA control chest X-ray was performed two weeks later (figure 2) and persistence of abnormal findings led to carry out a high resolution CT (images 3a, 3b).",
    "discussion": "Cryptogenic organizing pneumonia (COP)\nCOP is characterised by the presence of granulation tissue and macrophagic infiltrates in bronchiolar lumen and surrounding alveoli (1). The term of BOOP often used is misleading since in this process, clinical, functional and radiological findings are more the consequences of pulmonary than bronchiolar involvement. Usually no cause is identified although several conditions including medications, bacteria, radiation therapy and collagen vascular diseases have been shown associated with histologic features of COP.\nThe clinical typical  history is often suggestive: a flue-like syndrome lasting several weeks or months with dry cough, fever, fatigue and progressive dyspnea. Antibiotics are often given without success, but symptoms and radiological findings resolve dramatically under cortisteroid therapy (2)\nOn chest X-ray, uni or bilateral multifocal subpleural consolidations predominant usually in the lower lobes are present in 2 third of patients. Migratory infiltrates as shown in our case are also very suggestive. Other features include diffuse lung disease and solitary pulmonary nodule.\nHRCT findings have been reported in several series. Multiple areas of consolidation and / or groundglass opacities showing a peripheral or subpleural localisation and a peribronchial distribution are the most common. Pulmonary nodules are frequently present in patients with various types of immunosupression (3). Atypical radiological presentations have been reported including linear opacities and large nodules and masses (4,5)\n\nComplete regression is obtained with corticosteroid therapy in a large majority of cases. When clinical and imaging findings are strongly suggestive, a rapid resolution of clinical and CT findings following corticotherapy is sufficient and lung biopsy is not performed. However, recurrence may occur under a threshold when the patient undergoes a progressive decrease of corticosteroid dose. In less than 10% of the patients, the prognosis is worse and criteria of unfavourable evolution have been identified. They include rapid onset of the disease, interstitial lung infiltrates, a low rate of lymphocytes at bronchioalveolar lavage and histologic associated pattern of UIP (2).",
    "differential_diagnosis": "Cryptogenic, organising, pneumonia",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000816/000001.jpg?itok=VZ-l730N",
            "caption": "Chest X-ray showing a large area of ill defined consolidation of the left lung"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000816/000002.jpg?itok=oxMhE1W3",
            "caption": "Chest X-ray performed 2 weeks later showing areas of consolidation of the right upper lobe and of the left lower lobe whereas left upper lung abnormalities have cleared up."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000816/000003.jpg?itok=r6jmcyz9",
            "caption": "High resolution CT performed 24 hours after the chest X-ray showing areas of consolidation in the right upper lobe, upper segments of the right and left lower lobes. Areas of consolidation are located at the lung periphery and surrounded by groundglass opacities and dilated bronchi. A large area of groundglass attenuation is also seen in the left upper lobe."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000816/000004.jpg?itok=E4CCkKPk",
            "caption": "High resolution CT performed 24 hours after the chest X-ray showing areas of consolidation in the right upper lobe, upper segments of the right and left lower lobes. Areas of consolidation are located at the lung periphery and surrounded by groundglass opacities and dilated bronchi. A large area of groundglass attenuation is also seen in the left upper lobe."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT",
      "MR"
    ],
    "link": "https://www.eurorad.org/case/816",
    "time": "09.12.2001"
  },
  "822": {
    "case_id": 822,
    "title": "Thymic Cyst",
    "section": "Chest imaging",
    "age": "72",
    "gender": "male",
    "diagnosis": "Thymic cyst",
    "history": "A 72-year-old patient was referred to the hospital\u2019s outpatient department for evaluation worsening dyspnea.",
    "image_finding": "A 72-year-old patient was referred to the hospital\u2019s outpatient department for evaluation of a long-standing, slowly growing mediastinal mass occluding the left contour of the heart, pulmonary hilum and aortic arch. The patient had no history of previous thoracic surgery, radiation therapy or chemotherapy of a malignant tumor. The mass was evaluated with CT several years ago showing its cystic nature and was diagnosed as a pericardial cyst. The cyst was slowly growing. The patient developed worsening dyspnea during the last 11/2 years. Actually, the patient was referred to evaluate the possibility of surgical treatment. Because the last CT was performed several years ago and did not meet the current quality standards an MD-CT was performed (4x2.5 mm, 12.5 mm, 120 ml non-ionic contrast media with 370 mg/ml iodine i.v., 30 sec scan delay). CT showed a simple cyst occupying with its upper part the anterior mediastinum and with its lower part the left paracardial space displacing the left lung but not reaching the cardiophrenic angle. The cyst was not clearly separable from the pericardium. The density amounted 15-17 HE. No solid parts were seen. Conclusive diagnosis based only on CT criteria was not possible. Pericardial cyst, thymic cyst and lymphangioma have been discussed as differential diagnoses. The fact that the cyst was growing slowly and the possible impact on dyspnea due to lung compression where the reasons for thoracoscopic removal. Histopathologic assessment showed a benign thymic cyst.",
    "discussion": "Cystic lesions in the anterior mediastinum may be pericardial cyst, thymic cyst, or lymphangioma. Differential diagnosis based only on imaging techniques is often not effective. All three may have varying densities on CT ranging from water to low soft tissue density. In case of larger cysts the location don\u2019t serve as a useful criteria because the cyst may cover a range where all three kinds of cyst may occur with equal frequency. However, the fact that the cyst in the current case did not reach the cardiophrenic angle made a pericardial cyst less likely. On the other hand, growth along the pericardial reflection was more typical for a thymic cyst. Thymic cysts may be a part of cystic tumors such as cystic thymoma or thymic seminoma. They have been also reported in Hodgkin disease involving the thymus. Even when radiotherapy eradicates the tumor the cystic part may remain unchanged. In some cases the cysts may develop after irradiation of the mediastinum or chemotherapy and at least some of them are benign(1). Most of tumor-associated cysts are multiloculated (2). Hydatid cysts may occasionally present as thymic cysts (3). Multilocular thymic cysts with follicular lymphoid hyperplasia are found in HIV positive adults (4) and in 1 % of HIV positive newborn (5). MRI may provide useful additional information in order to differentiate real cysts from cystization of masses. \nIn conclusion, the clearly cystic nature of the mass, its location and growth pattern along the pericardial reflection without occlusion of the cardiophrenic angle, the very slow growth over several years and the absence of any history of tumor or tumor treatment make the diagnosis of a thymic cyst most likely.",
    "differential_diagnosis": "Thymic, cyst",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000822/000001.jpg?itok=mgXTMNpV",
            "caption": "Axial CT image showing a left-sided cystic lesion in the anterior mediastinum"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000822/000002.jpg?itok=qGwgvE68",
            "caption": "spiral, multidetectorAxial CT image showing a left-sided cystic lesion in the anterior mediastinum"
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000822/000003.jpg?itok=l2nInsB_",
            "caption": "Axial CT image showing a left-sided cystic lesion in the anterior mediastinum"
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000822/000004.jpg?itok=kCccZVZ6",
            "caption": "Axial CT image showing the cyst extending caudally along the left ventricle"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000822/000005.jpg?itok=xwC1Oq4f",
            "caption": "Coronal MPR showing the extension of the cyst from the upper mediastinum to the left paracardial space. The left costophrenic angle is not reached. The high density rim adjacent to the left lateral wall of the cyst represents dystelectatic lung in the left upper lobe."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000822/000006.jpg?itok=6CWEDU2G",
            "caption": "Coronal MPR showing the extension of the cyst from the upper mediastinum to the left paracardial space. The left costophrenic angle is not reached"
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000822/000007.jpg?itok=J9ijqK45",
            "caption": "Sagittal MPR showing the extension of the cyst in the upper anterior mediastinum"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/822",
    "time": "26.11.2001"
  },
  "827": {
    "case_id": 827,
    "title": "Subacute extrinsic allergic alveolitis",
    "section": "Chest imaging",
    "age": "24",
    "gender": "female",
    "diagnosis": "Subacute extrinsic allergic alveolitis",
    "history": "A 24-year-old sportive women showed exertional dyspnea beginning 2 month ago. Before that the patient was completely healthy and was an active mountain biker.",
    "image_finding": "A 24-year-old athletic women showed exertional dyspnea that had set in 2 months previously. Before the onset of these complaints she was a completely healthy and an active mountain biker, working in a bank during the week. In fact, she suffered from dyspnea even when at rest. CT showed disseminated ground-glass opacities in centrilobular distribution. No septal thickening was present. There were no CT signs of increased pulmonary arterial pressure, nor were there any signs of lung fibrosis.",
    "discussion": "Extrinsic allergic alveolitis is an allergic reaction of the terminal airways to repeated exposure to an airborne antigen. A large number of causal antigens have been identified including microorganisms (fungi, bacteria, etc) and animal and plant proteins, etc. Several termini have been defined corresponding to the related antigens and situations of exposure (maltworker\u2019s lung, birdbreader\u2019s lung, farmer\u2019s lung, mushroom worker\u2019s lung, salami workers lung etc.). Histopathologically the changes are classified into acute, subacute and chronic. Acute illness develops 4-8 hours after antigen exposure and consists of dry cough, chest tightness, dyspnea, wheeze, fever, chills, malaise, myalgia, and occasionally hemoptysis (1). After removal of the agent substantial improvement is seen in 1-2 days, complete recovery in 7-10 days. The subacute form is histopathologically characterized by the occurrence of non-caseating histiocytic granulomas and presents itself clinically as acute episodes superimposed by deteriorating respiratory function. If antigen exposure persists over a long time the illness may progress to a chronic phase in which the granulomas disappear and fibrotic changes occur. HR-CT findings in extrinsic allergic alveolitis include 1. centrilobular nodules representing cellular infiltrations and/or small granulomas within the alveolar septa (current case) 2. air-space consolidation or ground glass opacities (GGO) representing severe cellular infiltration and / or intra-alveolar histiocytes  3. mosaic perfusion due to shunting blood away from poorly ventilated areas 4. air trapping due to obstructive bronchiolitis  5. mixed opacities (GGO, air trapping, mosaic perfusion = \u201cheadcheese sign\u201d  and  6. Fibrosis with irregular linear opacities, honeycombing and traction bronchiectasis (chronic stage) (2). CT in the current case shows typical findings for acute / subacute stage presenting with ill-defined centrilobular nodules with even distribution in both lungs. There are no signs of fibrosis and no consolidations. In both lower lobes are several secondary lobules with reduced density probably corresponding to faint air trapping (Figure 1a, 2a-b). The identification of the antigen and prevention of further exposure is the most important task in clinical management (3). The patient was questioned about possible antigen exposure (birds, mold etc) but no obvious antigen was identified. However, two short absences from her home gave substantial relief from her complaints. In a further interview a 20-year-old mattress upholstered in natural silk was found to contain the antigen. The removal of the mattress provided relief from the symptoms within several days. Patients who present with HP are a minority of those exposed and do not have apparent increased exposure to the offending agent, compared with exposed, but not ill individuals. Although one environmental factor (i.e., patients with HP smoke less frequently than exposed subjects without disease) has been identified (4), it is clear that genetic differences between individuals must be very important in determining the outcome of exposure (sensitization \u00b1 clinical illness). Recent advances in molecular biology techniques allow to measure differences between individuals that may be important in determining susceptibility (5).",
    "differential_diagnosis": "Subacute, extrinsic, allergic, alveolitis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000827/000001.jpg?itok=Wak_9q_U",
            "caption": "Enlarged axial HRCT images of the right lower lobe showing patchy centrilobular ground glass opacities. Note several secondary lobules with reduced density probably representing areas of air trapping."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000827/000002.jpg?itok=sKbvq6H7",
            "caption": "Axial HRCT images of the right side showing centrilobular ground glass opacities with even distribution over the whole lung"
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000827/000003.jpg?itok=okgYcyEC",
            "caption": "Axial HRCT images of the right side showing centrilobular ground glass opacities with even distribution over the whole lung"
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000827/000004.jpg?itok=M-VxBCE_",
            "caption": "Axial HRCT images of the right side showing centrilobular ground glass opacities with even distribution over the whole lung"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000827/000005.jpg?itok=Yu7iuKXB",
            "caption": "Axial HRCT images of the left side showing centrilobular ground glass opacities with even distribution over the whole lung.  Note several secondary lobules with reduced density probably representing areas of air trapping."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000827/000006.jpg?itok=5e97KPjz",
            "caption": "Axial HRCT images of the left side showing centrilobular ground glass opacities with even distribution over the whole lung"
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000827/000007.jpg?itok=nDc9pRxu",
            "caption": "Axial HRCT images of the left side showing centrilobular ground glass opacities with even distribution over the whole lung"
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000827/000008.jpg?itok=M03y5lDl",
            "caption": "Axial HRCT images of the left side showing centrilobular ground glass opacities with even distribution over the whole lung"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000827/000009.jpg?itok=aeBLIRYP",
            "caption": "Coronal reconstruction in lung window settings showing the involvement of both lungs"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT",
      "CT",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/827",
    "time": "16.08.2001"
  },
  "881": {
    "case_id": 881,
    "title": "Mediastinal Extramedullary Hematopoiesis",
    "section": "Chest imaging",
    "age": "32",
    "gender": "male",
    "diagnosis": "Mediastinal Extramedullary Hematopoiesis",
    "history": "The patient was admitted for progressive weakness. Past medical history included left post-traumatic hemothorax with multiple rib fractures, gastritis and a congenital homozygous intermediary thalassemia necessitating transfusions during childhood. On clinical examination only a splenomegaly was found. Laboratory examinations showed anemia (hemoglobinemia 6.3 gr/dl and hematocrit 22.2%) associated with increased ferritinemia (2880 ng/dl). \n\nChest radiograph and CT scans of thorax and abdomen were performed.",
    "image_finding": "A 32-year-old Mediterranean man was admitted for progressive weakness. Past medical history included left post-traumatic hemothorax with multiple rib fractures, gastritis and a congenital homozygous intermediary thalassemia necessitating transfusions during childhood. On clinical examination only a splenomegaly was found. Laboratory examinations showed anemia (hemoglobinemia 6.3 gr/dl and hematocrit 22.2%) associated with increased ferritinemia (2880 ng/dl). Chest radiograph and CT scans of thorax and abdomen were performed.\nBased on clinical data and imaging findings, the diagnosis of extramedullary hematopoiesis was suggested.",
    "discussion": "Extramedullary hematopoiesis (EMH) occurs when bone marrow is insufficient or destructed like in myelofibrosis, thalassemia, sickle cell anemia, erythroleukemia, polycytemia vera, von Jacksch's anemia, chronic myeloid leukemia, lymphoma, carcinomatosis, vitamin B12 and folate deficiency. EMH often involves the spleen, liver and lymph nodes. Other locations, like in the kidney, skull and mediastinum, are less common.\n\nMediastinal lesions most commonly occur in the posterior mediastinum. Two different theories explain this location: herniation of myeloid tissue through the thin cortical bone of the posterior ribs and the activation of extramyeloid hematopoietic cell. Usually intrathoracic EMH is asymptomatic but paraplegia due to cord compression and massive hemothorax have been reported. CT scan reveals homogeneous, lobulated soft tissue masses. These are often bilateral but asymmetric and contain no calcifications. The lesion causes no bone destruction. Low attenuation values \u2013 approximating those of fatty tissue \u2013 are highly suggestive of EMH. Occasionally some alteration of the trabeculation of the adjacent vertebra may be observed. The differential diagnosis of the posterior mediastinal locations of EMH includes neurogenic tumors, lymphoma, paravertebral abscess and metastatic carcinoma. \n\nThe imaging methods that contribute to the diagnosis of EMH are: conventional chest radiographs, CT scan, MRI and radionuclide scanning (59/52Fe, 99mTC-sulfur colloid and 111Indium-transferrine). Fine needle biopsy confirms the diagnosis in doubtful cases. The differential diagnosis included lymphadenopathy. Scintigraphy revealed an increased extrahepatosplenic uptake of colloid. Erythropoietic hemochromatosis has been described with thalassemia.",
    "differential_diagnosis": "Mediastinal, Extramedullary, Hematopoiesis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000881/000001.jpg?itok=lSrbQ0Kt",
            "caption": "Digital chest radiograph \u2013 PA-view  shows multiple rounded masses located bilaterally in the paraspinal space and pleural thickening at the level of the left 6th rib."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000881/000002.jpg?itok=Z86oiDkm",
            "caption": "CT scan demonstrates ovoid soft tissue  masses without calcification in the posterior mediastinum with coarse trabecular pattern but no erosion of the vertebral bodies adjacent to the paraspinal masses."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000881/000003.jpg?itok=Xa1udX36",
            "caption": "CT scan of the chest  demonstrates ovoid soft tissue masses without calcification in the posterior mediastinum with coarse trabecular pattern but no erosion of the vertebral bodies adjacent to the paraspinal masses."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000881/000004.jpg?itok=g4oxcdlz",
            "caption": "Unenhanced CT scan of the upper abdomen, shows the hyperdense aspect of the liver parenchyma (98 \u2013 103 HU) suggesting hemochromatosis. Normal attenuation values of the spleen (55 HU) is noted. Irregular, linear to stellar calcifications are seen centrally within the splenic parenchyma. Diameter of the spleen is 13 x 12 x 9 cm."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "Digital radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/881",
    "time": "22.02.2001"
  },
  "896": {
    "case_id": 896,
    "title": "Rounded Pulmonary Atelectasis",
    "section": "Chest imaging",
    "age": "59",
    "gender": "male",
    "diagnosis": "Rounded atelectasis",
    "history": "Unsteady gait and vertigo. On clinical and laboratory examinations no abnormalities were found.",
    "image_finding": "Patient admitted to the hospital because of unsteady gait and vertigo. On clinical and laboratory examinations no abnormalities were found. However, on routine chest radiograph, opacities were seen, which were consecutively evaluated by CT scan.",
    "discussion": "Rounded atelectasis is an unusual form of peripheral lobar collapse, described in the literature under various names i.e. folded lung and atelectatic pseudotumor. The pathogenesis of rounded atelectasis remains controversial. Most authors believe that repeated pleural irritation from tobacco, asbestos and silica causes a localized visceral pleural fibrotic reaction. Subsequent pleural shrinkage causes folding and atelectasis of the underlying parenchyma with a rounded configuration. According to another theory, rounded atelectasis occurs secondary to compression of a peripheral portion of the lung by pleural effusion. The parenchyma collapses and becomes trapped within the effusion. When pleural effusion resolves, the atelectatic lung remains trapped and tends to roll into a ball.\nThe majority of patients with rounded atelectasis are clinically asymptomatic. Eighty percent of these lesions are localized in the posterior part of the lower lobes, mostly unilateral. Radiographic features of rounded atelectasis are characteristic and mostly diagnostic. Solitary atelectasis usually presents as a sharply marginated, rounded or oval pleural based mass, with a diameter of 4-7 cm. The mass forms an acute angle with the pleura, indicating its intrapulmonary location. Air bronchogram may be present while pleural thickening usually is most pronounced at the site of the mass. There is no or little radiographic evidence of volume loss, however a compensatory hyperinflation of the lung adjacent to the mass, thickened and/or displaced interlobar fissure, as well as limited pleural effusion are frequently observed.\nThe most characteristic feature is the so called \"comet tail\" sign, formed by the arcuate course of the pulmonary vessels and bronchi as they enter the atelectatic lung from above. Differential diagnosis should include mesothelioma and bronchogenic neoplasm. Frequent radiographic follow-up is needed to exclude malignancy. On the follow-up radiographs the lesion usually remains unchanged, but regression or even complete disappearance have also been reported.",
    "differential_diagnosis": "Rounded, atelectasis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000896/000001.jpg?itok=-LfJL4C0",
            "caption": "PA view: rounded mass lesion in the posteromedial part of both lung bases. \"Comet tail\" sign (arrow) on the left side, pleural thickening at the right base with blunting of the right cardiophrenic angle, and low position of the interlobar fissure are noted."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000896/000002.jpg?itok=KgWPoDnh",
            "caption": "Lateral view: rounded mass lesion in the posteromedial part of both lung bases. \"Comet tail\" sign (arrow) on the left side, pleural thickening at the right base with blunting of the right cardiophrenic angle, and low position of the interlobar fissure are noted."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000896/000003.jpg?itok=SD0QO81j",
            "caption": "Contrast enhanced CT-scan, mediastinal  window setting demonstrates well-defined, rounded masses posteriorly in both lungs."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000896/000004.jpg?itok=UpOMFDRg",
            "caption": "There is an acute angle between the masses and the pleura, small amount of bilateral pleural effusion and posterior displacement of arcuate left interlobar fissure. The \"comet tail\" sign on the right is indicated by an arrow."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/896",
    "time": "25.02.2001"
  },
  "912": {
    "case_id": 912,
    "title": "Pulmonary Sequestration",
    "section": "Chest imaging",
    "age": "22",
    "gender": "female",
    "diagnosis": "Pulmonary sequestration",
    "history": "Short history of recurrent pulmonary infections, progressive dyspnea and cough. No asthma, allergy or tuberculosis in the past. Smoked 25 cigarettes per day for several years.",
    "image_finding": "The patient, with a short history of recurrent pulmonary infections, progressive dyspnea and cough was admitted to the hospital. No asthma, allergy or tuberculosis in the past was reported, but she had smoked 25 cigarettes per day for several years. On physical examination no abnormalities were found. Laboratory tests revealed a slightly increased sedimentation rate and a normal white blood cell count. Further investigation included chest radiograph, CT scan of the chest, and digital subtraction angiography (DSA).",
    "discussion": "Pulmonary sequestration is a congenital pulmonary malformation in which a portion of nonfunctioning bronchopulmonary tissue is separated from the rest of the lung parenchyma. It always has an anomalous blood supply arising from the systemic arterial circulation. The anomaly may be intralobar or extralobar.\nA pulmonary sequestration is intralobar when its pleural envelope is in continuity with that of the rest of the lung. This type of sequestration is usually located above the diaphragm, in the posterior segment of the left lobe. In exceptional cases it can be found in the anterior segment of the right upper lobe. The anomaly is seldom bilateral. Radiologically, it manifests as single or multiple air-filled cavities or partially filled cystic lesions at the base of the lung. It is usually discovered on a routine chest radiograph, or when complications occur such as infection or hemoptysis.\nSequestration, regardless of the type, almost invariably derives its arterial supply from the systemic circulation, most often from lower thoracic and upper abdominal aorta, or its branches. The diagnosis is confirmed by demonstrating an abnormal artery arising from the aorta or its branches, supplying the involved segment. The venous return is pulmonary in intralobar sequestrations.",
    "differential_diagnosis": "Pulmonary, sequestration",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000912/000001.jpg?itok=EiSCXCj8",
            "caption": "Chest radiograph (PA - view), shows large thin-walled cavities in the left lower lobe, sharply demarcated from the adjacent normal parenchyma. In some of the cavities fluid levels are seen."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000912/000002.jpg?itok=NQaY1X4v",
            "caption": "CT scan (section through the lower lobes), demonstrates multiple thin and thick-walled cysts occupying the left lower lobe. Several air-fluid levels are seen within the cysts."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000912/000003.jpg?itok=6kk_RQ9J",
            "caption": "Arterial DSA of the lower thoracic and upper abdominal aorta, shows the celiac trunk with an aberrant artery on the left side running superiorly and to the left."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000912/000004.jpg?itok=mFuBJge6",
            "caption": "Selective injection of the aberrant arterial branch arising from the celiac trunk, penetrating the diaphragm, and supplying the left lower lobe. Subsequently bronchoscopy was performed. Endobronchial biopsies revealed no malignancy. Consecutively the patient underwent lobectomy of the left lower lobe. An intralobar sequestration of 12 cm diameter was removed. Pathohistology confirmed the diagnosis."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT",
      "MR"
    ],
    "link": "https://www.eurorad.org/case/912",
    "time": "25.02.2001"
  },
  "919": {
    "case_id": 919,
    "title": "Necrotizing Sarcoid Granulomatosis",
    "section": "Chest imaging",
    "age": "27",
    "gender": "female",
    "diagnosis": "Necrotizing sarcoid granulomatosis",
    "history": "Complaints of chest pain and non-productive cough. Symptoms had become apparent five weeks before. Personal history of the patient disclosed insulin-dependent diabetes. Clinical examination and extensive laboratory investigations, including renal function tests, were normal. Tuberculin reaction was negative.",
    "image_finding": "The patient was admitted to the hospital with complaints of chest pain and non-productive cough. Symptoms had become apparent five weeks before. A general practitioner made the diagnosis of common cold. Personal history of the patient disclosed insulin-dependent diabetes. Clinical examination and extensive laboratory investigations, including renal function tests, were normal. Tuberculin reaction was negative. Chest radiography and CT scan of the lungs were performed. Based on the findings, a percutaneous needle aspiration of one of the pulmonary lesions was carried out under CT guidance. This procedure was repeated twice but yielded only a non-diagnostic, serosanguilent fluid. Finally, a video-thoracoscopic resection of a peripheral lesion was performed, followed by microscopic examination of the specimen.",
    "discussion": "Most patient with necrotizing sarcoid granulomatosis (NSG) are middle aged. A varying female predominance is seen. The disease usually presents with a specific symptoms, such as dry cough, chest pain and fatigue. \nNSG has to be differentiated from pulmonary sarcoidosis. Massive necrosis and vasculitis, which are typical findings in NSG, are very uncommon in sarcoidosis. Moreover, T- and B-cell activity, as well as the angiotensin converting enzyme levels in serum and tissue are normal in this disease.\nOn chest radiographs, NSG is characterized by presence of a solitary, or more often, multiple pulmonary nodules. The latter image may be mistaken for malignancy. Pleural effusion and mediastinal lymphadenopathy are uncommon.\nDifferential diagnosis of NSG includes pulmonary sarcoidosis, being the most important, and pulmonary tuberculosis, Wegener\u2019s granulomatosis, and lymphomatoid granulomatosis.\nThe final diagnosis of NSG is made histologically. Pathohistologic hallmarks of NSG are necroziting, angiocentric, confluent granulomas with epitheloid and giant cells, as well as focal destructive vasculitis of small to medium sized vessels. \nThe prognosis of NSG is usually good, with mostly complete response after corticosteroid therapy.",
    "differential_diagnosis": "Necrotizing, sarcoid, granulomatosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000919/000001.jpg?itok=duCDU5xK",
            "caption": "Chest radiograph, PA-view shows multiple pulmonary nodules with a diameter of up to 3 cm predominantly in the lower zones of both lungs. The nodules are well-defined and non-calcified."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000919/000002.jpg?itok=7_21MaXQ",
            "caption": "CT scan of the lungs, section at the level of the lower lobes   confirms multiple pulmonary nodules of varying size. CT scan showed neither evidence for pleural effusion nor for mediastinal lymphadenopathy (not shown)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000919/000003.jpg?itok=3ZRevQhc",
            "caption": "Microscopy of a resected pulmonary nodule  shows the presence of multiple confluent granulomas with central necrosis. Pathohistologic examination of the resected specimen revealed necrotizing sarcoid granulomas."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/919",
    "time": "25.02.2001"
  },
  "922": {
    "case_id": 922,
    "title": "Sarcoidosis",
    "section": "Chest imaging",
    "age": "63",
    "gender": "female",
    "diagnosis": "Sarcoidosis",
    "history": "Patient belonging to a family of millers presenting with \u201cshortness of breath\u201d. Her father and one brother suffered from lung tuberculosis.",
    "image_finding": "The patient consulted for \u201cshortness of breath\u201d. She belonged to a family of millers. Her father and one brother suffered from lung tuberculosis.\n\nThere was a marked decline of her general condition and a weight loss of 20 kg over 2 years. Because ECG showed signs of ischemia a coronarography was planned but preoperative blood analysis revealed an alkaline phosphatase of 247 U/L (max 190 U/L) and a gamma GT of 60 U/L (max 24 U/L). Angiotensin-converting enzyme was elevated to 144 U/L (max 35 U/L), and there was a lymphocytosis of 35% (nl. 6-17%). Pulmonary function was restricted and diffusion capacity was decreased.\n\nPlain film of the chest, abdominal ultrasonography, CT scan of the abdomen and the thorax were performed. Biopsies were taken from lung, liver and bone.\n\nRadiological diagnosis",
    "discussion": "Sarcoidosis is a chronic multisystemic disease of unknown origin with accumulation of T-cell lymphocytes, mononuclear phagocytes and formation of non-caseating epitheloid granulomas. The presentation is most frequently with bilateral hilar lymphadenopathies, pulmonary infiltration and skin or eye lesions. Many subclinical cases are discovered on screening chest films. Virtually any organ can be affected. Clinical course and prognosis depend on which organs are involved. Although many granulomas resolve over time, some undergo fibrosis and pulmonary fibrosis may be the rule in many cases. On plain chest film and CT there are three basic patterns: reticular, acinar and large nodules. Cavitation, atelectasis, pleural effusion and spontaneous pneumothorax are rare manifestations. Bilateral hilar lymph node enlargement occurs in 75 to 85% although lymph nodes can be found anywhere as shown in our case.\n\nThe majority of patients with sarcoidosis are young or middleaged black adults. \n\nThe finding of non-necrotizing granulomas is a specific and the diagnosis is made by combining clinical, radiological and biochemical findings. BAL, Gallium scan and pulmonary function tests can give extra information. \n\nActivity can be assessed by plain chest film, ACE titer, BAL or Gallium scan. Corticosteroids remain the corner stone in therapy although it is not clear if it changes the course of the disease. \n\nWhen sarcoidosis presents in a disseminated form the differential diagnosis becomes wide and ncludes lymphoma, tuberculosis and extrinsic allergic alveolitis.",
    "differential_diagnosis": "Sarcoidosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000922/000001.jpg?itok=oM_UInKD",
            "caption": "Plain chest film, PA view   shows diffuse interstitial lung disease with nodular pattern. Nodules are spread bilaterally and of variable size (less than 1 cm). Normal cardiac width and double contour of the upper mediastinum and of the left hilus are seen."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000922/000002.jpg?itok=6uTC-AxZ",
            "caption": "Ultrasonography of the abdomen  demonstrates malposition of the cecum and appendix which are both located in the left upper quadrant of the abdomen."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000922/000003.jpg?itok=CWgd6G5w",
            "caption": "Contrast-enhanced CT scan of the abdomen  shows mild hepatosplenomegaly, with multiple small hypodense lesions in the liver and the spleen."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000922/000004.jpg?itok=yijsT9nc",
            "caption": "Multiple round and oval, well-delineated nodules of intermediate density around the celiac trunk, periaortic and inter-aortocaval region are demonstrated."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000922/000005.jpg?itok=tgkWdgqb",
            "caption": "Contrast-enhanced CT scan of the chest  demonstrates on mediastinal window setting  an inhomogeneous nodular mass in the superior mediastinum and subcarinal space."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000922/000006.jpg?itok=gxFy7bPi",
            "caption": "High-resolution CT scan  visualized disseminated pulmonary and subpleural nodules, and areas of infiltration and of ground glass appearance."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "Ultrasound",
      "Ultrasound",
      "MR",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/922",
    "time": "25.02.2001"
  },
  "934": {
    "case_id": 934,
    "title": "Bronchiolitis Obliterans Organizing Pneumoni",
    "section": "Chest imaging",
    "age": "50",
    "gender": "male",
    "diagnosis": "Bronchiolitis obliterans organizing pneumonia",
    "history": "Heavy smoker, referred to the radiology department for routine chest radiograph.",
    "image_finding": "The patient, a heavy smoker, was referred to the radiology department for routine chest radiograph because his physician noted \"crackles\" over the left hemithorax on lung auscultation. His medical history was irrelevant and he had no further complaints. \nHis first chest radiograph (not shown) showed infiltrates in the left lung. Despite antibiotic treatment, a control chest radiograph showed persistent infiltration in the left lower lobe. The patient was admitted to the hospital for further work-up. Physical examination and laboratory tests on admission were normal. Subsequent bronchoscopic examinations, sputum culture and cytology yielded no abnormalities. A CT scan of the chest was performed.\nBased on radiological findings, malignancy of the left lower lobe was suspected. After surgical resection of the left lower lobe, histological examination revealed bronchiolitis obliterans, associated with bronchiolitis obliterans organizing pneumonia.",
    "discussion": "Bronchiolitis obliterans (BO) is an uncommon lung disease characterized by the presence of polypous granulation tissue within the terminal bronchioles and alveolar ducts. In 50% of patients with BO there is no apparent cause or underlying disease. It is a nonspecific reaction caused by a variety of insults such as inhalation of gasses, infections, or as a complication of systemic connective tissue diseases. There is a suggested relationship with smoking. Eighty-five percent of patients with BO have airway obstruction, associated with interstitial and/or alveolar pneumonia, a complex which is referred to as Bronchiolitis Obliterans Organizing Pneumonia (BOOP). Clinically BO may cause fever, cough and progressive dyspnea as well as a mixed pattern of restrictive and obstructive disease on pulmonary functional test. According to the imaging findings on conventional chest radiographs and CT scans, 3 groups of patients can be distinguished: patients with multiple patchy alveolar infiltrates; patients with solitary lesions, usually in the upper lobe; and patients with diffuse interstitial lung disease. \nFinal diagnosis of BO is made after open lung biopsy or surgical resection of the diseased segment. BOOP is resistant to antibiotic therapy but temporary relief in combination with corticosteroids is described. Definitive therapy is often surgical.",
    "differential_diagnosis": "Bronchiolitis, obliterans, organizing, pneumonia",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000934/000001.jpg?itok=kOoRW8Fx",
            "caption": "AP view : Ill-defined area of parenchymal consolidation in the apical segment of the left lower lobe. No hilar or mediastinal lymphadenopathy is present."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000934/000002.jpg?itok=ErHp2UOz",
            "caption": "Lateral view: Ill-defined area of parenchymal consolidation in the apical segment of the left lower lobe. No evidence of  hilar or mediastinal lymphadenopathy."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000934/000003.jpg?itok=ziTSoJjT",
            "caption": "Section through the apical segment of the left lower lobe: narrowing and obliteration of the segmental bronchi, associated with extensive consolidation in the upper segment of the left lower lobe."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/934",
    "time": "25.02.2001"
  },
  "940": {
    "case_id": 940,
    "title": "Lymphoma of Mucosa-associated Lymphoid Tissue",
    "section": "Chest imaging",
    "age": "70",
    "gender": "female",
    "diagnosis": "Lymphoma of mucosa-associated lymphoid tissue",
    "history": "was admitted for evaluation of a tumor of the lacrymal gland. Medical history included gastric lymphoma, which was treated by normal gastrectomy, 4 years previously. CT scan of the chest was performed before and after therapy.",
    "image_finding": "The patient was admitted for evaluation of a tumor of the lacrymal gland. Medical history included gastric lymphoma, which was treated by normal gastrectomy, 4 years previously. CT scan of the chest was performed before and after therapy.\nChest radiography (AP projection)  shows bilateral interstitial infiltration with predominantly central distribution.\nHigh resolution CT scan of the lungs  demonstrates multiple interstitial peribronchovascular nodules, 2 to 3 mm in diameter, with central and subpleural distribution.\nOn conventional CT scan of the lungs obtained after six regimens of chemotherapy (same level as in fig. 2), most of the peribronchovascular lesions have vanished.\nA biopsy of the lacrymal gland was performed. Histological examinations showed Lymphoma of Mucosa-Associated Lymphoid Tissue (MALT), which was consistent with the histological diagnosis of the resected gastric tumor. Pulmonary CT findings ware consistent with Lymphoma of Bronchus-Associated Lymphoid Tissue (BALT), as the nodules appeared in the usual location of normal lymphoid tissue in the lung.\nMost of the lesions disappeared after chemotherapy.",
    "discussion": "Maltoma accounts for 85% of extra-nodal non-Hodgkin lymphomas. These tumors arise in the gastrointestinal tract or other mucosal organs, such as the lung, the salivary gland, the thymus, the thyroid and the lacrymal gland. Mucosa-Associated Lymphoid Tissue may be a normal component in the mucosa of the intestine (GALT) and bronchi of neonatal lung (BALT). It may be acquired in chronic gastritis, Hashimoto thyroiditis and Sj\u00f6gren syndrome. The great majority of Maltomas are from B-cell origin. In Western countries, B-cell gastric lymphoma is the most common. Histology of low grade B-cell lymphoma shows three main components: epithelial infiltrate of centrocyte-like cells (specific lymphoepithelial lesions), plasma cells and reactive B-cell follicles, which may simulate a benign lymphoid infiltrate, called in the past \"pseudolymphoma\". \n\nThe clinical features are characterized by a slow evolution of the lesions. The disease exhibits a better prognosis than lymphoma. \n\nPrimary lymphoma of Bronchus-Associated Lymphoid Tissue (BALT) occurs in about 3.6 percent of all extra-nodal non-Hodgkin lymphomas.\n\nPathology is characterized by multiple small nodular infiltrates of lymphoid cells, less than 5 mm in diameter with a primary peribronchial distribution, followed by extension into the septal interstitium and vascular wall invasion. \n\nCT scan shows peribronchovascular distribution of nodules, 2 to 4 mm in diameter, associated with bronchiectasis and bronchial wall thickening. \n\nIn correlation with the clinical history, CT findings can suggest the diagnosis of lymphomatous infiltration and guide transbronchial biopsy.",
    "differential_diagnosis": "Lymphoma, of, mucosa-associated, lymphoid, tissue",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000940/000001.jpg?itok=Nmj-qcBQ",
            "caption": "(AP projection) shows bilateral interstitial infiltration with predominantly central distribution."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000940/000002.jpg?itok=1mxZCvPl",
            "caption": "demonstrates multiple interstitial peribronchovascular nodules, 2 to 3 mm in diameter, with central and subpleural distribution."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000940/000003.jpg?itok=NMpxfBYm",
            "caption": "demonstrates multiple interstitial peribronchovascular nodules, 2 to 3 mm in diameter, with central and subpleural distribution."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000940/000004.jpg?itok=qwS9ffJK",
            "caption": "of the lungs obtained after six regimens of chemotherapy (same level as in fig. 2), most of the peribronchovascular lesions have vanished."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/940",
    "time": "21.02.2002"
  },
  "943": {
    "case_id": 943,
    "title": "Tuberous Sclerosis",
    "section": "Chest imaging",
    "age": "32",
    "gender": "female",
    "diagnosis": "Tuberous sclerosis",
    "history": "with mental retardation, seizures and multiple facial Pringle fibro-adenomas was admitted for respiratory distress and hyperthermia.",
    "image_finding": "A patient with mental retardation, seizures and multiple facial Pringle fibro-adenomas was admitted for respiratory distress and hyperthermia.Radiography of the chest, AP view shows diffuse reticular pattern on both lungs. CT scan of the thorax (slice thickness of 1.5mm) demonstrates diffuse interstitial thickening of the lung parenchyma and presence of innumerable thin walled air cysts.\nCT scan of the abdomen, hepatic level, shows the presence of multiple lobulated intrahepathic masses with fat density (- 84 HU).\nOn CT of the abdomen, pelvic level , gross enlargement of both kidneys is seen. Replacement of renal parenchyma by tissue with fat densities (- 59 HU), extending into the pelvis, is noted. This tissue did not further enhance after injection of contrast medium.\nBased on clinical and radiological features, the diagnosis of tuberous sclerosis was suggested.",
    "discussion": "Tuberous sclerosis is an autosomal dominant neuro-ectodermal disease. The penetrance is low, resulting in sporadic appearance in 60% of the cases. The incidence is 1/100 000 to 1/150 000 live births. The classical triad of clinical manifestations including: adenoma sebaceum, mental retardation and seizures is reported in 33%. The disease is characterized by hamartomas involving multiple organs. Dermatologic lesions are the most constant feature, including hypomelanotic macules, confetti skin lesions, facial angiofibromas, ungual fibromas and Shagreen's patches. The intracranial changes are due to \"tubers\", 1 to 2 cm in size, which can involve the cortex and/or the subependymal spaces. The subependymal lesions can degenerate into a giant cell astrocytoma in 2 to 15% of patients. This tumor, although usually benign, can grow large and cause symptoms due to its mass effect. Other organs involved include multiple rhabdomyomas of the heart allowing prenatal US diagnosis, renal cysts and bilateral angiomyolipomas. Renal angiomyolipomas are found in about two third of the cases at autopsy. There is a small risk of degeneration of the renal lesions into renal cell carcinoma. Pulmonary involvement has been considered as lymphangiomyomatosis involving 1% of female patients. Hepatic hamartomas are seen in about 25% of the pediatric age group, more commonly in older female children, and are generally without clinical consequences. Some authors consider lymphangiomyomatosis and angiomyolipomas a minor form of the disease.",
    "differential_diagnosis": "Tuberous, sclerosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000943/000001.jpg?itok=5EebCAT2",
            "caption": "AP view  shows diffuse reticular pattern on both lungs."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000943/000002.jpg?itok=JWPvtSxx",
            "caption": "(slice thickness of 1.5mm) demonstrates diffuse interstitial thickening of the lung parenchyma and presence of innumerable thin walled air cysts."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000943/000003.jpg?itok=rzU0GjDD",
            "caption": "On hepatic level, shows the presence of multiple lobulated intrahepathic masses with fat density (\u2013 84 HU)."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000943/000004.jpg?itok=A8Oroz8t",
            "caption": "On pelvic level, gross enlargement of both kidneys is seen. Replacement of renal parenchyma by tissue with fat densities (- 59 HU), extending into the pelvis, is noted. This tissue did not further enhance after injection of contrast medium. Based on clinical and radiological features, the diagnosis of tuberous sclerosis was suggested."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/943",
    "time": "21.02.2002"
  },
  "947": {
    "case_id": 947,
    "title": "Acute Hydrocarbon Pneumoni",
    "section": "Chest imaging",
    "age": "26",
    "gender": "male",
    "diagnosis": "Acute hydrocarbon pneumonia",
    "history": "fire-eater accidentally ingested a paraffin mixture (lamp oil) after vomiting. He was admitted a few hours later with complaints of right-sided chest pain and epigastric pain. \nLaboratory findings included an elevated white blood cells count and CRP of 267 mg/ml. \nLung function tests revealed restrictive impairment and decreased diffusing capacity.",
    "image_finding": "This fire-eater accidentally ingested a paraffin mixture (lamp oil) after vomiting. He was admitted a few hours later with complaints of right-sided chest pain and epigastric pain. \nLaboratory findings included an elevated white blood cells count and CRP of 267 mg/ml. \nLung function tests revealed restrictive impairment and decreased diffusing capacity.\nRadiography of the chest, PA-view shows infiltrate in the right middle lobe.\nCT scan of the chest on admission (lung window setting) shows on the enlarged view of the right\n lung base  an alveolar infiltrate with consolidation in the right middle lobe. \nMild perilesional reaction and effusion in the greater fissure are noted.\nEnlarged view of the left lung base demonstrates broncho-alveolar infiltration in the left \nlower lobe. More pronounced perilesional inflammatory reaction in the surrounding lung parenchyma\n is visible.\nFollow-up CT scan of the lungs, six months later, is almost normal, with only a focal \naccentuation of the interstitial pattern, with small cavity, persisting in the right middle \nlobe.\nBased on clinical history and radiological findings, the diagnosis of acute hydrocarbon\n pneumonia was retained.",
    "discussion": "Up to now, nine cases of fire-eaters pneumonia have been reported. Clinically, the respiratory symptoms usually occurs after inhalation of vomited material and progress in two phases: cough and dyspnea occurring one hour after inhalation, followed by increasing dyspnea, chest pain, hemoptysis and fever, one to 48 hours after the aspiration.\n\nOther non pulmonary symptoms are vomiting, abdominal pain, petrolic diarrhea, euphoria, convulsions, coma, acute renal failure and thrombopenia.\n\nRadiological signs include right middle and lower lobe infiltrates, homogeneous consolidation and cavitation, rarely pneumothorax and pleural effusion. Pulmonary complications are ARDS, abscess formation, pneumatocele, bronchiectasis, aseptic pleural effusion. \n\nManagement of the condition includes supportive care. Administration of emetics and gastric lavage are not recommended. Broad-spectrum antibiotic therapy and systemic corticosteroid administration are commonly used in acute hydrocarbon pneumonitis, although there is no proved evidence of their beneficial effect. \n\nEarly infusion of acetylcystein may protect against hepato-renal toxicity of the halogenated hydro-carbon. \nThe mortality rate is less than 1%, but recurent inhalation of hydrocarbon may cause chronic lung injury.",
    "differential_diagnosis": "Acute, hydrocarbon, pneumonia",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000947/000001.jpg?itok=b8C4wGsy",
            "caption": "PA-view shows infiltrate in the right middle lobe."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000947/000002.jpg?itok=Aw_JlM4q",
            "caption": "on admission (lung window setting) shows on the enlarged view of the right lung base  an alveolar infiltrate with consolidation in the right middle lobe. Mild perilesional reaction and effusion in the greater fissure are noted."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000947/000003.jpg?itok=SUB17a0e",
            "caption": "Enlarged view of the left lung base  demonstrates broncho-alveolar infiltration in the left lower lobe. More pronounced perilesional inflammatory reaction in the surrounding lung parenchyma is visible."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000947/000004.jpg?itok=uyFFKknf",
            "caption": "six months later, is almost normal, with only a focal accentuation of the interstitial pattern, with small cavity, persisting in the right middle lobe. Based on clinical history and radiological findings, the diagnosis of acute hydrocarbon pneumonia was retained."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/947",
    "time": "24.02.2002"
  },
  "948": {
    "case_id": 948,
    "title": "Giant Lymph Node Hyperplasi",
    "section": "Chest imaging",
    "age": "13",
    "gender": "female",
    "diagnosis": "Giant lymph node hyperplasia",
    "history": "No previous medical history, complained of a painless, left-supramammary swelling of progressive onset. \nSonography (not shown) reveals a non-homogeneous mass of the upper chest wall.\nShe was referred for a contrast enhanced CT scan of the chest wall. \nThereafter the lesion was surgically resected.",
    "image_finding": "The patient without previous medical history complained of a painless, left-supramammary swelling of progressive onset. \nSonography (not shown) reveals a non-homogeneous mass of the upper chest wall.\nShe was referred for a contrast enhanced CT scan of the chest wall. \nThereafter the lesion was surgically resected.\nContrast enhanced CT scan of the chest wall  shows a rounded, well delineated, encapsulated mass of eight centimeters diameter, located between the left pectoralis minor muscle and the ribs. There is no bone involvement, there are no signs of intralesional necrosis.\nThere is a pronounced and heterogeneous enhancement after IV injection of iodinated contrast material.\nMicroscopic examination after complete surgical resection of the mass with on the right side of the figure magnification of the inset (black arrow ) demonstrates lymphoid tissue with highly vascularized hyalin stroma and hyperplastic follicles. There is a stromal plasma cell accumulation and at higher magnification arterioles with thick hyalin wall entering the follicle centre are seen (double arrow).\nThese findings are highly suggestive of Castleman's disease of hyalin vascular (HV) and plasma cell-rich (PC) subtype. Final diagnosis is giant lymph node hyperplasia or angiofollicular lymph node hyperplasia or Castleman disease of the mixed subtype.",
    "discussion": "The disease was first described by Castleman et al. in 1956 while studying histological presentation of 13 isolated and asymptomatic mediastinal masses. The disease was then classified as prelymphomatous. Actual classification distinguishes localized and multicentric forms of Castleman's disease.\n\nLocalized form includes HV subtype (90%), PC subtype and mixed subtype. Prinicipal location is the mediastinum (60-75%), followed by the neck. Clinical presentation is frequently that of an isolated and asymptomatic mass of incidental discovering in a young adult. Symptoms are related to local tumefaction. Systemic symptoms such as asthenia, fever, loss of weight have been described in two thirds of PC subtype, and 3 to 10% of HV subtype. In some PC subtype cases, one can see a polyclonal peak on electrophoresis.\n\nSurgery is curative but local recurrence occurs.\n\nMulticentric form is defined by a peripheral polyadenopathy and multivisceral involvement. This form may present with four histological subtypes: plasmocytic (80-90%), proliferative, accumulative and fibrosed. Onset is around the 6th decade, and systemic signs are more frequent than in localized forms. A monoclonal immunohistochemical protein may be present. Various pathologic conditions have been associated with this form of Castleman's disease: auto-immune diseases, lymphomas, carcinomas, sarcomas such as Kaposi's, acquired or congenital immunodeficiencies.\nViral infections by EBV and KSHV (or HHV8) and dysregulation of the IL-6 secretion are possible causal factors but physiopathological pathways of this disease remain uncertain. \n\nActual treatment is chemotherapy; the prognosis is poor, with a medical survival of 30 months. \nCT findings of Castleman disease consist of well circumscribed, encapsulated, and hypervascular masses with or without focal necrosis or intralesional calcification. Since most of the masses are intrathoracic, US is of less value. Recent studies have shown high signal intensity on T2-weighted MR scans, with a strong enhancement after gadolinium injection making of MR imaging a valuable alternative to computed tomography.",
    "differential_diagnosis": "Giant, lymph, node, hyperplasia",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000948/000001.jpg?itok=qo6XMSBj",
            "caption": "shows a rounded, well delineated, encapsulated mass of eight centimeters diameter, located between the left pectoralis minor muscle and the ribs. There is no bone involvement, there are no signs of intralesional necrosis. There is a pronounced and heterogeneous enhancement after IV injection of iodinated contrast material."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000948/000002.jpg?itok=P8DeJbj5",
            "caption": "after complete surgical resection of the mass with on the right side of the figure magnification of the inset (<i>black arrow</i>) demonstrates lymphoid tissue with highly vascularized hyalin stroma and hyperplastic follicles. There is a stromal plasma cell accumulation and at higher magnification arterioles with thick hyalin wall entering the follicle centre are seen (<i>double arrow</i>). These findings are highly suggestive of Castleman's disease of hyalin vascular (HV) and plasma cell-rich (PC) subtype. Final diagnosis is giant lymph node hyperplasia or angiofollicular lymph node hyperplasia or Castleman disease of the mixed subtype."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/948",
    "time": "24.02.2002"
  },
  "954": {
    "case_id": 954,
    "title": "Pulmonary Interstitial Gas",
    "section": "Chest imaging",
    "age": "19",
    "gender": "female",
    "diagnosis": "Pulmonary interstitial gas",
    "history": "became tetraplegic after a motor-vehicle acident. A few days after admission, she developed a respiratory distress tackndrome (ARDS), and her ventilation had to be assisted. In order to exclude a pneumothorax a CT scan was performed.\n\nShe remained under the same ventilatory conditions for several weeks. Thereafter a left pulmonary opacity persisted, despite repeated endobronchial aspiration and physiotherapy. Twelve weeks after admission a control CT scan of the chest was performed.",
    "image_finding": "A patient became tetraplegic after a motor-vehicle acident. A few days after admission, she developed a respiratory distress tackndrome (ARDS), and her ventilation had to be assisted. In order to exclude a pneumothorax a CT scan was performed.\n\nShe remained under the same ventilatory conditions for several weeks. Thereafter a left pulmonary opacity persisted, despite repeated endobronchial aspiration and physiotherapy. Twelve weeks after admission a control CT scan of the chest was performed.\nCT scan of the chest, section at the level of the carina and at the level of the bronchus\n intermedius shows large areas of air space consolidation and air bronchogram predominantly in \nthe posterior parts of the lungs.\nCT scan of the chest performed 12 weeks after admission and at the same two levels as \nin Fig. 1 demonstrates collapse of the left lower lobe and area of decreased attenuation \nanteriorly in the right upper lobe.\nThe hyperlucent area corresponds to interstitial gas as a result of barotrauma due to a \npositive and expiratory pressure therapy (PEEP). The localization reflects these pulmonary \nzones that were still aerated and thus accessible to ventilation with PEEP at the time of \nthe ARDS. The consolidation has protected the posterior areas of the lung from barotrauma. \nThe posterior location of alveolar infiltrates is characteristic for ARDS.",
    "discussion": "Radiographic identification of pulmonary interstitial gas is a prime indicator of possible complications in patients treated with PEEP therapy for severe respiratory failure. The interstitial gas may further progress to a pneumomediastinum, an extrathoracic dissection, a pneumothorax, and a tension pneumothorax. Interstitial gas is seen radiographically as vesicular areas of low density (cystic changes), linear streaks along the bronchi and vessels, halos of gas around vessels, and subpleural gas. Pulmonary barotrauma is a frequent complication of PEEP. Pneumothorax, pneumomediastinum, and interstitial emphysema may lead to rapid deterioration in the condition of a patient maintained on mechanical ventilation with an already compromised respiratory status.",
    "differential_diagnosis": "Pulmonary, interstitial, gas",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000954/000001.jpg?itok=UizC5PcP",
            "caption": "section at the level of the carina"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000954/000002.jpg?itok=lHP7kECr",
            "caption": "and at the level of the bronchus intermedius  shows large areas of air space consolidation and air bronchogram predominantly in the posterior parts of the lungs."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000954/000003.jpg?itok=xNpHBZuI",
            "caption": "performed 12 weeks after admission and at the same two levels as in Fig. 2  demonstrates collapse of the left lower lobe and area of decreased attenuation anteriorly in the right upper lobe. The hyperlucent area corresponds to interstitial gas as a result of barotrauma due to a positive and expiratory pressure therapy (PEEP). The localization reflects these pulmonary zones that were still aerated and thus accessible to ventilation with PEEP at the time of the ARDS. The consolidation has protected the posterior areas of the lung from barotrauma. The posterior location of alveolar infiltrates is characteristic for ARDS."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000954/000004.jpg?itok=wpG6cBvf",
            "caption": ""
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/954",
    "time": "24.02.2002"
  },
  "957": {
    "case_id": 957,
    "title": "Poland\u2019s Syndrome",
    "section": "Chest imaging",
    "age": "28",
    "gender": "male",
    "diagnosis": "Poland\u2019s syndrome",
    "history": "These musculoskeletal abnormalities are typically found in what is known as Poland\u2019s syndrome.",
    "image_finding": "The patient presents with a congenital right thoracic deformity associated with abnormalities of the ipsilateral upper limb.\nFollowing esthetic complaints, a chest radiography, a chest CT scan and radiographs of both hands were performed.\nOn radiography of the chest, there is a hyperlucency of the right hemithorax shows air bubbles in a radial, streaky configuration within the upper pole of the left kidney.\nCT scan of the chest shows absence of the right pectoralis muscle associated with hypoplasia of the underlying ribs.\nOn radiography of both hands , there is a global hypoplasia of the right hand best seen when compared to the left one. Individual bones are affected: the metacarpal bones of the right hand are too short, there is hypoplasia of the middle phalanges of the third, fourth and fifth fingers and absence (aplasia) of the middle phalanx of the second finger.\nThese musculoskeletal abnormalities are typically found in what is known as Poland\u2019s syndrome.",
    "discussion": "Poland\u2019s syndrome is characterized by an association of a partial or complete absence of the pectoralis muscles and ipsilateral upper limb anomalies. Syndactyly is the most frequent associated anomaly of the hand. The right side of the body is involved twice as often as the left, with a 3 to 1 male predominance.\nA great number of other varied malformations have been described in association with Poland\u2019s syndrome, including abnormalities of the shoulder girdle and the skull, dextrocardia, genito-urinary and endocrine anomalies.\nThe frequency of Poland\u2019s syndrome is one in 32,000 live births and is reported in 10% of patients with syndactyly. Most cases, as this one, are sporadic, very few familial cases have been reported.\nThe pathogenesis of the syndrome is controversial. Some have proposed the hypothesis of a vascular etiology with the interruption of the subclavian artery at around the sixth week of gestation, precipitated by unknown factors. The coexistence of congenital anomalies at distant sites along with the demonstration of familial occurrence support the alternative hypothesis of a \u00abde nove\u00bb or inherited genetic abnormality.\nOf particular interest is the association of Poland\u2019s syndrome with malignant diseases notably leukemia, leiomyosarcoma and non-Hodgkin lymphoma.",
    "differential_diagnosis": "Poland\u2019s, syndrome",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000957/000001.jpg?itok=DoYSmuL5",
            "caption": "there is a hyperlucency of the right hemithorax  shows air bubbles in a radial, streaky configuration within the upper pole of the left kidney."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000957/000002.jpg?itok=wc7mMR08",
            "caption": "shows absence of the right pectoralis muscle associated with hypoplasia of the underlying ribs."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000000957/000003.jpg?itok=IpaizHol",
            "caption": "there is a global hypoplasia of the right hand best seen when compared to the left one. Individual bones are affected: the metacarpal bones of the right hand are too short, there is hypoplasia of the middle phalanges of the third, fourth and fifth fingers and absence (aplasia) of the middle phalanx of the second finger.  These musculoskeletal abnormalities are typically found in what is known as Poland\u2019s syndrome."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/957",
    "time": "24.02.2002"
  },
  "1025": {
    "case_id": 1025,
    "title": "Bronchogenic cyst",
    "section": "Chest imaging",
    "age": "60",
    "gender": "male",
    "diagnosis": "Bronchogenic cyst",
    "history": "The patient was referred for malaise.The chest X-ray showed a non-calcified homogeneous opacity lateral to the trachea with a well-defined interface with the lung.",
    "image_finding": "The patient was referred for malaise.\nThe chest X-ray showed a non-calcified homogeneous opacity lateral to the trachea with a well-defined interface with the lung.\nA cervicothoracic sign indicated the posterior localisation of the mass.\nCT  with and without contrast media showed a large homogeneous mass of low attenuation arising in the right paratracheal space extending posteriorly. A thin wall and  absence of enhancement suggested the diagnosis of a primary cyst of the mediastinum. \nAt MR examination, the mass showed an intermediate signal intensity on the T1 and a bright signal intensity on the T2 weighted image, indicating a high protein content.\nThe cyst wall is thin, barely perceptible and the content homogeneous.",
    "discussion": "Bronchogenic cysts belong to the category of the foregut cyst and are the result of abnormal budding of the tracheal primordium or abnormal branching of the tracheobronchial tree.\nBronchogenic cysts are the most common primary cysts of the mediastinum, which account for about 20% of the primary tumors of the mediastinum. Most of them are asymptomatic but they  may be revealed by compression of airways, oesophagus and, in some very rare cases by infection or haemorrhage.\nThey can be discovered during child or adulthood.\nThey are located most frequently along the tracheobronchial tree but may also be seen in any part of the mediastinum. Conversely to their pulmonary counterpart, they are not connected to bronchi when located in the mediastinum.\nOn chest X-ray, they are revealed by a homogeneous well-defined opacity of the mediastinum displacing a mediastinal line.\nCT with and without contrast media shows a homogeneous non-enhancing mass of variable size and attenuation with a thin wall.\nProteinous and hemorrhagic content are responsible for the high attenuation values found in many cases. The cyst wall may be calcified.\nOn MRI examination, the MR signal is typical of a high protein content cyst i.e. high or intermediate signal intensity on T1 and very high signal intensity on T2 (similar to CSF)\nBut a similar pattern at CT and MR may be seen in every kind of primary cyst of the mediastinum. The diagnosis of origin is suggested by the topography but BC may also be found far from the bronchial tree.\nThe main characteristic of the histologic examination is the presence of a stratified respiratory epithelium.\nSurgical resection is usually recommended to prevent complications.\nPercutaneous aspiration or therapeutic abstention and follow-up had been advocated by some.",
    "differential_diagnosis": "Bronchogenic, cyst",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001025/000001.jpg?itok=JZTye7B9",
            "caption": "The chest X-ray showed a non-calcified homogeneous opacity lateral to the trachea with a well-defined interface with the lung. A cervicothoracic sign indicated the posterior localisation of the mass."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001025/000002.jpg?itok=x6GNsT3m",
            "caption": "CT  with and without contrast media showed a large homogeneous mass of low attenuation arising in the right paratracheal space extending posteriorly. A thin wall and  absence of enhancement suggested the diagnosis of a primary cyst of the mediastinum."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001025/000003.jpg?itok=SYGS3FNn",
            "caption": "CT  with and without contrast media showed a large homogeneous mass of low attenuation arising in the right paratracheal space extending posteriorly. A thin wall and  absence of enhancement suggested the diagnosis of a primary cyst of the mediastinum. Note the vascular structure visible on the right aspect of the oesophagus indicating a right aberrant subclavian artery."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001025/000004.jpg?itok=oFEVqGgq",
            "caption": "At MR examination, the mass showed an intermediate signal intensity on the T1 weighted image, indicating a high protein content. The cyst wall is thin, barely perceptible and the content homogeneous."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001025/000005.jpg?itok=JUewOuQr",
            "caption": "At MR examination, the mass showed an intermediate signal intensity on the T1 and a bright signal intensity on the T2 weighted image, indicating a high protein content. The cyst wall is thin, barely perceptible and the content homogeneous."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT",
      "MR"
    ],
    "link": "https://www.eurorad.org/case/1025",
    "time": "01.08.2002"
  },
  "1147": {
    "case_id": 1147,
    "title": "Primary  pulmonary nodular amyloidosis. A case report.",
    "section": "Chest imaging",
    "age": "80",
    "gender": "male",
    "diagnosis": "Primary  pulmonary nodular amyloidosis, with no other organ involvement.",
    "history": "A 80 year old man presented with multiple bilateral pulmonary nodules, progressively enlarging and multiplying during the last three years.",
    "image_finding": "A 80 year old man presented with multiple bilateral pulmonary nodules, progressively enlarging and multiplying during the last three years. No other complaints were reported and no other clinical signs were revealed during physical examination. There was no history of drug ingestion and no significal past medical history. Laboratory tests including complete blood count, serum chemistry and arterial blood gases revealed normal results. The patient\u2019s serum analysis showed IgG lamda type monoclonal gammopathy. No Bence-Jones protein was found in 24h urine collections. Pulmonary function tests showed slight obstruction with normal diffusion. Bronchoscopy revealed a normal tracheobronchial tree. Bronchoalveolar lavage was negative for malignancy. Transthoracic fine-needle aspiration of pulmonary nodules was negative, twice during these years. Thyroid, heart and upper abdomen ultrasonographic examination was normal. Histological examination of gastric and bowel mucosa was negative for amyloid or active inflammatory disease. Open-lung biopsy and microscopically examination showed that pulmonary nodules were composed of waxy eosinophilic material. The diagnosis of amyloidosis was made histologically by the finding of apple-green birefringence under polarized light, in Congo red stained sections. Staining was abolished by pretreatment of the sections with potassium permanganate. The presence of lambda light chains showed that it was AL in origin.",
    "discussion": "Amyloidosis is a group of diseases due to deposition of insoluble protein fibrils, or proteins complexes with polysaccharide material in connective tissue, around parenchymal tissue cells and in the walls of blood vessels. The disease can be either localized (10% to 20% of cases) or systemic (80% of cases). Systemic form is classified as primary or secondary. Secondary type is found in patients with chronic inflammatory disease (such as tuberculosis, osteomyelitis, bronciectasis, rheumatoid arthritis, leprosies, Crohn\u2019s disease, ankylosing spondylitis, Reiter\u2019s syndrome, psoriatic arthritis, chronic rheumatic heart disease, dermatomyositis, scleroderma, Behcet\u2019s syndrome and rarely in systemic lupus erythymatosus), in patients with familiar Mediterranean fever and in those with malignant neoplasm (such as Hodgkin\u2019s disease and hypernephroma). In 75% of cases of the generalized disease there are amyloid deposits in the mucosa of rectal biopsy specimens. In the rare primary type of the disease, amyloid is deposited in the hurt, gastrointestinal tract, lungs, muscle and skin. It develops in patients with no other disease and in those with plasma-cell abnormalities or abnormal immunoglobulins.\nAmyloid deposition of primary form is of light chain protein type known as AL amyloidosis. Systemic or reactive amyloidosis known as AA amyloidosis (due to protein A amyloid deposition) is the acquired disorder that may develop in patients with chronic infections or inflammatory diseases. AA amyloidosis can be associated with generalized organ involvement such as spleen, liver, adrenal glands and kidneys, with renal involvement producing the earliest manifestations. Amorphous amyloid protein material with the microscopic appearance of paraffin infiltrating between cells, when exposed to Congo red stain and vied under polarized light microscope shows apple-green birefringence. \nOur report shows the natural radiological 3 years history of an almost clinically asymptomatic primary pulmonary nodular AL amyloidosis, in an 80 years old male patient, with no other organ involvement. Primary nodular pulmonary amyloidosis is an uncommon manifestation. In this form amyloid is deposited in the alveolar walls and around the intralveolar capillaries, as well as in the walls of the smaller blood vessels in the lung. Deposits may also occur in bronchical and tracheal walls. The disease runs a benign course, but usually becomes a diagnostic problem due to nonspecific histological features. Most pulmonary deposits are asymptomatic, some may become manifested as nodular shadows that may be up to several cm in size easily identified on chest roentgenograms or CT scans in a peripheral or sudpleural location. The shadows are growing slowly over the years and may cavitate or become calcified. The nodular form of amyloidosis may show contrast enhancement on CT and MRI. Occasionally amyloid deposition is confined to hilar and mediastinal lymph nodes. Pleural effusion may be present. Radiological differential diagnosis must include metastatic disease, abscesses, granulomatous disease, rheumatoid lung, sarcoidosis, mucoid impaction and fungal disease.",
    "differential_diagnosis": "Primary, pulmonary, nodular, amyloidosis,, with, no, other, organ, involvement.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001147/000001.jpg?itok=LQurYGsK",
            "caption": "A solitary small, 2 cm in diameter, nodule is seen above the left hilus."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001147/000002.jpg?itok=q7kqO_-e",
            "caption": "Bilateral relatively poorly-defined nodular lesions, up to 2 cm in diameter, are seen in the middle lung fields."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001147/000003.jpg?itok=FRsmFxv5",
            "caption": "At least three soft tissue attenuation nodules are depicted in the right lung, one of which is punctured. Pay attention to two smaller nodules in asubpleural location bilaterally."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001147/000004.jpg?itok=n7N2QBBk",
            "caption": "Increase in number and size of right sided pulmonary nodules. Pay attention to some small new nodules in the right lower lung fields. Subtle hyper aeration of the left lung is also evident. Twenty months after the first x-ray, considerable advance of the disease is evident."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001147/000005.jpg?itok=U_1gGx0o",
            "caption": "One soft tissue attenuation nodule is depicted in the left lung field."
          },
          {
            "number": "Figure 5b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001147/000006.jpg?itok=ApUCcs6h",
            "caption": "A large left sided pleural effusion is present. Note the large mass based on the left pleura at aortic arch level."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001147/000007.jpg?itok=kkw6OY37",
            "caption": "Aspiration of the large mass, abutting the left pleura surface."
          }
        ]
      },
      {
        "number": "Figure 7",
        "subfigures": [
          {
            "number": "Figure 7",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001147/000008.jpg?itok=05vOqdX0",
            "caption": "Large left pleural effusion in addition to bilateral poorly-defined mass lesions. Hyperlucent area of right upper lung is evident."
          }
        ]
      },
      {
        "number": "Figure 8",
        "subfigures": [
          {
            "number": "Figure 8",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001147/000009.jpg?itok=RyZ0d7Bz",
            "caption": "Only resolution of the left sided pleural effusion is seen, meanwhile lung and pleural lesions are remaining."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT",
      "CT",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/1147",
    "time": "01.01.2002"
  },
  "1189": {
    "case_id": 1189,
    "title": "Pulmonary Fat Embolism",
    "section": "Chest imaging",
    "age": "28",
    "gender": "male",
    "diagnosis": "ARDS secondary to fat embolism",
    "history": "Polytrauma patient with acute respiratory distress",
    "image_finding": "Case: \n\t28-years old polytrauma patient admitted with multiple fractures of the right tibia and talus, who developed 24 hours after the event a severe dyspnea and confusion. \nLegends: \n\tFig 1: Admission chest film reveals no lung pathology. Orthopaedic surgery is recognizable by the presence of osteosynthesis material of T6 from a previous trauma.\n\tFig 2: Chest film obtained three days later displays numerous confluent alveolar opacities which predominate in the middle and lower lung fields\n\tFig 3A-B: 5mm CT sections reconstructed with a lung algorithm demonstrate posterior bilateral condensations and diffuse ground-glass patchy ill-defined opacities which slightly predominate in the right lung, highly suggestive of ARDS",
    "discussion": "Introduction:\n\tFat embolism syndrom (FES) relates to the presence of fat droplets in \tthe bloodstream and clinical symptoms including respiratory, \tneurological and cutaneous signs, which typically ocur 24 to 72 hours after the event.(1-4)\n\t\nClinical features:\n\tFES includes symptoms and paraclinical signs with two types of \tpresentation.(1)\n\tThe first type relates to a fulminating letal presentation with \tpulmonary and systemic fat embolisms with secondary right \tventricular failure and cardiovascular collapse.(1)\n\tThe second type is the most frequent and is characterized by a \tgradual onset. It includes general symptoms, such as pyrexia and \ttachycardia, respiratory symptoms such as tachypnea, cough, \themoptysia and hypoxemia and neurological symptoms such as stupor, \tdelirium, seizures and coma. Petechial rash is frequent and typically \tinvolves the oral mucous membranes, axillary folds, conjunctiva and \tretina.(1) \n\tThe combination of respiratory, neurologic and cutaneous signs \tconstitutes the FES.(1-4)\nPredisposition:\n\tThe highest incidence of FES occurs in polytrauma patients with \tlower limbs and pelvic fractures.(1;3)\n\tHowever FES is also reported in many other conditions such as \torthopedic procedures, bone marrow transplant, liposuction, massive \thepatic necrosis, acute pancreatitis, acute sickle cell crisis, altitude \tillness, lipid or propofol infusion and total parenteral nutrition.(1)\nPathophysiological mechanisms:\n\tThree main theories deal with the origin  of fat in the FES but none of them is \tentirely satisfactory.(1;3)\n\tThe first theory is mechanical. It relates to fat droplets of bone \tmarrow which pass through lacerated bone medullary veins and \tdisseminate in pulmonary and systemic bloodstream through a \tpatent foramen ovale. This mechanism is enhanced by platelets or \tred blood cell aggregates.(1)\n\tThe second theory has been experienced only in dogs. It relates to the \tplasticity of fat droplets which are wraped by a marked \televation of the pulmonary arterial blood pressure, allowing them to \tmigrate through the pulmonary capillary bed filter.(1)\n\tThe third theory is biochemical. It relates to a stress trauma which \tinduces a massive liberation of catecholamines which provoke the \tmobilisation of free fatty acids (FFA) from the body stock by the \tactivation of the endothelial lipases. Similarly, it is emphasized that \tFFA mobilisation also results from bone disruption after trauma. \tFFA exert a direct toxic action on vessels endothelium  . This \tvascular damage induces activation of the complement cascade, \ta release of toxins from leukocytes and a platelet activation with \tfurther exaggerated endothelial injuries and \tmicrothrombosis \tresulting in multisystemic failure.(1)\n\tThe second and the third theories appear seem more logical than the \tmechanical one to explain the presence of systemic fatty droplets \tembolism in patients with no patent foramen ovale.\nRadiological patterns:\n\tChest radiograph findings are important for the assessement of the \tdiagnosis of FES, although its appearance is variable and not specific.(2)\n\tThe chest radiograph remains normal in minor cases. When fat \tembolism is extensive, a combination of numerous focal alveolar, \tinterstitial and nodular opacities develops within 12-72 hours of latency.(2) These nodules may represent alveolar edema secondary to ARDS or early alveolar hemorrhage secondary to coagulopathy associated with FES(4) \tThe shadows pattern is variable. They can be found in the \tperipheral lung zones or may predominate in the perihilar areas, \tsimulating a batwing pressure pulmonary edema pattern.(2)\n\tCT sections demonstrate a typical ARDS pattern, characterized by focal \tor diffuse consolidation areas and ground-glass opacities, with small \tnodules of various sizes. Distribution of lung lesions is even without\tantero-posterior gradient.(2)\n\nTreatment:\n\tTreatment is symptomatic and supportive. (1;3)",
    "differential_diagnosis": "ARDS, secondary, to, fat, embolism",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001189/000001.jpg?itok=i3ND-1uO",
            "caption": "Admission chest film reveals no lung pathology. Orthopedic surgery is recognizable by the presence of osteosynthesis material of T6 of a previous trauma."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001189/000002.jpg?itok=v-A2c5Ni",
            "caption": "Chest film obtained three days later displays numerous confluent alveolar opacities which predominate in the mid and lower lung fields"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001189/000003.jpg?itok=f2FdzjBb",
            "caption": "5mm CT sections reconstructed with a lung algorithm demonstrate posterior bilateral condensations and diffuse ground-glass patchy ill-defined opacities which slightly predominate in the right lung, highly suggestive of ARDS"
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001189/000004.jpg?itok=ut4GNVM-",
            "caption": "5mm CT sections reconstructed with a lung algorithm demonstrate posterior bilateral condensations and diffuse ground-glass patchy ill-defined opacities which slightly predominate in the right lung, highly suggestive of ARDS"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT",
      "MR"
    ],
    "link": "https://www.eurorad.org/case/1189",
    "time": "09.10.2001"
  },
  "1198": {
    "case_id": 1198,
    "title": "Pericardial Cyst",
    "section": "Chest imaging",
    "age": "45",
    "gender": "female",
    "diagnosis": "Pericardial Cyst.",
    "history": "Pain in the right shoulder.",
    "image_finding": "A 45-year-old lady presented with right shoulder pain, there was no associated cough or dyspnoea. A frontal chest X-ray was performed which showed a soft tissue mass in the right lower zone, a lateral CXR showed the mass to be in the cardiophrenic angle. A follow up CT of the chest and upper abdomen was performed, which confirmed the presence of a well defined homogenous cystic lesion in the right cardiophrenic angle measuring approximately 8 cm in diameter with a wide attachment to both pleura and pericardium. The mass was removed by Video Assisted Thoracoscopic Surgery (VATS). Unfortunately the pain in the shoulder remains and the lesion was a coincidental finding on the CXR.",
    "discussion": "Pericardial cysts are a rare benign condition accounting for 6-7% of all mediastinal masses [1-4]. Aetiology is due to incomplete coalescence of foetal lacunae during formation of the pericardial sac. They are typically unilocular and lined by endothelium or mesothelium, containing clear serous fluid. They rarely communicate with the pericardial space. 75 % occur in the cardiophrenic angle with a Right: Left ratio of 3:1. The remaining 25% occur higher, usually in the subcarinal or pericardial space [5], very rarely occupying the posterior mediastinum in the midline. Progressive enlargement can occur and most are discovered as an incidental finding on CXR in adults. Usual size is between 3-8 cm though they can become giant cysts (upto 28 cm has being reported). Most are asymptomatic though they can present with atypical chest pain, cough, expectoration or dyspnoea. Recognised complications are pericardial effusion, cardiac tamponade, cyst rupture, infection and very rarely right ventricular outflow obstruction. There have been no reported cases of malignant transformation. Detection is usually by CXR and diagnosis is confirmed by Ultrasound, CT, MRI [2] or Transthoracic/transoesophageal echocardiography. Treatment is required only if symptomatic or diagnosis is of doubt. Treatment options include thoracotomy and excision or VATS excision, with thoracotomy being preferred for larger complicated cysts. Sometimes VATS or CT guided fine needle aspiration of the fluid is performed in selected patients who are unfit for surgery, although this carries the risk of haemorrhage into the cyst or recurrence (22%). Differential diagnosis is of other mediastinal cysts (bronchogenic, echinococcus, enteric, thymic) or mediastinal tumours (thymic, neurogenic, germ cell tumours, lymphoma, mesenchymal) [4].",
    "differential_diagnosis": "Pericardial, Cyst.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001198/000001.jpg?itok=kCpvz45m",
            "caption": "Large well defined mass in the right lower zone merging with the right heart border. Adjacent lung normal."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001198/000002.jpg?itok=fh_OlqAs",
            "caption": "Lateral x-ray shows the mass silhouetting the right hemidiaphragm anteriorly."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001198/000003.jpg?itok=f6ShwGQp",
            "caption": "The fluid attenuation mass is seen to lie adjacent the pericardium, in the right cardiophrenic angle. There is a fat plane between the cyst and the pericardium anteriorly.The high attenuation rim (partial) posterior to this cyst is most likely to represent adjacent atelectatic lung."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001198/000004.jpg?itok=LR90XI-Q",
            "caption": "The cyst as seen at a different level"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001198/000005.jpg?itok=JYrntxgj",
            "caption": "Normal cardiomediastinal contour. The previously seen soft tissue mass is no longer present and the lung fields are clear."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/1198",
    "time": "09.12.2001"
  },
  "1223": {
    "case_id": 1223,
    "title": "Pulmonary Wegener\u2019s granulomatosis with splenic involvement",
    "section": "Chest imaging",
    "age": "18",
    "gender": "female",
    "diagnosis": "Wegener's granulomatosis",
    "history": "An 18-year-old female was admitted to hospital with fever, dry cough, abdominal pain and a pathological chest radiograph.",
    "image_finding": "An 18-year-old female presented with a three-month history of intermittent fever (38.5\u00b0C), dry cough and abdominal pain. On the basis of these findings and an abnormal chest radiograph she had been treated as an outpatient with four successive courses of different antibiotics, but she had deteriorated further.\n\nRoutine laboratory tests revealed leukocytosis (WBC, 16.300 X 109/L). The erythrocyte sedimentation rate was 128mm/h. Examination of urinary sediment showed a number of dysmorphic erythrocytes. Sputum and blood cultures were negative for common pathogens. \n\nA chest radiograph showed patchy consolidations in both lung bases and in the right middle lung zone (Figure 1). Pre- and post-contrast conventional chest CT and HRCT were also performed and these revealed multiple patchy consolidations in the right upper and lower lobes. In the right upper lobe the lesions were centrally located in a peribronchovascular distribution with cavitations and air  bronchogram. In the right lower lobe the consolidations were mainly peripheral, abutting the pleura. A large consolidation with hypodense areas considered to represent necrosis was observed in the left lung base. Ground-glass opacities and small pleural effusions were also seen (Figure 2). \n\nPost-contrast abdominal CT showed a hypodense splenic lesion involving almost the entire spleen, with a peripheral rim of enhancement, considered as infarction (Figure 3).\n\nA serum test for antineutrophil cytoplasmic antibodies was positive by immunofluorescence in a perinuclear (pANCA) pattern (titer, 1:160).\n\nBiopsies of the kidney, skin and nasal mucosa were performed.",
    "discussion": "Wegener\u2019s granulomatosis is a rare multisystem disease that, in its full-blown state, is characterised pathologically by necrotising granulomatous inflammation of the upper and lower respiratory tracts, glomerulonephritis, and necrotising vasculitis of the lungs and many systemic organs and tissues. A variety of aetiological agents and pathogenic processes have been considered including heredity, infectious organisms, antibodies, antigen-antibody complex deposition and cell-mediated immunity.\n\nThere are four criteria in the diagnosis: a) nasal or oral inflammation;  b) an abnormal chest radiograph; c) an abnormal urinary sediment; and d) granulomatous inflammation on a biopsy specimen. At least two of these criteria are necessary for the diagnosis of the disease. \nIn our patient renal biopsy showed focal necrotizing glomerulonephritis, nasal mucosa specimen revealed vasculitis and granulomatous inflammation, and finally skin biopsy showed inflammatory lesions.\n\nThoracic symptoms consist most often of non-productive cough, haemoptysis, dyspnoea and pleuritic pain. Sinusitis, nasal ulceration and symptoms from the upper respiratory tract are the most common manifestations (1). The typical pattern on the chest radiograph consists of multiple nodules of varying size, widely distributed, often with cavitations, peripheral spiculation and a feeding vessel. Other common findings are air-space consolidations and ground-glass opacities due to pulmonary haemorrhage. On CT, areas of consolidations may have a peribronchoarterial distribution or appear as wedge-shaped peripheral infiltrates abutting the pleura. CT may also demonstrate the presence of cavitation and bronchial wall involvement. The differential diagnosis of cavitated, vessel-related pulmonary lesions includes septic emboli, pulmonary infarcts and haematogenous metastases (1,2,3). \n\nSplenic involvement is rare in Wegener\u2019s granulomatosis. Focal or diffuse splenic infarction can occur from occlusion of distal parenchymal arteries due to the diffuse arteritis caused by the disease. This explains the massive infarction, as seen in this case. Depending on the clinical setting, haematoma, abscess and tumour should be considered in the differential diagnosis (4).",
    "differential_diagnosis": "Wegener's, granulomatosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001223/000001.jpg?itok=EX_mjOgk",
            "caption": "Chest radiograph shows patchy consolidations in both lung bases and in the middle lung zone."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001223/000002.jpg?itok=4OEjk14N",
            "caption": "Conventional CT at the level of the carina depicts two nodular-shaped consolidations in the right upper lobe in a central peribronchovascular distribution."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001223/000003.jpg?itok=PxK_Qejs",
            "caption": "HRCT at the level of the main bronchi presents a small cavitation in the right upper lobe, accompanied by a slight thickening of the adjacent peripheral bronchovascular bundles. A second consolidation in the apical segment of the right lower lobe abuts the pleura. A small pleural effusion is seen in the right interlobar fissure."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001223/000004.jpg?itok=5G6e9_mz",
            "caption": "HRCT at the level of the basal bronchi shows areas of ground-glass attenuation on the left."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001223/000005.jpg?itok=yh1pMTs0",
            "caption": "Post\u2013contrast conventional CT, mediastinal window settings, at the level of the main bronchi reveals necrotic areas in the right upper lobe consolidation."
          },
          {
            "number": "Figure 2e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001223/000006.jpg?itok=mvX0aK05",
            "caption": "Post-contrast conventional CT, mediastinal window settings, at the level of the lung bases discloses a small cavitary nodule abutting the pleura on the right and a large consolidation with  hypodense areas considered to represent necrosis on the left."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001223/000007.jpg?itok=j4ogkpeo",
            "caption": "Post-contrast abdominal CT near the upper splenic pole reveals an extensive hypodense lesion compatible with infarction which leaves intact only the peripheral rim of the spleen."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001223/000008.jpg?itok=_N-hmhF1",
            "caption": "Post-contrast abdominal CT near the lower splenic pole shows extension of necrosis throughout the entire splenic parenchyma."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/1223",
    "time": "30.10.2002"
  },
  "1272": {
    "case_id": 1272,
    "title": "Intrathoracic goitre",
    "section": "Chest imaging",
    "age": "70",
    "gender": "female",
    "diagnosis": "Intrathoracic goitre",
    "history": "Chronic dyspnoea and cough",
    "image_finding": "The patient presented with chronic dyspnoea and cough. The medical history was unremarkable.",
    "discussion": "Mediastinal goitre is a well-known benign disease. The descent of a cervical goitre below the plain of the thoracic inlet to become substernal in location, is fairly rare, but not exceptional, with an incidence, derived from several large series of operated patients, ranging from 1% to 13%. The importance of this particular location of the goitre arises chiefly from the fact that the thyroid is growing in a limited space with many surrounding structures that unavoidably, sooner or later, will be compressed or strained.\n\nThe goitre may provoke respiratory symptoms (such as cough, dyspnoea, or stridor) or difficulty in swallowing or may determine a superior vena cava syndrome with venous stasis in the neck and in the upper thorax, and with facial oedema. Left recurrent laryngeal paralysis may occur. \n\n\nThe substernal location, which already constitutes a complication of the basic thyropathy, can be further aggravated by incidental malignant transformation of the substernal goitre or by the development of a thyrotoxicosis due to hyper-functioning intra-thoracic thyroid tissue.\n\n\nConventional chest examination continues to be the basic roentgen procedure. The basis of the conventional studies is the analysis of the pleuro-mediastinal interfaces which represent the lateral mediastinal borders.\nThe anterior mediastinal line represents the thickness of the visceral and parietal pleura of the two contiguous upper lobes, possibly with a small amount of alveolar tissue interposed. Measuring no more than 1-2 mm in diameter it is commonly visualised on posteroanterior radiograms projected over the air column of the trachea, for several centimeters distal to the plane of the junction of the manubrium and the body of the sternum. \n\nThe goitre appears as a  right superior mediastinal mass with deviation of the anterior mediastinal line from right to left from above downward. The goitre may displace the trachea or the oesophagus. Other mediastinal structures may be shifted.  \n\nMost intrathoracic goitres are located in the right mediastinal compartment and tend to protrude to the right on the chest film. Posterior extension of a goitre into the middle mediastinum occurs occasionally. Goitres of this type always project to the right side on frontal radiograms. Rarely an ectopic mass of thyroid tissue called heterotopic mediastinal thyroid, is present in the  mediastinum and enlarges to form a visible mass lesion.\n\nGoiters can rarely extend into the posterior mediastinum. \n\nCT remains the study of choice, since it can be used to confirm the presence of mediastinal masses, but it also helps to define the location and extent of the lesion into different mediastinal compartments, adjacent organ involvement, or vascular involvement. The goitre is a well-defined mediastinal mass with important enhancement after IV contrast medium injection. It may be homogenous or heterogenous with calcifications. It shifts the mediastinal structures without evidence of adjacent organ infiltration. \n\nThe administration of contrast is problematic since it will make further lab and scintigraphic evaluation as well as treatment virtually impossible for several weeks or even months. \n\nIntrathoracic goitres are one of the commonest causes of upper mediastinal enlargement. The main differential diagnosis of anterior mediastinal masses include thymic benign and malignant neoplasms, a normal hyperplasic thymus, teratoid neoplasms (benign or malignant teratoma, dermoid cyst, seminoma, choriocarcinoma, or embryonal cell carcinoma), lymphoma, lymph node enlargement, pericardial disease (cyst, effusion, neoplasm), sternal lesions, haematoma and aneurysm of the ascending aorta of Valsalva.",
    "differential_diagnosis": "Intrathoracic, goitre",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001272/000001.jpg?itok=fDXamC7V",
            "caption": "The plain film demonstrates an upper right mediastinal mass."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001272/000002.jpg?itok=y_vsWbSC",
            "caption": "The trachea and the anterior mediastinal line are displaced to the left (arrows) demonstrating that the mass is in the anterior mediastinal compartment."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001272/000003.jpg?itok=asBlp6zc",
            "caption": "The intrathoracic mass is the thyroid (arrow). The CT demonstrates tracheal compression and displacement (arrowheads)."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001272/000004.jpg?itok=iOsueVsp",
            "caption": "Sagittal MPR reconstruction from the axial CT images after IV contrast administration demonstrating the anterior, retrosternal position of the goitre (arrow)."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/1272",
    "time": "12.01.2002"
  },
  "1281": {
    "case_id": 1281,
    "title": "CT demonstration of vertical veins",
    "section": "Chest imaging",
    "age": "52",
    "gender": "male",
    "diagnosis": "Vertical vein",
    "history": "An unusual vessel is detected left of the aortic arch on an axial CT slice in an asymptomatic patient.",
    "image_finding": "The patient was referred for a chest CT because of a nodular opacity in the right upper lobe seen on the chest radiograph. The CT demonstrated a vascular structure in the left upper mediastinum. It branched to the left brachiocephalic vein and had a vertical course in the mediastinum, left of the aortic arch. The vessel  also branched to veins arising from the left upper pulmonary lobe (Figures 1a-d). In addition, the CT demonstrated the absence of the left upper pulmonary vein at the level of the left main stem bronchus were it is usually located. \n\nA curved reconstruction obtained with multi-row detector CT in a similar case (Figure 2a) demonstrates the course of this unusual vessel.",
    "discussion": "The vertical vein is a congenital abnormality of the venous return of the left upper pulmonary lobe, representing up to one-third of all vascular congenital pulmonary disorders. It is seen in 2% of congenital cardiac malformations (1). Instead of draining to the left auricle, the venous blood of the left upper lobe goes to the superior vena cava through a vertically oriented mediastinal vein located left of the aortic arch. This course is similar to that of a systemic congenital venous variant, the left superior vena cava (2-4) - seen in 0.3% of asymptomatic individuals - because both vessels originate from the same congenital vein, the anterior cardinal vein. \n\nCT allows differentiation of these variants by demonstrating their inferior course and branching patterns. The vertical vein branches to the left upper lobe veins as seen in Figure 2a. The vertical vein is frequently misdiagnosed, mainly because it is considered to be a left superior vena cava (2,3). \n\nMR imaging can demonstrate the direction of the blood flow, which is upward in a vertical vein and downward in a superior vena cava (1). A vertical vein usually causes no functional impairment because it results in a non-cyanotic left-right shunt. It may be clinically important in cases of right upper lobectomy (cancer surgery of the right upper lobe) or pneumonectomy. However, a patient with a vertical vein may remain asymptomatic after a right upper lobectomy (Figures 3a and 3b).",
    "differential_diagnosis": "Vertical, vein",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001281/000001.jpg?itok=YnxVa66g",
            "caption": "Helical CT axial slice with iodine contrast injection at the level of the brachiocephalic vein (v). An abnormal left mediastinal vein is branching (white arrow) to it."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001281/000002.jpg?itok=_GYxeWOM",
            "caption": "Same examination as in Fig 1a. CT slice at the level of the aortic arch (Ao). The abnormal vein is located left of the aortic arch (white arrow) and is similar to a left superior vena cava. The right superior vena cava (star) is normal."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001281/000003.jpg?itok=tHrGmzWN",
            "caption": "Same examination as in Fig 1a. Axial slice at the level of the pulmonary trunc (PA). The abnormal mediastinal vein seen in Figures 1a and 1b is branching with vessels arising from the left upper pulmonary lobe (white arrow). Aorta: Ao. Superior vena cava: star."
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001281/000004.jpg?itok=cDG_Get3",
            "caption": "Same examination as in Fig 1a. Axial CT slice at the level of the left auricle (LA). The arrow indicates the usual position of the left upper pulmonary vein, which is not seen in this case. White star: left lower lobe bronchus. Black star: superior vena cava."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001281/000005.jpg?itok=FYxbclVf",
            "caption": "Contrast-enhanced multi-row detector CT of the chest with 4 x 1mm collimation and a pitch of 2.  Curved multiplanar reformation demonstrating a vertical vein from its origin in the left upper pulmonary lobe to the left brachicephalic vein and the superior vena cava."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001281/000006.jpg?itok=Hg25xWSb",
            "caption": "Axial CT slice at the level of the aortic arch, showing an unusual rounded structure located left of the aorta (arrow). Patterns of right upper lobectomy are seen (pleural calcification and loss of volume of the right lung)."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001281/000007.jpg?itok=l5Q0Iuee",
            "caption": "Axial CT slice at the level of the left auricle. The left upper vein is missing at the anterior aspect of the left stem bronchus (white star)."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001281/000008.jpg?itok=-zFC-M6N",
            "caption": "Multiplanar reformation in the coronal plane showing the branching of the mediastinal vein with the left upper lobe pulmonary veins. On the right side, the pulonary loss of volume is demonstrated by the upward displacement of the right hemidiaphragm. LPA: left pulmonary artery. Ao: Aorta."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT",
      "CT",
      "CT",
      "MR"
    ],
    "link": "https://www.eurorad.org/case/1281",
    "time": "14.01.2002"
  },
  "1320": {
    "case_id": 1320,
    "title": "ndobronchial metastasis from renal cell carcinom",
    "section": "Chest imaging",
    "age": "80",
    "gender": "male",
    "diagnosis": "Endobronchial metastasis from renal cell carcinoma",
    "history": "The patient presented with recurrent episodes of haemoptysis, cough and dyspnoea. An endobronchial lesion was demonstrated on CT scanning of the chest.",
    "image_finding": "This patient was admitted to the hospital because of recurrent episodes of haemoptysis, cough and dyspnoea. Patient had history of renal cell carcinoma, and  right nephrectomy 2 years prior to the examination.\n\nOn physical examination respiratory sounds in the inferior right lung field were decreased. Routine blood tests were normal.\n\n A CT scan of the chest was performed. The examination revealed a 2.5-cm solid endobronchial lesion partially obstructing the main and lower lobe bronchus of the right lung.  Multiple areas of atelectasis were present. An enlarged lymph node, 4 cm in diameter, was present in the anterior superior mediastinum. Bronchoscopy confirmed the presence of an endobronchial\npolypoid lesion protruding into the lumen of the main and lower lobe bronchus of the right lung. Histological examination of the lesion revealed\nan endobronchial metastasis of renal cell carcinoma.",
    "discussion": "The lung is an extremely common site for metastases from extrathoracic\ntumours. Endobronchial metastases from non-pulmonary carcinoma is uncommon, occurring in only 2-5% of patients with cancer, according to autopsy findings [1-3]. \nThe tumours showing endobronchial metastasis with greatest frequency are, in decreasing order: breast cancer, renal cell cancer, colon cancer and melanoma. Other authors have found that renal cell carcinoma is\nthe most common lesion involving the bronchus secondarily [4].\n\n Tumour dissemination occurs by haematogenous or lymphatic spread. In fact the bronchi are supplied by the systemic circulation and receive centripetal\nlymphatic drainage, and thus distal tumour emboli can migrate into the\nbronchus. The most typical symptoms are coughing and haemoptysis, while dyspnoea is seen less frequently. The radiological manifestations are various and can mimic a central bronchogenic carcinoma. The most typical manifestation is a partial or complete atelectasis [3].\n\n The most frequent sites for metastasis from renal cell carcinoma are: lung, ganglia, liver, adrenal glands, controlateral kidney and brain.\nEndobronchial metastasis are very rare.\n\n After surgical removal of renal cell carcinoma, follow-up imaging is especially important in the first 2 years, when recurrence is most likely [5].",
    "differential_diagnosis": "Endobronchial, metastasis, from, renal, cell, carcinoma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001320/000001.jpg?itok=bVC0JE-c",
            "caption": "Enhanced CT scan showing a solid endobronchial lesion obstructing the right principalis bronchus (arrow). A round 4-cm node is seen on the anterior mediastinum (arrowhead)."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001320/000002.jpg?itok=ZEJgRpdV",
            "caption": "Enhanced CT scan showing a solid endobronchial lesion obstructing the  right inferior bronchus (arrow)."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001320/000003.jpg?itok=AB28hxz6",
            "caption": "Enhanced CT scan showing a solid endobronchial lesion obstructing the  right inferior bronchus (arrow)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001320/000004.jpg?itok=luCOOFcc",
            "caption": "On the parenchymal window diffuse multiple areas of atelectasis on the superior and inferior right lobe are well demonstrated."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001320/000005.jpg?itok=FxuiTWNv",
            "caption": "On the parenchymal window diffuse multiple areas of atelectasis on the superior and inferior right lobe are well demonstrated."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/1320",
    "time": "24.10.2001"
  },
  "1329": {
    "case_id": 1329,
    "title": "Sternal metastasis from breast cance",
    "section": "Chest imaging",
    "age": "62",
    "gender": "female",
    "diagnosis": "Osteolytic metastasis from breast cancer",
    "history": "The patient had undergone complete mastectomy of the left breast 3 years previously. At follow-up, a painful and localised mass was detected in the upper part of the sternum on clinical examination.",
    "image_finding": "The patient underwent mastectomy of the left breast 3 years before. At follow-up, a painful and localised mass was detected in the upper part of the sternum on clinical examination.\nAfter conventional x-ray examination, showing an osteolytic lesion, a CT scan was performed.",
    "discussion": "Solitary bone metastases are not a rare finding in breast cancer follow-up. These are found most frequently in the spine, the bone of thorax and the femur neck.\nThe sternum is a rare location for solitary metastasis. \n\nDiagnosis is mainly by nuclear imaging even if, as in this case, the history points clearly to the possibility of a metastasis from breast cancer. Biopsy confirms the nature of the osteolytic mass.",
    "differential_diagnosis": "Osteolytic, metastasis, from, breast, cancer",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001329/000001.jpg?itok=gB6Oa66o",
            "caption": "The cranial portion of the body of the sternum shows a dishomogeneous aspect."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001329/000002.jpg?itok=gLs0ehT-",
            "caption": "A lytic area is displayed in median-paramedian position inside the spongy bone."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001329/000003.jpg?itok=v1tHNoxl",
            "caption": "The cortical bone appears thinner than usual and the lytic area is enlarged in a caudal slice."
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001329/000004.jpg?itok=mzQMFMyh",
            "caption": "The bone structure is completely destroyed and a lytic lesion appears clear in nodular shape."
          },
          {
            "number": "Figure 1e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001329/000005.jpg?itok=il-hXh3t",
            "caption": "A sclerotic region is also present inside the nodular lesion."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/1329",
    "time": "29.09.2002"
  },
  "1343": {
    "case_id": 1343,
    "title": "Foreign-body aspiration in a young girl",
    "section": "Chest imaging",
    "age": "2",
    "gender": "female",
    "diagnosis": "Unilateral hyperinflation of the right lung due to foreign-body aspiration.",
    "history": "Sudden onset of persistent cough and difficulty breathing.",
    "image_finding": "The patient was referred with sudden onset of persistent cough and difficulty breathing. She had recently been treated with antibiotics for an angina that persisted for 2 weeks.\nPhysical examination revealed a mildly raised body temperature (38.3\u00b0C) and bilateral wheezing. The child's overall appearance was rather good. A routine laboratory examination showed a CRP of 3.1 mg/dl and a white blood cell count of 12,200 with normal differentiation. There was no history suggestive of foreign-body aspiration.\nA chest radiograph showed an asymmetric, unilateral and right-sided hyperaeration with increased transparency of the right lung (Figure 1). Following this finding a CT examination of the thorax was performed, confirming a hyperlucent and overexpanded right lung (Figure 2). A closer examination of the mediastinum revealed a small soft tissue mass in the main right bronchus, causing an endobronchial obstruction (Figure 3 a,b). \nFurther endoscopic examination revealed an aspirated peanut, which was consequently removed.",
    "discussion": "Airway foreign bodies are a common and serious clinical problem in children, with a peak incidence at the age of 1-2 years. Peanuts are the most frequently retrieved objects on endoscopic examination. The foreign body is more commonly located on the right side, because the carinal angle is here less acute than on the left side [2].\nImaging findings include hyperinflation, air trapping, regional oligaemia, consolidation, pleural fluid, pneumomediastinum, pneumothorax and bronchiectasis [3,4]. A complete bronchial obstruction may lead to total atelectasis of the affected lung. \nOne must always remember that a normal inspiration chest radiograph does not exclude an airway foreign body. If the child is cooperative and the initial chest radiograph is not conclusive, an expiratory radiograph under fluoroscopic monitoring is recommended [1]. On inspiration, the mediastinum shifts to the affected side, and on expiration it moves again to the normal side.\nSerious complications may arise from aspirated foreign bodies, sometimes leading to death [1,2]. Long-standing airway foreign bodies are associated with considerable morbidity. Also, clinical symptoms and radiographic findings are not pathognomonic [2]. For these reasons a diagnostic endoscopy must always be performed when the history is compatible with foreign-body aspiration, with or without radiological confirmation [5].",
    "differential_diagnosis": "Unilateral, hyperinflation, of, the, right, lung, due, to, foreign-body, aspiration.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001343/000001.jpg?itok=s-3Qo_CT",
            "caption": "The initial chest radiograph clearly shows an asymmetric expansion of the thorax, with a right-sided hyperaeration and shift of the mediastinum to the left side. These findings are suggestive of an obstructive air trapping process on the right mainstem bronchus."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001343/000002.jpg?itok=2EPUohy2",
            "caption": "This CT image shows the hyperlucent and overexpanded right lung and the mediastinal shift to the left."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001343/000003.jpg?itok=nu5cuxiF",
            "caption": "A closer examination of the mediastinal bronchial structures reveals a small mass with soft tissue density in the main right bronchus, responsible for an endobronchial obstruction with consequently air trapping in the right lung."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001343/000004.jpg?itok=kJzlkpq9",
            "caption": "Retrospectively, the shape of the soft tissue mass indeed closely resembles that of the aspirated peanut."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT",
      "CT",
      "MR"
    ],
    "link": "https://www.eurorad.org/case/1343",
    "time": "18.02.2002"
  },
  "1373": {
    "case_id": 1373,
    "title": "Tension pneumothorax",
    "section": "Chest imaging",
    "age": "50",
    "gender": "female",
    "diagnosis": "Tension pneumothorax",
    "history": "Elderly lady with acute onset shortness of breath and right sided pleuritic chest pain",
    "image_finding": "The patient presented with acute shortness of breath and right-sided pleuritic chest pain. She was a smoker. On clinical examination she was alert, tachypnoeic, acyanotic and apyrexial. The trachea was deviated to the right, with decreased air entry on the right, and the right upper chest was more resonant. X-ray examination showed a pneumothorax with pleural tethering, but the most crucial finding on the chest X-ray was the eversion of the anterior costophrenic gutter, which suggested that the pneumothorax was under tension. CT examination of the thorax confirmed subtotal collapse of the right lung. Immediate release of the tension pneumothorax with an 8.5 pigtail catheter drain led to almost complete expansion of the lung.",
    "discussion": "Air in the pleural space is known as pneumothorax.  There are several causes of adult pneumothorax, including spontaneous primary and spontaneous secondary (airflow obstruction, pulmonary infection, pulmonary infarction, neoplasm, diffuse lung disease, etc), traumatic and iatrogenic causes. Tension pneumothorax is the one that is life threatening and here intra-pleural pressure becomes positive relative to atmospheric pressure for a significant part of the respiratory cycle. It is usually found in the setting of trauma, but it is important to diagnose this condition immediately, even in the absence of trauma.\n\nThe radiographic appearance of a pneumothorax depends critically on radiographic projection, the patient's position and the presence or absence of loculation. Erect chest X-ray in inspiration and expiration is used as the first line of investigation. On a supine film the sensitivity for diagnosis is only 50-70%, depending on the size of the pneumothorax. CT examination of the chest is more sensitive and may be limited to lung bases. Radiographic findings of a tension pneumothorax include a completely collapsed lung, deviation of the trachea, and mediastinal shift to the contra-lateral side. Depression of the diaphragm is a more important and useful observation than mediastinal shift, especially if there is pre-existing tethered pleura. \n\nTension pneumothorax is unusual in primary pneumothorax and is commonly seen in association with trauma or mechanical ventilation. Treatment is immediate decompression. Complications of pneumothorax include pleural fluid, re-expansion pulmonary oedema, recurrence and pneumomediastinum/pneumoperitoneum. If tension pneumothorax is left untreated it may prove to be fatal.",
    "differential_diagnosis": "Tension, pneumothorax",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001373/000001.jpg?itok=PuV5ZM4z",
            "caption": "Frontal chest X-ray showing a right-sided pneumothorax. Although the amount of air in the pleural cavity appears relatively insignificant, note the depression of the right hemidiaphragm and tethering of the pleura. The presence of the former suggests tension."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001373/000002.jpg?itok=D8PUbiQ9",
            "caption": "Image through the apex showing a large pneumothorax."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001373/000003.jpg?itok=3X1p7Jhg",
            "caption": "Scan through the hilum shows tethering of the visceral pleura, which disguises the extent of the condition."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001373/000004.jpg?itok=V0w-5bFW",
            "caption": "Image through the base showing similar tethering and depression of the right hemidiaphragm. (Left hemidiaphragm seen at this level.)"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001373/000005.jpg?itok=cYwFSW-x",
            "caption": "Drain in situ with almost complete re-expansion of the lung."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001373/000006.jpg?itok=wMNoAoKj",
            "caption": "Image through the hilum shows re-expansion."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/1373",
    "time": "20.10.2002"
  },
  "1389": {
    "case_id": 1389,
    "title": "CR 2002 COD #7: Bronchioloalveolar carcinoma of the lung",
    "section": "Chest imaging",
    "age": "70",
    "gender": "female",
    "diagnosis": "Bronchioloalveolar carcinoma of the lung",
    "history": "The patient was admitted to hospital with cough and progressive dyspnoea. Large amounts of mucous sputum were expelled during major cough attacks. There was no history of drug ingestion and no significant past medical history. Physical examination, including appropriate laboratory tests and pulmonary function tests, revealed diffuse pulmonary parenchymal involvement. Bronchoscopy showed normal major bronchi. Bronchoalveolar lavage was negative for malignancy.",
    "image_finding": "The patient was admitted to hospital with cough and progressive dyspnoea. Large amounts of mucous sputum were expelled during major cough attacks. There was no history of drug ingestion and no significant past medical history. Physical examination, including appropriate laboratory tests and pulmonary function tests, revealed diffuse pulmonary parenchymal involvement. Bronchoscopy showed normal major bronchi. Bronchoalveolar lavage was negative for malignancy.\n\nOn chest x-ray (Fig. 1), bilateral shaggy multiple pulmonary nodular densities, of various dimensions, producing confluent infiltrates were seen scattered in the middle and lower lung fields. There was no hilar enlargement or pleural effusion. On CT scanning (Fig. 2), multiple confluent nodules were seen in both upper lobes and in the right middle lobe. Ill-defined areas of consolidation were visible in both lower lobes. Opacified normally branching vessels were clearly visible within the low relative attenuation of consolidations.\n\nFour months later repeat chest x-rays (Fig. 3) demonstrated grouping of \"acinar\" shadows, with increased lung infiltration and one year after initial presentation chest x-rays (Fig. 4) demonstrated considerable advance of the disease with extensive infiltrative lesions, in both lower and middle lung fields.\n\nCT scans taken one year after initial presentation (Fig. 5) showed an increase in number and dimension of shadows throughout both lungs with radiolucencies in some of the nodules. There was no lymph node involvement or pleural effusion.\nA chest x-ray (Fig. 6) taken 14 months after initial presentation showed diffuse bilateral involvement with fluffy, extensive confluent infiltrates bilaterally.",
    "discussion": "Bronchioloalveolar carcinoma (BAC) is a variant of adenocarcinoma that constitutes about of 2-10% of all primary lung carcinomas. Of all cases of BAC 30-50% occur in women, with no other organ involvement . Usually there is no association with smoking. There is an increased incidence of this malignancy among patient with previous pulmonary scarring, fibrosis, diffuse interstitial inflammation or scleroderma. BAC begins as a single peripheral, well-differentiated, low-grade neoplasm that tends to spread by infiltrating contiguous lung parenchyma, using the lung structure as stroma. Aerogeneous spread of tumour cells to other parts of the lung results in diffuse pulmonary disease. Distant metastases occur via lymphatic and haematogenous routes. In the early unifocal stage the patient has no symptoms at all, or complains only of mild cough with bronchorrhoea. Abundant mucoid expectoration can produce hypovolaemia and electrolyte depletion, a symptom that indicates extensive lung disease.\nPotential cells of origin are mucin-secreting bronchial epithelial cells, non-ciliated secretory bronchiolar cells, and type 2 alveolar epithelial cells. Two general gross pathologic types are described: a tumour-like or nodular form and a diffuse form. The first form tends to remain localised and has an excellent prognosis after resection, while the second form represents an aggressive malignancy with poor prognosis regardless of surgery.\nRadiographically, BAC may have one of the following three patterns: solitary nodule or mass, localised area of parenchymal consolidation and multicentric or diffuse disease. X-ray films, in the first pattern, may show a non-specific peripheral well-circumscribed coin lesion, occasionally producing puckering of the pleura. Irregular margins are present in 73% of cases. This lesion often grows very slowly and can be relatively stable for as long as 5-10 years. Air bronchogram or pseudocavitation due to dilatation of intact air spaces from desmoplastic reaction, bronchiectasis and focal emphysema may be present in 60% of cases. In the second pattern, when the disease occurs locally, a lung segment or an entire lobe may become consolidated, resembling pneumonia. Alternatively, in the third pattern, when there is bronchogenic spread of the disease, a multinodular pattern, resembling haematogenous metastases, can be seen. Air-space consolidation due to mucous secretion may affect both lungs. Hilar and mediastinal lymph node involvement has been observed in 18% of patients. Pleural effusion is present in 8-10% of cases. True cavitations in BAC are uncommon and have been observed in 7% of cases. In conclusion, radiographically, the disease may resemble pyogenic or granulomatous inflammation, vascular, or tumoral disease.\nCytological examination of the sputum leads to the correct diagnosis in only about one-third of cases. Final diagnosis of the disease is based on histological examination of tissue obtained by transbronchial or open lung biopsy.\n\nThe condition of this patient was further aggravated despite the fact that adequate treatment was provided immediately after specific diagnosis. This report shows the radiological findings over 14 months in a case of BAC of the lung with no adenocarcinoma elsewhere in the body.",
    "differential_diagnosis": "Bronchioloalveolar, carcinoma, of, the, lung",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001389/000001.jpg?itok=OxEp2Tpt",
            "caption": "Bilateral shaggy multiple pulmonary nodular densities producing confluent infiltrates, of various dimensions are seen scattered in the middle and lower lung fields. There is no hilar enlargement or pleural effusion."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001389/000002.jpg?itok=jF69wVEe",
            "caption": "x"
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001389/000003.jpg?itok=wxIV8lpE",
            "caption": "x"
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001389/000004.jpg?itok=-wPaM5r2",
            "caption": "x"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001389/000005.jpg?itok=jdG8vRKl",
            "caption": "Multiple confluent nodules are seen in both upper lobes, and in the right middle lobe. Ill-defined areas of consolidation are seen in both lower lobes. Note the opacified normally branching vessels clearly visible within the low relative attenuation of consolidations."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001389/000006.jpg?itok=TX5Cytx1",
            "caption": "There is grouping of the 'acinar' shadows, with increased lung infiltration."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001389/000007.jpg?itok=JW3Uz45y",
            "caption": "x"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001389/000008.jpg?itok=OXbJPHbr",
            "caption": "Considerable advance of the disease is evident. There are extensive infiltrative lesions, in both lower and middle lung fields."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001389/000009.jpg?itok=sL30UsUW",
            "caption": "x"
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001389/000010.jpg?itok=bysDb2GK",
            "caption": "Increase in the number and dimension of shadows throughout both lung fields. Note the presence of radiolucencies in some of the nodules. There is no lymph node involvement or pleural effusion."
          },
          {
            "number": "Figure 5b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001389/000011.jpg?itok=NEFJeoGO",
            "caption": ""
          },
          {
            "number": "Figure 5c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001389/000012.jpg?itok=e3V1z_we",
            "caption": ""
          },
          {
            "number": "Figure 5d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001389/000013.jpg?itok=hq0p9CSn",
            "caption": ""
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001389/000014.jpg?itok=t9mnlFgV",
            "caption": "Diffuse bilateral involvement with fluffy, extensive confluent infiltrates bilaterally."
          },
          {
            "number": "Figure 6b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001389/000015.jpg?itok=-8-3H5xC",
            "caption": "x"
          },
          {
            "number": "Figure 6c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001389/000016.jpg?itok=vV6YIL5g",
            "caption": "x"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT",
      "MR",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/1389",
    "time": "11.04.2002"
  },
  "1402": {
    "case_id": 1402,
    "title": "CR 2002 COD #19: Diffuse alveolar haemorrhage in systemic lupus erythematosus",
    "section": "Chest imaging",
    "age": "53",
    "gender": "female",
    "diagnosis": "Diffuse alveolar haemorrhage in systemic lupus erythematosus",
    "history": "The patient, who had a 3-month history of systemic lupus erythematosus, was admitted to our hospital with mild haemoptysis, dyspnoea, cough, weakness, tachycardia, cyanosis and fever. Physical examination revealed fine crackles and dullness to percussion over both lower and upper lung areas. In the 2 days following admission the symptoms and the respiratory situation worsened.",
    "image_finding": "The patient, who had a 3-month history of systemic lupus erythematosus, was admitted to our hospital with mild haemoptysis, dyspnoea, cough, weakness, tachycardia, cyanosis and fever. Physical examination revealed fine crackles and dullness to percussion over both lower and upper lung areas. In the 2 days following admission the symptoms and the respiratory situation worsened.\n\nChest X-rays and control examinations were subsequently performed. In addition on the first day a spiral computed tomography (CT) examination of the lung was performed. \n\nThe initial chest X-ray showed a bilateral reticulonodular pattern with superimposed ground-glass opacities and patchy air-space consolidation. A control chest X-ray showed rapid resolution of the consolidation with persistence of the bilateral pleural effusions.\n\nSpiral CT of the lung showed patchy areas of ground-glass opacity and consolidation, and pleural effusion bilaterally with compression atelectasis.",
    "discussion": "Pleuropulmonary disease in systemic lupus erythematosus includes:\nPleuritis with and without effusion \nAcute lupus pneumonitis \nInterstitial pneumonitis with fibrosis \nPulmonary haemorrhage \nPulmonary thromboembolism \nBOOP \n\nDiffuse alveolar haemorrhage is a rare manifestation with an incidence of 1.6%. The triad of anaemia, air-space consolidation and haemoptysis should support the possibility of pulmonary haemorrhage. Because of the prognostic implications, the diagnosis should be considered in a patient who has dyspnoea and diffuse air-space consolidation even in the absence of haemoptysis [1]. Anaemia with a dropping haematocrit in the face of worsening radiological abnormalities, as in this case, is characteristic. After cessation of bleeding, radiographic and clinical improvement is rapid. Transbronchial biopsy confirmed the underlying vasculitis in this case.\n\nCT findings supporting pulmonary haemorrhage include: patchy or diffuse ground-glass opacity, consolidation or both, as well as ill-defined centrilobular nodules and interlobular septal thickening developing over days, occasionally with superimposition of the signs (crazy-paving) [3]. \n\nThe main differential diagnoses regarding the aetiology of diffuse pulmonary haemorrhage include antiglomerular basement membrane diseases (Goodpasture's syndrome, other collagen-vascular diseases, Wegener's granulomatosis), anticoagulation and thrombocytopenia. Systemic lupus erythematosus-related thrombocytopenia can be an aggravating factor for pulmonary haemorrhage. \n\nThe patient was treated only with corticosteroids and received oxygen for the first 3 days. At follow-up over 1 week the clinical symptoms resolved.",
    "differential_diagnosis": "Diffuse, alveolar, haemorrhage, in, systemic, lupus, erythematosus",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001402/000001.jpg?itok=r3_D60Og",
            "caption": "Bilateral reticulonodular pattern with superimposed ground-glass opacities and patchy air-space consolidation."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001402/000002.jpg?itok=JiNhKJfX",
            "caption": "Control chest X-ray after 5 days showing rapid resolution of the consolidation with persistence of the bilateral pleural effusions."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001402/000003.jpg?itok=lURDh4Mj",
            "caption": "Pleural effusion bilaterally with compression atelectasis."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001402/000004.jpg?itok=e6Agq1Cf",
            "caption": "Pleural effusion bilaterally with compression atelectasis."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001402/000005.jpg?itok=D4-EDspx",
            "caption": "Patchy areas of ground-glass opacity and consolidation."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001402/000006.jpg?itok=zXBz2uWJ",
            "caption": "Patchy areas of ground-glass opacity and consolidation."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/1402",
    "time": "26.05.2002"
  },
  "1437": {
    "case_id": 1437,
    "title": "Swyer-James Syndrome",
    "section": "Chest imaging",
    "age": "40",
    "gender": "female",
    "diagnosis": "Swyer-James syndrome (MacLeod's syndrome)",
    "history": "The radiological findings of a hyperlucent lung with air trapping, bronchiectasis and a hypoplastic pulmonary artery are typical for the Swyer-James syndrome (MacLeod's syndrome).",
    "image_finding": "The patient presented in the emergency room because of left-sided chest pain, probably of musculo-skeletal origin. The conventional chest radiograph demonstrated a hyperlucent left lung, with evidence for hypoperfusion. CT scan was performed to rule out pulmonary embolism.Conventional chest radiograph (PA-view)  shows a hyperlucent left hemithorax and small left hilum. Rarefaction of the pulmonary vessels is noted.\nContrast-enhanced CT scan of the thorax  shows hypoplastic left pulmonary artery, compared to the right side. No pulmonary embolism is seen.\nHigh resolution CT scan of the lungs  demonstrates on the scans taken during breath hold in inspiration  a reduced density of the lung parenchyma on the left. Areas with cystic bronchiectasis in the posterobasal segment of the left lung are also seen. Scans taken during expiration  demonstrate a slight mediastinal shift to the right. No change in density nor volume of the left lung compared to the inspiratory scan is noted. The radiological findings of a hyperlucent lung with air trapping, bronchiectasis and a hypoplastic pulmonary artery are typical for the Swyer-James syndrome (MacLeod's syndrome).",
    "discussion": "Swyer-James syndrome is characterised by hyperlucent lung with air trapping. The cause seems to be a viral infection of the airways in the early childhood. The bronchiolitis prevents the normal development of the peripheral airways and leads to a reduced pulmonary perfusion. Therefore hypoplasia of the pulmonary arteries is another typical finding is this syndrome. The resulting postinfectious bronchiolitis obliterans causes the air trapping and bronchiectasis which are often found in patients with the syndrome. Bronchiectasis can lead to recurrent pulmonary infections and therefore influence the prognosis of the disease. According to the literature, patients without bronchiectasis or with cylindrical bronchiectasis have a lower incidence of pneumonias and therefore a better prognosis than those with cystic bronchiectasis. The extent and the type of bronchiectasis are best demonstrated with a high-resolution CT. In- and expiratory scans clearly depict the amount of air trapping.",
    "differential_diagnosis": "Swyer-James, syndrome, (MacLeod's, syndrome)",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001437/000001.jpg?itok=0plN6t1K",
            "caption": "shows a hyperlucent left hemithorax and small left hilum. Rarefaction of the pulmonary vessels is noted."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001437/000002.jpg?itok=xpsp6MqV",
            "caption": "shows hypoplastic left pulmonary artery, compared to the right side. No pulmonary embolism is seen."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001437/000003.jpg?itok=YKBjTk6L",
            "caption": "demonstrates on the scans taken during breath hold in inspiration  a reduced density of the lung parenchyma on the left."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001437/000004.jpg?itok=VFCMwBs5",
            "caption": "demonstrates on the scans taken during breath hold in inspiration  a reduced density of the lung parenchyma on the left."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001437/000005.jpg?itok=rsl_Gm-N",
            "caption": "Areas with cystic bronchiectasis inthe posterobasal segment of the left lung are also seen. Scans taken during expiration  demonstrate a slight mediastinal shift to the right."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT",
      "CT",
      "MR"
    ],
    "link": "https://www.eurorad.org/case/1437",
    "time": "13.01.2002"
  },
  "1461": {
    "case_id": 1461,
    "title": "Bronchial atresi",
    "section": "Chest imaging",
    "age": "57",
    "gender": "female",
    "diagnosis": "Bronchial atresia of the lateral basal segment of the right lower lobe",
    "history": "A known asthmatic, who had been under the care of her GP for 7 years, presented with an acute exacerbation. A chest radiograph showed a trefoil-shaped mass lesion in the right lower zone.",
    "image_finding": "A known asthmatic, who had been under the care of her GP for 7 years, presented with an acute exacerbation. A chest radiograph showed a trefoil-shaped mass lesion in the right lower zone. On questioning the patient recalled that she had  \"scarring of her right lung\",  seen on a chest radiograph about 7 years previously in a different hospital. Bronchoscopy and bronchial washings were normal. \nA CT examination of the thorax was performed to assess the right lower zone lesion. Dynamically enhanced CT showed no enhancement of the lesion. There was no additional mass lesion or pathologically enlarged mediastinal lymph nodes. The liver and adrenals were normal. Follow-up radiographs showed no change in the appearance of the lesion.",
    "discussion": "Bronchial atresia is a rare benign condition that can give rise to considerable diagnostic confusion. This anomaly comprises a focal obliteration of a lobar or segmental bronchus. The bronchi distal to the atretic segment are normal except for the lack of communication with the more proximal bronchus. Distal bronchi continue to secrete mucus since they are lined by respiratory epithelium. Proposed causes are (1) local interruption of bronchial arterial perfusion after 15 weeks of gestation when bronchial branching is complete or (2) primitive bronchial bud separation with continual growth  of the distal tip. The lesion  is usually asymptomatic. \n\nA characteristic triad is often present and is more readily seen on CT than plain radiography:\n1.\tLocalised central mass density representing mucus plug impacted in the patent distal bronchus,\n2.\tSurrounding low attenuation changes due to hyperinflation, and \n3.\tHypoperfusion of the affected segment. \n\nCollateral air drift keeps the segment inflated and it becomes hyperinflated as a result of expiratory air trapping. The hypoperfusion probably reflects hypoplasia of the vessels resulting from hypoxia in the affected segment. It is most commonly seen to involve the left upper lobe bronchus. Usually no treatment is necessary. Recognition of this condition avoids unnecessary intervention.",
    "differential_diagnosis": "Bronchial, atresia, of, the, lateral, basal, segment, of, the, right, lower, lobe",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001461/000001.jpg?itok=P3LIeZjU",
            "caption": "PA chest radiograph showing right lower zone mass lesion."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001461/000002.jpg?itok=dIi2IrGV",
            "caption": "Magnified view of the lesion."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001461/000003.jpg?itok=JFxRMMME",
            "caption": "CT image through the lesion in mediastinal window settings showing the mucus-filled patent bronchus distal to the atretic segment."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001461/000004.jpg?itok=FXb5rBVO",
            "caption": "Image throgh the mass lesion showing trefoil shaped mucus filled distal bronchial segment with surrounding hyperinflated lung and hypoplastic vessels."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001461/000005.jpg?itok=c6yciPXO",
            "caption": "Trefoil-shaped mass lesion due to mucus-filled patent bronchial segment distal to the atretic segment. Note the surrounding hyperinflated lung and hypoplastic vessels in the affected segment."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001461/000006.jpg?itok=idlOutGp",
            "caption": "Trefoil-shaped mass lesion due to mucus-filled patent bronchial segment distal to the atretic segment. Note the surrounding hyperinflated lung and hypoplastic vessels in the affected segment."
          },
          {
            "number": "Figure 2e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001461/000007.jpg?itok=YGDHzZZ6",
            "caption": "Trefoil-shaped mass lesion due to mucus-filled patent bronchial segment distal to the atretic segment. Note the surrounding hyperinflated lung and hypoplastic vessels in the affected segment."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/1461",
    "time": "15.07.2002"
  },
  "1483": {
    "case_id": 1483,
    "title": "Anderson Lesion in Ankylosing Spondylitis",
    "section": "Chest imaging",
    "age": "47",
    "gender": "male",
    "diagnosis": "Andersson lesion",
    "history": "The imaging findings are characteristic for an Andersson lesion which is a pseudoarthrosis in ankylosing spondylitis.",
    "image_finding": "The patient, suffering from ankylosing spondylitis since 1972, was admitted because of severe back pain. The pain had been continuously present over a period of 4-5 months, and could not be relieved with medication.Conventional radiograph of the thoraco-lumbar spine, lateral view shows destruction of the endplates at the level of TH12-L1. There is reactive sclerosis, extending for a varying depth into the vertebral bodies. Increased height of the disc space is noted. The same destruction is present in the apophyseal joints. Ankylosis at other levels of the spine is observed.\nCT scan of the thoraco-lumbar spine, 2-D reconstruction level, TH12-L1demonstrates widening of the disc space TH12-L1 with extensive sclerosis of the endplates. Similar involvement of the apophyseal joints is seen. \nMRI of the thoraco-lumbar spine  shows on sagittal gradient echo T2-weighted image a wide disc space with high signal-intensity, together with low signal-intensity of the endplates and subchondral areas. \nOn Gd-enhanced sagittal SET1-weighted image with fat suppression pronounced enhancement of the endplates (disco-vertebral junction), with no enhancement of the central part of the disc is observed. The same changes are seen at the level of the posterior elements. The imaging findings are characteristic for an Andersson lesion which is a pseudoarthrosis in ankylosing spondylitis.",
    "discussion": "Andersson was the first to report disco-vertebral destructive lesions occurring in ankylosing spondylitis. The radiological features of these abnormalities are: reduction or enlargement of the affected disc space, vertebral body defect with a wide surrounding zone of sclerosis and angular kyphosis of the affected spinal segment.\nAccording to the literature distinction is made between the inflammatory and non-inflammatory type of disco-vertebral destructive lesions. The inflammatory type is caused by invasion of the disc by granulation tissue through defects in the vertebral plates. Radiologically, a reduction of the disk space is seen, with a defect of the vertebral bodies and dense sclerosis of the cancellous bone. \nThe non-inflammatory type occurs during the advanced stage of ankylosing spondylitis. The lesions correspond with a pseudoarthrosis and/ or a transdiscal stress fracture in an osteoporotic, rigid spine. Microscopically, the disk has been replaced by fibrous tissue consisting of a poorly vascularised central zone with areas of fibrinoid necrosis, and a peripheral zone which contains irregular bundles of collagen fibers and aggregates of blood vessels. Inflammatory cells are absent or negligible. \nThese lesions are localised near the thoraco-lumbar junction. Usually there is also a fracture or mobile facet joint. Extension of the lesion is best shown on CT scan, while demonstration of its relation to the myelum and differentiation from true infectious spondylitis and primary or metastatic tumors of the spine, is best done by MRI.\nThe term Andersson lesion should be used to include all disco-vertebral lesions related to ankylosing spondylitis whether or not of inflammatory origin.",
    "differential_diagnosis": "Andersson, lesion",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001483/000001.jpg?itok=IMdjT-WM",
            "caption": "lateral view  shows destruction of the endplates at the level of TH12-L1."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001483/000002.jpg?itok=qlVrbnFd",
            "caption": "2-D reconstruction level, TH12-L1  demonstrates widening of the disc space TH12-L1 with extensive sclerosis of the endplates. Similar involvement of the apophyseal joints is seen."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001483/000003.jpg?itok=OGrwnHNr",
            "caption": "shows on sagittal gradient echo T2-weighted image (fig. 3 A) a wide disc space with high signal-intensity, together with low signal-intensity of the endplates and subchondral areas."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001483/000004.jpg?itok=gKSDfSL_",
            "caption": "On Gd-enhanced sagittal SET1-weighted image with fat suppression  pronounced enhancement of the endplates (disco-vertebral junction), with no enhancement of the central part of the disc is observed. The same changes are seen at the level of the posterior elements."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT",
      "MR"
    ],
    "link": "https://www.eurorad.org/case/1483",
    "time": "12.02.2002"
  },
  "1486": {
    "case_id": 1486,
    "title": "Anomalous Pulmonary Venous Drainage",
    "section": "Chest imaging",
    "age": "55",
    "gender": "male",
    "diagnosis": "Vertical vein",
    "history": "CT findings are characteristic of a vertical vein, an anomalous venous return of the left superior pulmonary lobe.",
    "image_finding": "A chest computed tomography (CT) is performed 4 years after a right inferior pulmonary lobectomy for lung cancer in a patient. Preoperative CT had demonstrated a left superior vena cava. On CT scan of the chest at the level of the aortic arch  a vertical vessel is seen left to the aortic arch (arrow). The (right) superior vena cava is in a normal position.\nOn CT scan of the chest at the level of the left main bronchus (star)  the left superior pulmonary vein is not seen in its normal position i.e. anteriorly to the left main bronchus. \nOn CT scan of the chest, pulmonary window setting at the level of the aortico-pulmonary recess, pulmonary veins are branching toward the anomalous mediastinal vein. \nOn CT scan of the chest with coronal reconstruction  there is branching of the left upper lobe pulmonary veins into the mediastinal vein (arrow). AO = Aortic arch. LPA = left pulmonary artery.\nCT findings are characteristic of a vertical vein, an anomalous venous return of the left superior pulmonary lobe.",
    "discussion": "A vertical vein represents one third of all venous pulmonary abnormalities and is seen in 2% of all congenital cardiac malformations. Instead of draining into the left auricle, the blood of the left upper lobe is drained into the superior vena cava through a vertical ascending mediastinal vein and the left brachiocephalic vein. The appearance of the vertical vein is similar to that of another congenital variant, the left superior vena cava (LSVC), much more frequent, seen in 0.3% of all individuals and draining into the coronary sinus. The LSVC and the vertical vein originate from the anterior cardinal vein. Chest CT scan allows a correct diagnosis by demonstrating the precise anatomy. Differential diagnosis is made on cross sectional images. Normally only the left superior vein is seen anteriorly of the left main stem bronchus. In case of LSVC, two veins are seen while in case of a vertical vein, there are no veins in this location. MRI gives additional information about the direction of the blood flow, craniocaudal in the LSVC and caudocranial in the vertical vein. A non-cyanotic and asymptomatic left to right shunt is associated with the vertical vein. Clinically respiratory impairment may be seen if a massive pulmonary tromboembolism occurs or after a right pulmonary lobectomy or pneumonectomy. Our patient had no impairment after his right inferior lobectomy.",
    "differential_diagnosis": "Vertical, vein",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001486/000001.jpg?itok=DsZ_VW16",
            "caption": "a vertical vessel is seen left to the aortic arch (arrow). The (right) superior vena cava is in a normal position."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001486/000002.jpg?itok=cX2KhIYC",
            "caption": "the left superior pulmonary vein is not seen in its normal position i.e. anteriorly to the left main bronchus."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001486/000003.jpg?itok=jfnaf0bt",
            "caption": "pulmonary window setting at the level of the aortico-pulmonary recess, pulmonary veins are branching toward the anomalous mediastinal vein."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001486/000004.jpg?itok=41ApLgSs",
            "caption": "there is branching of the left upper lobe pulmonary veins into the mediastinal vein (arrow). AO = Aortic arch. LPA = left pulmonary artery."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT",
      "CT",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/1486",
    "time": "12.02.2002"
  },
  "1568": {
    "case_id": 1568,
    "title": "Tracheobronchopathia osteochondroplastic",
    "section": "Chest imaging",
    "age": "41",
    "gender": "male",
    "diagnosis": "Tracheobronchopathia  osteochondroplastica",
    "history": "A patient with a history of mild restrictive lung disease, asbestos exposure, ozaena and recurrent respiratory tract infections, presented with a severe infection of the lower airways.",
    "image_finding": "A patient with a history of mild restrictive lung disease, asbestos exposure, ozaena and recurrent respiratory tract infections, presented with a severe infection of the lower airways.\n\nBronchoscopic evaluation revealed a severe inflammation of the tracheobronchial mucosa and submucosal nodules protruding into the lumen of the trachea and bronchi.\n\nA plain chest X-ray film was obtained and a CT examination of the chest was performed.",
    "discussion": "Tracheobronchopathia  osteochondroplastica, which was first described by Rokitansky in 1855, is a rare disease of the respiratory tract, characterised by the presence of osseous and cartilaginous nodules in the tracheobronchial tree.\nSeventy-five percent of patients are male, and presentation is usually in middle age.\n\nThe majority of patients remain asymptomatic, but a small number develop severe airway stenosis. The common presenting symptoms are non-specific: dyspnoea, hoarseness, cough, haemoptysis and recurrent pulmonary infections. The simultaneous occurrence of ozaena is not rare. Chronic infection in the tracheal mucosa can act as an aetiological factor in the pathogenesis. Chemical irritation and heredity also have been suggested as aetiological factors.\nThe chest radiograph may be normal or it may demonstrate atelectasis, consolidation and tracheal narrowing. CT reveals submucosal nodules with or without calcification and tracheal narrowing.\n\nThe posterior tracheal wall is characteristically not involved, as it lacks the cartilaginous  elements from which the nodules are thought to arise. In the case of posterior wall involvement other entities such as amyloidosis should be considered. In the absence of calcification, submucosal nodules with posterior wall involvement may represent tracheal papillomatosis or endobronchial sarcoidosis. The differential diagnoses of multiple nodules within the tracheobronchial tree therefore are papillomatosis, amyloidosis, sarcoidosis and neoplasm.\n\nBronchoscopic evaluation shows submucosal nodules, protruding into the lumen of the trachea and bronchi. In severe cases the tracheal mucosa can have a \"cobblestone appearance\".\n\nThe definitive diagnosis is made on pathology. The nodules are composed of hyaline cartilage and lamellar bone, which contains haematopoietic bone marrow elements.\n\nSymptomatic airway obstruction can be treated with laser surgery, bronchoscopic resection, radiation therapy and stenting.",
    "differential_diagnosis": "Tracheobronchopathia, osteochondroplastica",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001568/000001.jpg?itok=QDwJ4mHh",
            "caption": "PA view shows a subtle narrowing of the trachea."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001568/000002.jpg?itok=JPvFCN6N",
            "caption": "There is no evidence of narrowing on the lateral radiograph."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001568/000003.jpg?itok=3DeBsEA2",
            "caption": "Tracheobronchial narrowing and submucosal nodules with associated calcification protruding into the tracheobronchial lumen. These nodules only occur on the anterior and lateral tracheobronchial walls."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001568/000004.jpg?itok=Zk_26iu1",
            "caption": "Tracheobronchial narrowing and submucosal nodules with associated calcification protruding into the tracheobronchial lumen. These nodules only occur on the anterior and lateral tracheobronchial walls."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001568/000005.jpg?itok=T4Qwx_lQ",
            "caption": "Tracheobronchial narrowing and submucosal nodules with associated calcification protruding into the tracheobronchial lumen. These nodules only occur on the anterior and lateral tracheobronchial walls."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001568/000006.jpg?itok=93Gu3Ttl",
            "caption": "Tracheobronchial narrowing and submucosal nodules with associated calcification protruding into the tracheobronchial lumen. These nodules only occur on the anterior and lateral tracheobronchial walls."
          },
          {
            "number": "Figure 2e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001568/000007.jpg?itok=JB1n7c62",
            "caption": "Tracheobronchial narrowing and submucosal nodules with associated calcification protruding into the tracheobronchial lumen. These nodules only occur on the anterior and lateral tracheobronchial walls."
          },
          {
            "number": "Figure 2f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001568/000008.jpg?itok=ml4n8AGK",
            "caption": "Tracheobronchial narrowing and submucosal nodules with associated calcification protruding into the tracheobronchial lumen. These nodules only occur on the anterior and lateral tracheobronchial walls."
          },
          {
            "number": "Figure 2g",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001568/000009.jpg?itok=svDSIW4D",
            "caption": "Tracheobronchial narrowing and submucosal nodules with associated calcification protruding into the tracheobronchial lumen. These nodules only occur on the anterior and lateral tracheobronchial walls."
          },
          {
            "number": "Figure 2h",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001568/000010.jpg?itok=f6SIrsUq",
            "caption": "Tracheobronchial narrowing and submucosal nodules with associated calcification protruding into the tracheobronchial lumen. These nodules only occur on the anterior and lateral tracheobronchial walls."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/1568",
    "time": "16.10.2002"
  },
  "1583": {
    "case_id": 1583,
    "title": "Solitary pulmonary metastasis of mesocolic leiomyosarcom",
    "section": "Chest imaging",
    "age": "47",
    "gender": "male",
    "diagnosis": "Pulmonary metastasis from a colonic leiomyosarcoma",
    "history": "In a male patient a solitary pulmonary nodule was found in the right lower lobe. The patient had undergone a right-sided hemicolectomy and Whipple's procedure due to leiomyosarcoma of the colon 6 years previously.",
    "image_finding": "The patient, who had in 1994 undergone a right-sided hemicolectomy and Whipple's procedure due to leiomyosarcoma of the colon, was admitted again in April 2000 because of abdominal pain. Abdominal CT and ultrasound revealed a solid mass with a diameter of 10cm close to the region of the anastomosis. A recurrent disease of leiomyosarcoma of the colon was histologically confirmed after repeat laparotomy.\n \nA preoperative chest radiograph revealed a sharply delineated pulmonary nodule with a diameter of 2.5cm in the right lower lobe of the lung. CT of the chest confirmed a solitary pulmonary nodule in the right lower lobe. One month later, the patient underwent thoracotomy with segmental resection of the previously described lesion.",
    "discussion": "Leiomyosarcoma of the colon is a rare tumour of large intestine. In a collective review of all available case reports of smooth muscle (stromal) tumors of the appendix and large intestine in the world literatur, spanning from 1875 to 2000, a total number of 263 cases of leiomyosarcomas of colon is reported.  The peak age of incidence of leiomyosarcomas was 50 to 59 years. \nPrimary muscle tumours are exceedingly rare in the lungs despite the existence of smooth muscle cells in the tracheobronchial tree. Metastases of leiomyosarcoma are most commonly hepatic, but can  also involve bones or lungs. \nIn general, lung metastases present almost invariably as multiple pulmonary nodules. However, the differential diagnosis of a solitary pulmonary nodule is extensive and also includes the possibility of a solitary metastasis. Quint et al. reported that in patients with melanoma, bone tumours and soft tissue sarcomas with solitary pulmonary nodules more likely represent a solitary metastasis than primary lung cancer. \n\nWe conclude that, in patients with leiomyosarcoma, a single pulmonary nodule may represent a solitary metastasis. Radiological features do not reliably allow discrimination from other entities; thus, histological proof is necessary. The histological examination in this case revealed a solitary pulmonary metastasis from a colonic leiomyosarcoma.",
    "differential_diagnosis": "Pulmonary, metastasis, from, a, colonic, leiomyosarcoma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001583/000001.jpg?itok=NxFe-gLu",
            "caption": "PA view: 2.5cm spherical nodule in the right lower lobe."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001583/000002.jpg?itok=iwAY0qOF",
            "caption": "Lateral view: 2.5cm spherical nodule in the right lower lobe."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001583/000003.jpg?itok=jP2iPoB5",
            "caption": "CT scan Pulmonary window showing a well-defined 2.5cm spherical nodule in the right lower lobe."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001583/000004.jpg?itok=_9O0-vLJ",
            "caption": "Contrast material-enhanced spiral CT scan shows mesocolic tumor surrounding the left part of the transverse colon"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/1583",
    "time": "09.10.2002"
  },
  "1606": {
    "case_id": 1606,
    "title": "Intrathoracic phaeochromocytom",
    "section": "Chest imaging",
    "age": "21",
    "gender": "female",
    "diagnosis": "Phaeochromocytoma",
    "history": "A 21-year -old lady presented with hypertension and a posterior mediastinal mass and raised urinary catecholamines.",
    "image_finding": "A 21-year-old lady presented with hypertension which was difficult to control. She had blood and urine tests. Routine blood tests were normal. Renin/aldosterone were within normal limits. Tests for auto-immune tests were normal. Urine catecholamines were raised and a repeat test performed which too showed raised levels consistent with paeochromocytoma. ( Noradrenaline= 12.4, dopamine 3.39, HMMA 64 and HVA 9: all in micromol/spec). A chest x-ray showed a posterior mediastinal mass. CT, MRI and isotope scanning were performed. These were suggestive of phaeochromocytoma and the mass was operated upon.The histology was that of an extra-adrenal paraganglioma/pheochromocytoma.\nThe patient remains asymptomatic at follow-up. The raised levels of catecholamines in the urine returned to normal levels after surgery.",
    "discussion": "Phaeochromocytoma is a rare but important endocrine tumour. Clinical and biochemical manifestations are mainly caused by excess circulating catecholamines and hypertension. Manifestations mimic many conditions, which may result in erroneous diagnosis and improper treatment.\nSustained or paroxysmal hypertension associated with headaches, sweating, or palpitations, occurs in 95% of patients, but at least 5% are normotensive. All patients with manifestations of hypercatecholaminaemia or coexisting neoplasm should be investigated for phaeochromocytoma.\nThe diagnosis is made by finding raised plasma norepinephrine/epinephrine and/or raised urinary catecholamine. Plasma free metanephrines provide the best test for excluding or confirming phaeochromocytoma and should be the test of first choice for diagnosis of the tumour. The pentolinium suppression test (which does not affect an autonomous adrenal medullary tumour) is also diagnostic, but is considered dangerous.\nPhaeochromocytomas are usually large (some weighing as much as 4kg), but are occasionally only 3-5mm in diameter. Ten percent of tumours are extra-adrenal, 10% multiple and 10% malignant. Nearly 95% are within the abdomen. Many studies report a higher rate of malignancy for extra-adrenal phaeochromocytomas than for adrenal phaeochromocytomas. A recent paper by Goldstein et al. suggests that patients with extra-adrenal phaeochromocytomas have the same risk of malignancy and the same overall survival as patients with adrenal phaeochromocytomas. The commonest sites for extra-adrenal tumours are the renal hilum and the organ of Zuckerkandl. The tumour may be familial in Sipple's syndrome or MEN IIA and MEN IIB and is also associated with neurofibromatosis in 5% of cases. It may also be associated with tuberous sclerosis and von Hippel-Lindau syndrome.\nUltrasound can show these tumours if they are large and is the modality of choice in children. In adults, CT is the ideal imaging modality. Intravenous contrast enhancement is important.This may show uniform enhancement, rim enhancement being seen in tumours with necrosis. Hyperplastic adrenals show generalised enlargement with preservation of normal glandular configuration. A phaeochromocytoma is of mixed attenuation, and 7% show calcification. Peripheral enhancement is seen and there are central non-enhancing areas caused by tumour necrosis. MR is reserved for equivocal cases, and is particularly useful in the detection of extra-adrenal phaeochromocytomas. 123I-MIBG (meta-iodobenzylguanidine) will concentrate in phaeochromocytoma and is therefore of use in locating extra-adrenal tumours. Arteriography and venous sampling have both been used in localisation of extra-adrenal phaeochromocytomas. 18F DOPA PET scans have been used recently and appear a highly sensitive and specific biochemical imaging approach for detection of pheochromocytomas.\nSurgical resection is successful in 90% of cases, but 10% of tumours are malignant. Phaeochromocytomas less than 5cm in diameter can be removed laparoscopically; larger tumours should be removed by open surgery. Currently, pheochromocytoma removal is a safe operation with mortality rates ranging from 0 to less than 3%. Preoperative alpha-adrenergic blockage with phenoxybenzamine or prazosin is important in decreasing the operative risk. Beta-blockers may be necessary for cardiac arrhythmia. Drug treatment prior to and during surgery is mandatory. Drug treatment, chemotherapy and radiation therapy are used to treat malignant lesions. Lifelong follow-up for patients with phaeochromocytoma is important.",
    "differential_diagnosis": "Phaeochromocytoma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001606/000001.jpg?itok=N5BExoA-",
            "caption": "Frontal chest x-ray showing a posterior mediastinal mass on the left. It is seen in the left paravertebral region, and has a smooth outline.(marked)"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001606/000002.jpg?itok=XVPa80cF",
            "caption": "Axial CT of the chest at the level of the carina showing a soft tissue mass in the posterior mediastinum. There is some rib moulding but no CT evidence of bony destruction. The mass is closely related to the descending thoracic aorta anteriorly and lies in line with the sympathetic chain."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001606/000003.jpg?itok=F07sMFsm",
            "caption": "Coronal T2-weighted image showing the mass lying just lateral to the spine. The mass has a high T2 signal.Once again there is no evidence of bony destruction. The mass is smooth."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001606/000004.jpg?itok=TOffCjYz",
            "caption": "Sagittal T1-weighted image showing an intermediate signal mass in the paraspinal region. The mass is well defined."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001606/000005.jpg?itok=lEseZF03",
            "caption": "Axial T2-weighted image  showing the paraspinal high signal mass. It is well defined and appears smooth."
          },
          {
            "number": "Figure 3d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001606/000006.jpg?itok=qISYYhKt",
            "caption": "T1-weighted sagittal image showing the relationship to the intervertebral foramen."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001606/000007.jpg?itok=fClktMiW",
            "caption": "Posterior view from an MIBG scan showing increased activity in the left paraspinal region. This is 98% specific for this diagnosis."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT",
      "MR",
      "Nuclear medicine conventional"
    ],
    "link": "https://www.eurorad.org/case/1606",
    "time": "09.10.2002"
  },
  "1618": {
    "case_id": 1618,
    "title": "Invasive aspergillosis",
    "section": "Chest imaging",
    "age": "45",
    "gender": "male",
    "diagnosis": "Invasive aspergillosis",
    "history": "An immunocompromised patient presenting with productive cough and dyspnoea.",
    "image_finding": "A patient with a renal transplant presented with productive cough and dyspnoea. Plain films were obtained, followed by CT scans. The patient required a left pneumonectomy.",
    "discussion": "Aspergillosis can be regarded as a spectrum of pathology with three major components:\nmycetoma,\ninvasive and semi-invasive aspergillosis, and \nallergic bronchopulmonary aspergillosis (ABPA).  There is overlap between these entities, and semi-invasive aspergillosis is known to occur in chronic cavities in patients with mild immunocompromise and lung damage.\n\nBronchopulmonary aspergillosis is a relatively common association with asthma. The condition is usually seen in adults, although children are occasionally affected. ABPA, occurring almost exclusively in asthma patients, is characterised radiographically by fleeting pulmonary alveolar opacities caused by deposition of immune complexes and inflammatory cells within the lung parenchyma. Mucus plugging and bronchial wall thickening can be expected in time. Aspergilloma, occurring in patients with structural lung disease, typically appears radiographically as a focal intracavitary mass and is characterised initially by an increase in the wall thickness of a pre-existing cavity or cyst. \n\nInvasive aspergillosis is virtually confined to immunocompromised patients, especially in patients with lymphoma and leukaemia. Invasive aspergillosis is characterised by mycotic vascular invasion, thrombosis, and infarction leading to necrosis and cavitation. The lungs may be seeded via the airways or via the bloodstream. The appearance on x-ray is variable. One-third of cases with symptoms will have a normal chest x-ray. A common pattern is one of rounded consolidations, which are randomly distributed in the lungs and have an indistinct margin. These represent foci of infarction resulting from vascular invasion. This results in central necrosis with a rim of haemorrhagic infarction and inflammation. These lesions may have irregular outlines and may contain air bronchogram. They may cavitate. Cavitation occurs with recovery from neutropenia. Cavitation is therefore a favourable sign, indicating a significant defence mechanism. Rarely a widespread miliary pattern is seen. CT may reveal a halo or ground-glass attenuation and is more accurate in the detection of early disease. This is the precursor of the crescent sign. Histologically this corresponds to surrounding haemorrhagic inflammation. Although this CT finding is not diagnostic, it is certainly suggestive. Thick-walled cavitary lesions are the most common radiological manifestation of invasive pulmonary aspergillosis in AIDS. The findings are more numerous and better defined on CT scans. Cavitation often develops with time and typically results in the air crescent sign. The single or multiple areas of consolidation slowly enlarge over 7 to 28 days. Hilar lymphadenopathy is not a feature. Pleural effusions are seen only if haemorrhagic infarction causes bleeding into the pleural space. Invasion of the chest wall is rare but has been documented. MRI has been used to diagnose invasive pulmonary aspergillosis. The majority of rounded consolidations have a target-like appearance, a hypointense centre and an isointense or hyperintense rim on T1-weighted images. Areas of central haemorrhage result in foci of hyperintensity within the low intensity central core. Enhancement is variable. \n\nIn semi-invasive aspergillosis, local invasion of the lung parenchyma is seen. This is seen in debilitated patients with pre-existing lung disease. The fungus may originate in a pre-existing cavity or may form its own cavity. This results in a thick-walled cavity in which a mycetoma may form. Semi-invasive aspergillosis is radiographically similar to the invasive form but differs in clinical course, being associated with mild immunosuppression or chronic illness and typically progressing over the course of months rather than weeks.",
    "differential_diagnosis": "Invasive, aspergillosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001618/000001.jpg?itok=yv2FGcAo",
            "caption": "This frontal film shows unilateral widespread confluent consolidation."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001618/000002.jpg?itok=dheSmKMN",
            "caption": "Axial section above the carina shows bilateral emphysematous changes. On the left there is patchy airspace shadowing and a crescent sign."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001618/000003.jpg?itok=fkbajOz8",
            "caption": "This axial image below the level of the carina shows confluent consolidation involving both upper and lower lobes."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001618/000004.jpg?itok=iueCKC3A",
            "caption": "Post-pneumonectomy x-ray shows air-fluid level in the left hemi-thorax and a normal right lung."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001618/000005.jpg?itok=1AKVAhk4",
            "caption": "A later film shows complete opacification of the left hemi-thorax. Now there is patchy airspace opacity in the right upper zone."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001618/000006.jpg?itok=56ixmf_X",
            "caption": "Axial CT above the carina shows fluid-filled left chest and beginning of consolidation in the right upper lobe"
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001618/000007.jpg?itok=UYE2yD5r",
            "caption": "Axial image below the carina shows similar appearance. Apart from the emphysematous changes, the right lung showed no evidence of these changes on the earlier scan."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/1618",
    "time": "29.09.2002"
  },
  "1637": {
    "case_id": 1637,
    "title": "chinococcus infection of the lung",
    "section": "Chest imaging",
    "age": "21",
    "gender": "male",
    "diagnosis": "Intrapulmonary echinococcus cyst",
    "history": "A Turkish patient was referred with dyspnoea. Chest radiography and CT revealed multiple round intrapulmonary lesions, one of which had a fluid-air level. As albendazole was administered systemically, the symptoms decreased and control CT scans showed no significant morphological progression of disease.",
    "image_finding": "The patient was referred to the emergency ward of our hospital with a short history of dyspnoea. He was of Turkish origin, employed in Austria and used to travel infrequently to his family in Istanbul, Turkey. The admission chest radiograph showed a well-circumscribed cavitation with a diameter of about 10 cm in the left lower lobe and two round lesions (diameter 4 cm) at the region of the right hilus (figure 1a and b). Subsequently, a CT scan of the chest was performed (figure 2a and b), confirming the findings of the plain radiograph and suggesting echinococcus infection of the lungs. For differential diagnosis, cystic adenomatoid malformations, bronchogenic cysts or multiple abscesses, respectively, were taken into consideration. However, the patient was hospitalised and antihelminthical treatment with albendazole was initiated; furthermore antimicrobial drugs (Metronidazol, Levofloxacin) were administered. Confirming radiology, serological examinations showed highly positive titers of anti-echinococcus antibodies. Additional radiological screening for echinococcus affection proofed negative (abdominal ultrasound, CT and MR of the brain). Throughout the following three weeks the patient\u2019s symptoms decreased continuously, and as control chest radiographs did not show any progression of the lung lesions, no surgical procedure was performed. Instead, conservative treatment with a total of three cycles of albendazole p.o. at an outpatient basis was completed. When the patient was discharged from hospital 23 days after admission, a multislice CT-scan revealed no significant change except for a pseudo-membrane around the largest lesion in the left lower lobe (figure 3a and b). Eight weeks after admission, another multislice CT-scan showed a moderate reduction in size and a slight rarefication of the cyst wall in the left lower lobe (figure 4a and b).",
    "discussion": "Echinococcus (or hydatid) infection is caused by Echinococcus granulosus  or Echinococcus multilocularis . Usually dogs are the primary hosts, whereas secondary (intermediate) hosts include sheep, cows and sometimes humans. The disease is endemic in the sheep-raising areas of Australia, South Africa and the Mediterranean countries. Ova of adult worms, living in the small intestine of the primary host, are passed in faeces and ingested by the secondary host. Larvae develop in the duodenum of the new host and migrate predominantly to the liver (65-70% of cases) and the lungs (15-30%) (1) by direct migration or through the bloodstream. \nEchinococcus cysts are usually well-circumscribed, spherical or oval masses of homogeneous density, of up to 10cm or and even 20cm in size, in otherwise normal lungs. They may be single or multiple (in about 33% of cases); more than ten cysts are occasionally seen (2). There is a predilection for the lower lobes, the posterior segments and the right lung (3). If a communication develops between the cysts and the bronchial tree, air may enter between the outer layers of the cyst (pericyst and ectocyst), producing the appearance of a thin crescent of air around the cyst. This is therefore called the crescent or meniscus sign. Additionally, a fluid level may be identified. Sometimes the membrane of a cyst, which has ruptured into the bronchial tree, floats on the fluid within the cysts, giving rise to the name, the water lily sign. Calcification is a common feature of hydatid cysts in the liver, but is rare in lung disease. On CT, the fluid contents of the cysts have densities similar to that of water, and the cyst walls range from 1mm to 1cm in thickness.\nThe classical treatment of hydatid cysts is operative (4). The surgical aim is to remove any cysts without disseminating the organism. Commonly, a surgical procedure is preceded by medical therapy with albendazole, which has replaced mebendazole as the therapy of choice because of its superior absorption and distribution characteristics (5). As shown here, in certain cases without progression in size of the lung lesions, in young, otherwise healthy subjects, surgery can even be set aside.",
    "differential_diagnosis": "Intrapulmonary, echinococcus, cyst",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001637/000001.jpg?itok=awy3ZUi8",
            "caption": "PA chest radiograph. There is a large cystic lesion in the left lower lobe with an air-fluid level (arrow). Probably corresponding to the middle lobe, there are two smaller spheric opacities lateral to the hilus (arrowheads)."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001637/000002.jpg?itok=Z-fwIutR",
            "caption": "Lateral view of the chest radiograph."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001637/000003.jpg?itok=Nsx3eB2Q",
            "caption": "Non-contrast helical CT of the thorax, soft tissue window. Cystic lesion in the left lower lobe with air-fluid level and hyperdense collapsed membrane of the cyst (water lily sign, arrow). Discrete atelectasis anterior to the cyst. Smaller cystic lesion in the middle lobe (arrowhead)."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001637/000004.jpg?itok=jdFC4ESW",
            "caption": "Non-contrast helical CT of the thorax, lung window."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001637/000005.jpg?itok=WSXGVzX7",
            "caption": "Multislice CT of the thorax, soft tissue window. No significant change in the morphology of the lesions after antihelminthical therapy, except for a pseudo-membrane around the lesion in the left lower lobe (arrow)."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001637/000006.jpg?itok=SWJrzQ9m",
            "caption": "Multislice CT of the thorax, lung window."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001637/000007.jpg?itok=hr08joll",
            "caption": "Contrast enhanced multislice CT of the thorax, obtained eight weeks after admission, showed a moderate reduction in size and a rarefication of the wall of the cystic lesion in the left lower lobe (arrow)."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001637/000008.jpg?itok=p3kftvuE",
            "caption": "Multislice CT of the thorax, coronal reconstruction."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT",
      "CT",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/1637",
    "time": "01.08.2002"
  },
  "1643": {
    "case_id": 1643,
    "title": "Fibrolipoma of the chest wall simulating gynaecomasti",
    "section": "Chest imaging",
    "age": "71",
    "gender": "male",
    "diagnosis": "Fibrolipoma of the chest wall",
    "history": "A mass lesion of the right chest wall in the breast region with ultrasound and mammographic appearances of diffuse gynaecomastia.",
    "image_finding": "The patient presented with a one-year history of a gradually increasing mass lesion of the right breast. The patient was on no medication other than taking anti-hypertensive drugs for the previous 10 years. On physical examination, there was a palpable, soft mass located on the right breast. \n\nThe patient was referred for mammographic evaluation. Mediolateral and craniocaudal mammographies showed a mammographic appearance similar to that of a heterogeneously prominent dense female breast (Fig. 1). There was no mass lesion with identifiable borders.\n\nUltrasound (US) examination also showed heterogeneous areas similar to fibroglandular tissues as seen in the female breast (Fig. 2). \n\nAxial computed tomography (CT) sections showed a mass lesion of the right breast, approximately 8cm x 4cm x 9cm in size. The lesion was hypodense relative to surrounding muscle. CT density values of -47HU to -56HU were detected, consistent with fat tissue (Fig. 3). On the basis of the CT findings a diagnosis of fibrolipoma was suggested. \n\nSurgery revealed that the lesion originated in the chest wall. Histopathological examination revealed mature fatty tissue elements intermixed with fibrous tissue, consistent with fibrolipoma (Fig. 4).",
    "discussion": "Fibrolipoma is a rare benign neoplastic lesion originating from hypertrophy of mature fat and fibroblasts in the perineurium. It is most often described in the upper extremities (78-96% of cases), with a marked predilection for the median nerve. Other sites include the lower extremities (4-22% of cases), ulnar nerve, radial nerve and brachial plexus (1). In the literature, there there are reports of lesions in the oesophagus, intestine, nuchal region and chest wall. \n\nChest wall tumours generally originate from the bone and soft tissues of the chest wall. Benign lesions that originate from the bone cartilage are enchondroma, fibrous dysplasia, osteochondroma, granular cell tumour, eosinophilic granuloma and aneurysmal bone cyst. Malignant chest wall tumours are plasmacytoma, chondrosarcoma and osteosarcoma. \n\nThe differentiation of soft tissue tumors from those originating from bone is easy on the basis of imaging findings and special imaging characteristics of these lesions. The benign soft tissue tumours that can be seen originating from the soft tissues of the chest wall are neurilemoma, fibroma, lipoma and fibrolipoma. Fibrosarcoma, desmoid tumour, malignant fibrous histiocytoma, leiomyosarcoma, tendon sheath sarcoma, haemangiosarcoma and neurosarcoma are malignant in nature and are rarely located at the chest wall (2). \n\nIn this case the detection of hypodense fat tissues interspersed within isodense areas provided the diagnosis. Lipomas have only hypodense areas, with the density values of fat tissue on CT, whereas fibromas can be seen as isodense lesions when compared with muscle tissue. \n\nThe location of the lesion in this case simulated gynaecomastia on physical examination. Gynaecomastia and breast cancer are the two most important diseases of the male breast. Gynaecomastia is common in the male population over 44 years of age (57%). It is characterised by hyperplasia of ductal and stromal elements of the male breast (3). Three mammographic patterns of gynaecomastia have been described: nodular, dendritic and diffuse. Diffuse gynaecomastia represents a mammographic pattern like a heterogeneous dense female breast. The nodular type of gynaecomastia appears as fan-shaped density radiating from the nipple. The mammographic appearances of nodular gynaecomastia can simulate mass lesions. \n\nIn this case the mammographic appearance of the lesion simulated diffuse gynaecomastia, because the relatively large lesion occupied all of the breast tissue. Because the myxoid component of the lesion was very prominent and intermixed with fatty tissues, mammography and US revealed heterogeneous areas similar to the stromal and fatty elements in female breast. CT provided the diagnosis by revealing the dense myxoid component and serpentine areas of fatty tissue within the lesion.",
    "differential_diagnosis": "Fibrolipoma, of, the, chest, wall",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001643/000001.jpg?itok=B26nNNeF",
            "caption": "Mediolateral mammography of the right breast shows an appearance that is very similar to that of excessively dense female breast."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001643/000002.jpg?itok=hxG5HDPA",
            "caption": "Transverse US section reveals heterogeneous areas, mostly hyperechoic intermixed with hypoechoic areas."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001643/000003.jpg?itok=5Zft6tw3",
            "caption": "Axial CT section through the lesion demonstrates a hypodense lesion relative to surrounding muscle tissue. There are hypodense areas in the right lateral portion of the lesion. The densities of these areas range from -45HU to -57HU, consistent with fatty tissue."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001643/000004.jpg?itok=vShNYbhv",
            "caption": "Histopathological evaluation shows mature fatty tissue elements and fibrous tissue elements."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "Mammography",
      "Ultrasound",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/1643",
    "time": "27.06.2002"
  },
  "1653": {
    "case_id": 1653,
    "title": "Pulmonary blastomycosis after heart transplantation",
    "section": "Chest imaging",
    "age": "57",
    "gender": "female",
    "diagnosis": "Pulmonary blastomycosis",
    "history": "In a patient who had undergone a heart transplant two years previously, with no complaints, on routine follow-up, two shadows were observed on the chest X-ray.",
    "image_finding": "The patient underwent a heart transplantation in December 1999 for idiopathic dilated cardiomyopathy. Acute rejection occurred 15 days post-operatively, for which the patient was treated with solumedrol.\n\nBecause of dysfunction of the sinus node of the graft a Medtronic Thera DR 7960i-pacemaker was inserted. \n\nOn annual evaluation in February 2002 there were no complaints. The patient was not immunocompromised at this moment.  A control chest X-ray showed two suspected shadows in the right lung. Further imaging work-up of the patient consisted of helical CT and PET scanning.",
    "discussion": "Blastomycosis is primarily an airborne fungal disease with the lung acting as the portal of entry.  It occurs in both acute and chronic forms.  It is endemic to the central and southern areas of the United States. Patients range from the asymptomatic to those with symptoms of acute pneumonia. It must be strongly considered in the differential diagnosis of pulmonary lesions in geographical areas where the disease is endemic.\n\nPulmonary blastomycosis has a number of manifestations on chest radiography that may closely resemble those of tuberculosis, histoplasmosis, other fungal diseases and malignant disease.  Radiographic presentations of pulmonary blastomycosis include mass lesions, consolidation, air bronchograms, intermediate-size nodules, satellite lesions, pleural thickening and small effusions. Calcifications, lymphadenopathy and cavitation are seen less frequently. \n \nIn this patient, with no complaints and with a heart transplantation in the history, the first diagnosis to be considered is a post-transplant lymphoproliferative disorder. Other possible differential diagnoses are a lung tumour (primary or secondary) or a focal infection. The patient underwent a thoracoscopic exploration with a wedge resection of one of the lesions.  The findings on microscopic examination were an interstitial granulomatous infection with Grocott-positive rounded  intracytoplasmatic inclusions in giant cells.   This strongly suggested blastomycosis. Neither the patient nor the donor had ever visited the United States, so there was no direct explanation for the infection with blastomyces.",
    "differential_diagnosis": "Pulmonary, blastomycosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001653/000001.jpg?itok=n2_5kaMs",
            "caption": "Status post heart transplantation and pacemaker insertion. Nodular lesion in the periphery of the right lung, middle field. Shadow in the paracardiac region on the right side."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001653/000002.jpg?itok=G1HlbYLu",
            "caption": "Status post heart transplantation and pacemaker insertion. Nodular lesion in the periphery of the right lung, middle field. Shadow in the paracardiac region on the right side."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001653/000003.jpg?itok=w6zuQwj6",
            "caption": "Nodular lesion in the anterior segment of the right lower lobe, in the paracardiac region."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001653/000004.jpg?itok=xA5IU1Kg",
            "caption": "Small nodular lesion in the centre of the right middle lobe."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001653/000005.jpg?itok=kMwYybCN",
            "caption": "Nodular lesion in the right lower lobe next to the thoracic wall, without signs of thoracic wall invasion."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001653/000006.jpg?itok=AYF22LFx",
            "caption": "Hot spot in the middle field of the right lung and two other hot spots in the paracardiac region of the right lung. No mediastinal or hilar lymphadenopathies."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "Digital radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/1653",
    "time": "10.01.2003"
  },
  "1673": {
    "case_id": 1673,
    "title": "Lymphangioleiomyomatosis",
    "section": "Chest imaging",
    "age": "42",
    "gender": "female",
    "diagnosis": "Pulmonary lymphangioleiomyomatosis",
    "history": "The patient presented with progressive exertional dyspnoea over more than a year. There was no significant medical history.",
    "image_finding": "The patient presented with progressive exertional dyspnoea over more than a year. There was no significant medical history.  Cardiac investigation was negative. Conventional radiographs and CT of the chest were performed. Based on the presence of a chylothorax and numerous thin-walled cysts, a diagnosis of pulmonary lymphangioleiomyomatosis (LAM) was suggested. Diagnosis was confirmed on open lung biopsy. Two years after the initial diagnosis, the patient underwent unilateral lung transplantation.",
    "discussion": "Pulmonary lymphangioleiomyomatosis (LAM) is a rare disorder and occurs almost exclusively in women of childbearing age. Abnormal proliferation of immature smooth muscle cells around the airways, blood vessels and lymphatic vessels, explains the clinical manifestations. Lymphatic obstruction leads to the formation of a chylothorax. Obstruction of the pulmonary vessels causes venular congestion and disruption, resulting in haemoptysis. Airflow obstruction, secondary to the compressed airways, leads to alveolar disruption, which is responsible for the formation of the thin-walled cysts. CT can easily detect these cysts within the lungs. The cysts appearing in LAM are quite characteristic in the correct clinical setting and can be differentiated from other similar pathologies, such as Langerhans cell histiocytosis, Wegener granulomatosis, septic pulmonary emboli, pneumocystic carinii pneumonia, usual interstitial pneumonia, lymphocytic interstitial pneumonia, etc. Cysts in LAM are numerous, thin walled, varying in size from a few millimeters to 5cm and with a distribution in all lung zones. In conjunction with these cysts, characteristic abdominal findings, are useful in establishing the diagnosis. The most common abdominal findings include renal angiomyolipoma (54%), enlarged abdominal lymph nodes (39%), and lymphangiomyoma (16%). \n\nLAM can occur as a rare sporadic disease or as a complication of tuberous sclerosis (TSC).  The concomitant finding of renal angiomyolipomatas (the hallmark of TSC) in LAM, supports the hypothesis that both entities are linked; LAM is actually considered as a form fruste of TSC. TSC, however, occurs in patients of either sex. Diagnosis of LAM is made on open lung biopsy, as there is still debate whether the diagnosis may be ruled out on the basis of a normal CT scan. LAM continues to frustrate clinicians attempting to treat it. Great importance was given to hormonal therapy as the entity occurs almost exclusively in women, but this did not prove to be effective. Although disease-related complications are frequent, lung transplantation can be a valuable therapy for patients with end-stage LAM.",
    "differential_diagnosis": "Pulmonary, lymphangioleiomyomatosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001673/000001.jpg?itok=CmOvfk-o",
            "caption": "Chest X-ray showing a reticular pattern, most obvious in the lower lobes."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001673/000002.jpg?itok=xLITKP4f",
            "caption": "Chest X-ray showing a reticular pattern, most obvious in the lower lobes."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001673/000003.jpg?itok=BUIMRDMA",
            "caption": "CT scan showing numerous thin-walled cystic air spaces with variable diameter in the middle lung fields.  The pseudocystic appearance of the chest tube anteriorly in the right lung field should not be confused with a true (lymphangioleiomyomatosis) cyst."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001673/000004.jpg?itok=Xvb5qQ0r",
            "caption": "CT scan showing numerous thin-walled cysts in the apices. We again notice the presence of a chest tube in the right lung field. Endotracheal tube and oesophageal tube."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001673/000005.jpg?itok=yjcnEPM5",
            "caption": "CT scan showing numerous thin-walled cysts in the lung bases. Presence of a chest tube anteriorly in the right lung field."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001673/000006.jpg?itok=RiIixt2R",
            "caption": "Microscopic specimen showing multiple irregular cystic spaces."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001673/000007.jpg?itok=-gsMFmoz",
            "caption": "The walls of the cystic spaces are formed from elongated cells which contain fibrillar cytoplasm."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001673/000008.jpg?itok=BBmyfO-q",
            "caption": "Immunohistochemical staining with alpha-SMA (smooth muscle actin) confirms the smooth muscle origin of these cells."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001673/000009.jpg?itok=JQDzr-wb",
            "caption": "CT scan showing the transplanted left lung, complicated with an anterior pneumothorax, and the cystic pattern of the right lung."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "Digital radiography",
      "CT",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/1673",
    "time": "06.10.2002"
  },
  "1676": {
    "case_id": 1676,
    "title": "Intrathoracic gossypiboma: radiological features",
    "section": "Chest imaging",
    "age": "62",
    "gender": "female",
    "diagnosis": "Intrathoracic gossypiboma",
    "history": "The patient presented with left-sided chest pain. She had undergone surgery for a coronary artery bypass two years previously. Chest radiographs showed a round mass, located in the lower segment of the left hemithorax.",
    "image_finding": "A 62-year-old woman presented with left sided chest pain. She had undergone surgery for a coronary artery bypass two years ago. Chest radiographs showed a round mass, located in lower segment of the left hemithorax (Fig 1). Unenhanced CT  sections showed a smooth, heterogeneous mass with central low attenuation nidus (Fig 2). On T1-weighted MR images, the lesion displayed heterogeneous signal intensities. The central portion of the lesion was seen relatively decreased signal intensity in comparison with periphery of the lesion (Fig3a). T2 weighted images also showed heterogeneous lesion with wavy decreased signal intensities within it (Fig 3b). The lesion showed peripheral contrast enhancement on post-contrast T1-weighted images like an abscess (Fig 3c). The mass had a hyperechogenic center and posterior acoustic shadowing in ultrasonography (Fig 4). At surgery, a mass with extensive fibrosis and adhesion to the pleura was found in the left pleural space. Gross examination showed that the mass was a surgical sponge surrounded by purulent material.",
    "discussion": "Retained surgical sponge  (also called gossypiboma) are a continuing problem. The oversight of a foreign body during surgery is rare, but can sometimes occur despite the extreme caution of the surgical teams. The incidence of foreign bodies varies from 1 per 1000 to per 10000. A retained cotton matrix can lead very quickly, on the first day, to a local inflammation which precludes a granulomatous reaction after about a week, and fibrosis formation after a fortnight. If the retained material becomes infected, it may cause an abscess which can subsequently drain itself through a cutaneous fistula. Non-specific clinical manifestations such as fever or aches appear long after the initial surgical procedure. Secondary infection of the cotton matrix mimics a non-specific inflammatory reaction. Radiological characteristics of gossypiboma have been reported by several authors. Plain chest radiographs reveal a heterogeneous mass, which can be calcified or contain both dense material and air pockets. Ultrasonography shows a mass with an echogenic center and posterior acoustic shadowing. The CT appearance of a retained surgical foreign body is a sharply defined and rounded mass with a dense central part and an enhancing wall. There is no enhancement of the centre of the lesion which is already inhomogeneously dense. The sponge may not be recognized easily because of organization. An organized haematoma should be considered in the differential diagnosis. The centre of the mass on MR imaging may show variable intensities depending on the amount of fluid and protein concentration. MR imaging displays a well-delineated formation with intermediate signal intensity on T1-weighted images. On T2-weighted images, high-signal-intensity structures with wavy, striped and/or spotted appearances within the mass have also been described. A gossypiboma should be considered in the differential diagnosis of a mass located in any part of the body in patients with an atypical thin-or thick-walled mass who has undergone a previous operative procedure. Considering the possibility that a mass might be the result of a retained sponge is probably the most important step in making the diagnosis.",
    "differential_diagnosis": "Intrathoracic, gossypiboma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001676/000001.jpg?itok=0x7IDuCh",
            "caption": "Chest-x ray shows a round and well-defined opacity  in the left lower lung."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001676/000002.jpg?itok=ypRfm521",
            "caption": "Axial unenhanced CT scan reveals a round- well defined lesion with heterogeneous signals within it in close proximity to diaphragma and left ventricle. Note  a low-attenuation nidus in the centre of the lesion due to air pockets."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001676/000003.jpg?itok=sbb31XYo",
            "caption": "Coronal T1-weighted MR image also reveals a heterogeneous mass lesion with relative decreased signal intensities at the centre of the lesion."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001676/000004.jpg?itok=ddLRR4YE",
            "caption": "T2-weighted axial MR section  reveals high-signal-intensity mass with wavy decreased signal intensities within it."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001676/000005.jpg?itok=s7JgSNxp",
            "caption": "Sagital, T1-weighted image after contrast medium injection shows moderate contrast  enhancement at the wall of the lesion."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001676/000006.jpg?itok=zSoeY0Aj",
            "caption": "Ultrasonography shows hyperechogenic center and posterior acoustic shadowing due to air-pockets within the lesion."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT",
      "MR",
      "Ultrasound"
    ],
    "link": "https://www.eurorad.org/case/1676",
    "time": "09.10.2002"
  },
  "1678": {
    "case_id": 1678,
    "title": "Pectus excavatum",
    "section": "Chest imaging",
    "age": "34",
    "gender": "female",
    "diagnosis": "Pectus excavatum",
    "history": "This patient was referred by her GP for a chest X-ray because of persistent cough and wheeze.",
    "image_finding": "This patient was referred for a chest X-ray because of persistent cough and wheeze. The clinical diagnosis was asthma, but her GP wanted to exclude other causes. An abnormality was seen on her PA chest radiograph and she was recalled for a lateral view to be taken.",
    "discussion": "This patient has a chest wall deformity with a depressed sternum known as pectus excavatum or \"funnel chest\". This deformity is quite common, and patients are almost always asymptomatic, but it does cause radiographic abnormalities that can be mistaken for pathology. \n\nIn patients with pectus excavatum the heart is displaced dorsally and often \"squeezed\" between the depressed sternum and the spine. This causes the cardiac silhouette to be shifted to the left and can give the impression of cardiomegaly. The left heart border becomes straightened as a result, and the main pulmonary trunk can look enlarged. \n\nThe right heart border may bulge to the right if the heart is compressed against the spine, but is usually displaced to the left. Ill-defined shadowing in the right cardio-phrenic angle gives the impression of right middle lobe pathology, but does not show an air bronchogram. Its cause is the tissues of the anterior chest wall projected over the lung adjacent to the right heart. \n\nClues as to the presence of pectus excavatum on the PA radiograph are the easy visibility of the thoracic vertebral bodies and inter-vertebral discs through the heart shadow (as the heart is displaced to the left) and horizontal posterior ribs with downward sloping anterior ribs (giving a \"7\" and \"reverse-7\" configuration). Clinical examination of the patient will confirm the presence of a depressed sternum. A lateral radiograph demonstrates the sternal depression, which varies from minor sternal flattening causing slight reduction in the AP diameter of the chest to marked sternal depression and compression of the heart against the spine. The lateral radiograph also confirms the absence of right middle lobe disease and cardiomegaly. \n\nRarely pectus excavatum is associated with mitral valve prolapse and patients with Marfan's syndrome may have pectus excavatum.",
    "differential_diagnosis": "Pectus, excavatum",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001678/000001.jpg?itok=Cy5con5p",
            "caption": "PA chest radiograph showing an indistinct right heart border and ill-defined opacity in the right cardio-phrenic angle. There is however no air-bronchogram to indicate consolidation, and no volume loss in the right lung signifying collapse."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001678/000002.jpg?itok=5LYs52mz",
            "caption": "Lateral chest radiograph confirming a depressed sternum or pectus excavatum which is the cause of the apparent abnormality on the frontal radiograph."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001678/000003.jpg?itok=wp1wgwff",
            "caption": "The PA radiograph shows a slight shift of the mediastinum to the left with a straight left heart border and blurring of the right heart border with increased opacity adjacent to the right of the vertebral column. Note the increased downward inclination of the anterior ribs."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001678/000004.jpg?itok=vKSbFHkF",
            "caption": "Lateral chest radiograph confirms the posterior depression of the sternum and absence of any right middle lobe pathology."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "Digital radiography"
    ],
    "link": "https://www.eurorad.org/case/1678",
    "time": "29.09.2002"
  },
  "1701": {
    "case_id": 1701,
    "title": "Bronchial atresi",
    "section": "Chest imaging",
    "age": "56",
    "gender": "male",
    "diagnosis": "Bronchial atresia",
    "history": "Casual chest X-ray discovery of a round, peripherally ramified opacity in an asymptomatic patient.",
    "image_finding": "The patient was admitted after sudden onset of vertigo. Physical examination, ECG and laboratory tests were unremarkable. Routine chest X-ray revealed a well-defined 2.5cm round opacity, peripherically ramified, near the left hilum with hyperinflation and oligaemia of the left upper lobe. Evaluation with  chest CT was performed. Pre-contrast  and  contrast-enhanced images were obtained according to the following  protocol: spiral acquisition, 100ml of non-ionic iodinated contrast (Ultravist 370, Schering), injection rate 3ml/s,  start at 25s, 7mm collimation, 5mm reconstruction interval, pitch 1.3. Previously observed opacity appeared peripherally ramified and showed no of contrast enhancement. The lesion density was slighty higher than water (18HU).Complete absence of the normal appearing air-filled bronchus of the left upper lobe was observed. Severe hyperinflation and oligaemia of the left upper lobe was confirmed.\nPulmonary arteriography excluded the possibility of a sequestration and better delineated the lobar oligaemia. The final diagnosis was bronchial atresia of the left upper lobe, enlarged and mucus filled, with hyperinflation of the lung parenchyma distal to the lesion.",
    "discussion": "Although uncommon, congenital bronchial atresia remains one of the most frequent congenital anomalies of  the  bronchial tree. The origin, still unknown, seems to be related to an ischaemic insult occuring after the 15th week  and producing focal obliteration of a segmental or, more rarely, a lobar bronchus. Distally the normal  bronchial branches appear dilated and full of mucus and may form a bronchocele, as in this case. A mucus-filled bronchocele may be recognised as an ovoid, round, or ramified mass surrounded by hypoperfused and hyperinflated parenchyma. Distal air-trapping derives from collateral ventilation (through Lambert's ducts and Kohn's pores); hypoventilation results in hypoxic vasoconstriction, with loss of perfusion that may be observed in pulmonary angiography. Most patients are asymptomatic or have minimal physical findings; rarely shortness of breath, cough or infection may be observed. The paucity of  symptoms may explain why diagnosis is generally delayed and is often incidental. \n\nSpiral CT is the examination of choice, not only to show all the components of the anomaly and to estimate the air-trapping extension, but even for differential diagnosis with other types of obstructive bronchial pathology and vascular lesions such as bronchogenic cyst, bronchiectasis, TBC, aspergillosis, completely thrombosed arteriovenous malformation or  pulmonary aneurysms and, naturally, tumours. \n\nMRI may be employed to describe the mucoid nature of the bronchocele content (hyperintense on T2- and moderately intense, between muscle and fat intensity, on T1-weighted images). Pulmonary angiography may exclude the possibility of sequestration. In the past, treatment of bronchial atresia was controversial, but currently non-surgical therapy is suggested, except in complicated cases such as those involving compression or uncontrollable infection of adjacent lung.",
    "differential_diagnosis": "Bronchial, atresia",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001701/000001.jpg?itok=DD1zG7kD",
            "caption": "Axial CT image showing hypoperfusion of the left upper lobe and a well-defined round opacity near the left hylum."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001701/000002.jpg?itok=QM6cqPJT",
            "caption": "Mediastinic window setting at the same level as Figure 1a underlines the absence of contrast enhancement in the lesion."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001701/000003.jpg?itok=UT4eruAc",
            "caption": "Coronal MIP reconstruction showing the relationship between the lesion and the left hylum."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001701/000004.jpg?itok=KLEntwJ-",
            "caption": "3D surface reconstruction of the left hylum."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001701/000005.jpg?itok=MMiVL09X",
            "caption": "Volume rendering reconstruction of both lungs confirms the marked hypoperfusion with hyperinflation of the left upper lobe."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001701/000006.jpg?itok=MT7kwvWG",
            "caption": "Selective DSA of the left pulmonary artery confirms hypoperfusion of the left upper lobe."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001701/000007.jpg?itok=MQtg6xEF",
            "caption": "Well-defined 2.5 cm opacity, peripherically ramified, near the left hilum with hyperinflation and oligoemia of the left upper lobe."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/1701",
    "time": "20.10.2002"
  },
  "1720": {
    "case_id": 1720,
    "title": "Combined Thoracic and Abdominal Lymphangioma in an Adult",
    "section": "Chest imaging",
    "age": "23",
    "gender": "male",
    "diagnosis": "Lymphangioma",
    "history": "Persistent cold without fever, no significant past medical history.",
    "image_finding": "A patient without significant medical history presented to our hospital with a persistent cold without fever. He had no abdominal complaints.\nPhysical examination revealed some dullness to percussion and reduced breath sounds at the base of the right lung. Routine laboratory tests were normal and HIV serology was negative. The chest radiograph showed an elevation of the right hemidiaphragm and scalloping of the left one. Subsequently abdominal ultrasound and CT scan of the thorax and abdomen were performed.Radiograph of the chest, PA-view (fig. 1) shows marked elevation of the right and scalloping of the left hemi-diaphragm.\nUltrasonography of the abdomen (fig. 2) demonstrates a large multilocular cystic mass at the base of the right hemi-thorax. The cysts are separated by multiple thick septa.\nContrast-enhanced CT scan of the thorax (fig. 3) shows well defined fluid collections in both pleural spaces (A), and extension into the anterior, upper mediastinum (B).\nOn contrast-enhanced CT scan of the abdomen (fig. 4), the intrathoracic cystic lesions communicate through the hiatus of the anterior diaphragm with similar lesions in the left upper abdomen (A) and extension is seen through the mesentery with presence of multiple small and large cystic lesions (B). There is a ring-calcification at the right side.\nThin needle aspiration of the lesion at the right pleural space yielded milky yellow-white fluid. Cytological analysis showed chylomicrons. At thoracotomy, a large lobulated cystic tumor was found located between the diaphragm and the right lower lobe of the lung and resected. The left sided cystic mass was not resected. At laparatomy, multiple small cysts and dilated veins were found. The abdominal cystic lesions could not be removed radically, but biopsies were taken.\nPathological examination confirmed the diagnosis of lymphangioma, with lesions of the cystic hygroma type in the thorax and a mixed cystic and cavernous type in the abdomen.",
    "discussion": "Lymphangiomatosis is a rare condition probably related to a developmental malformation of the lymphatic system. Lymphangiomas most often present during childhood or adolescence but may occur at any age, mostly with minor symptoms. A potential aggressive behavior has been described but is uncommon. They present as (pseudo-) cystic lesions with fluid attenuation. They seldom show intralesional calcifications. They tend to surround and invade normal structures but have no malignant potential. Most commonly they arise in the head and neck (95%). Abdominal lymphangiomas arise in the mesentery and omentum but are extremely rare. Combination of an abdominal and intra-thoracic lymphangioma is seldomly found. Four histologic subtypes of lymphangiomas have been described:- cystic hygroma,- cavernous lymphangioma,- capillary lymphangioma and the-  vasculolymphatic malformation. These types are considered as a spectrum of the same disease. Combinations of these four types may be seen in the same lesion. The presence of endothelial-lined lymphatic channels separated by connective tissue, is the dominating histologic feature. Anatomic location of the lymphatic malformation and size of the lymphatic spaces play an important role in determining the histologic type of lymphangioma.\nThe lesions in our patient were predominantly of the cystic hygroma type in the thorax and of the mixed cystic - cavernous type in the abdomen. A vasculolymphatic component in the abdomen is suggested based on laparoscopic and CT scan findings.\nDifferential diagnosis includes other cystic masses such as enteric duplication cyst, pancreatic pseudocyst, enteric and mesothelial cyst, teratoma and cystic pancreatic tumors. Mediastinal lymphangioma has to be differentiated from cavernous hemangioma or pericardial cyst. The simultaneous presentation of thoracic and abdominal lesions are in favor of the systemic lymphatic origin of the tumor. Treatment of lymphangiomas should be aimed at complete surgical excision whenever possible. Radiotherapy and sclerotherapy have also been described as treatment modalities for non resectable lesions.",
    "differential_diagnosis": "Lymphangioma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001720/000001.jpg?itok=oGHvM9iF",
            "caption": "Radiograph of the chest, PA-view  shows marked elevation of the right and scalloping of the left hemi-diaphragm."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001720/000002.jpg?itok=JHbVcjjd",
            "caption": "Ultrasonography of the abdomen  demonstrates a large multilocular cystic mass at the base of the right hemi-thorax. The cysts are separated by multiple thick septa."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001720/000003.jpg?itok=8o8Zii6i",
            "caption": "Contrast-enhanced CT scan of the thorax  shows well defined fluid collections in both pleural spaces"
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001720/000004.jpg?itok=ofdMGXlf",
            "caption": "Contrast-enhanced CT scan of the thorax (fig. 3) shows well defined fluid collections and extension into the anterior, upper mediastinum (B)."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001720/000005.jpg?itok=Pd2XcszP",
            "caption": "On contrast-enhanced CT scan of the abdomen, the intrathoracic cystic lesions communicate through the hiatus of the anterior diaphragm with similar lesions in the left upper abdomen"
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001720/000006.jpg?itok=56D7efWl",
            "caption": "Extension is seen through the mesentery with presence of multiple small and large cystic lesions. There is a ring-calcification on the right side."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "Ultrasound",
      "CT",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/1720",
    "time": "15.10.2002"
  },
  "1767": {
    "case_id": 1767,
    "title": "Computerised tomography diagnosis of oesophageal rupture caused by an ingested chicken bone",
    "section": "Chest imaging",
    "age": "57",
    "gender": "male",
    "diagnosis": "Oesophageal rupture by ingested bone",
    "history": "The patient was admitted with acute chest pain, which began just after dinner.",
    "image_finding": "A  57year  old  man  was  admitted  to  our  general  hospital  for  an  acute  chest  pain, just after dinner. On clinical examination he had shortness of breath. There was no history of  vomiting,  fever  or  dyspnea. Chest  x-ray  was  not  specific,  ECG  was  negative  and  laboratory  studies  were  normal. Computerized  Tomography  was  perfomed  in  emergency,  since  the  chest  pain  was  still  strong. It showed perforation of the thoracic esophagus by ingested foreign body, in our case a chicken bone. There was no pneumothorax. Right-sided  pneumomediastinum was the critical  sign  on  CT.  CT  showed  esophageal wall thickening next to the perforation site,  the  exact  point  of  rupture  and  even  demonstrated  the  bone  itself,  which  was  situated   in  esophagus  underneath the level of carina.  A  small right  pleural  effusion was present. All  these  findings  were  strongly  suggestive  of  esophageal  perforation. The patient was transferred to surgery  immediately. Surgical  aid  included  primary  sutured  dosure,  drainage  and  long-term  antibiotic  treatment. Postoperative recovery  was  uneventful.",
    "discussion": "The  perforation  of  thoracic  esophagus  by  ingested  foreign  body  is  a  potentially  life-threatening  event  because  periesophageal  mediastinum  communicates  with  extraluminal  air  and   fluids  that  can  lead  to  a  septic  shock.. The  extraluminal  leakage  will  promptly  contaminate  and  incite  a  necrotizing  inflammation  in  mediastinum  and  pleural  spaces. \nThere  are  multiple  etiology  factors  that  cause  esophageal  perforation,  like\niatrogenic (55% of cases), foreign body (14%) and trauma (10%). Spontaneous  esophageal perforation (Boerhaave\u2019s syndrome) is a  rare  condition (15%). Underlying  esophageal  disease,  like  strictures,  achalasia  or  cancer,  is  present  commonly. Perforation  by  ingested  foreign  bodies  stop  at  the  sites  of  narrowing  or  angulation  of  the  gastrointestinal  tract. Aproximatelly  80%  of  accidentally  shallowed  foreign  bodies  are  entrapped  in  the  pharyngoesophageal  region.\n\nThe  clinical  symptoms  include  dysphagia  or  odynophagia,  fever,  chest  pain,  tachycardia,  cyanosis,  hypotension  and  respiratory  distress.\n\nThe  situation  may  be  confused  with  myocardial  infraction,  rupture  of  dissending  thoracic  aorta\u2019s  aneurysm  or  even  with  a  perforated  peptic  ulcer.\nEarly  diagnosis  is  critical  for  survival.\nChest  x-ray  is  the  initial  investigation  tool. The  earliest  sign  is  the  presence  of  linear  air  collections  in  the  mediastinum,  fascial  planes  of  the  neck  and  supraclavicular  regions.  Further  leakage  combined  with  inflammation  and  edema  cause  mediastinal  widening. If  perforation  extends  to  the  adjacent  pleura,  effusion,  with  or  without  pneumothorax,  will  develop. Mediastinal  air  and  subcutaneous  emphysema  are  present  in  about  90%  of  cases.\nContrast  esophagram  is  the  diagnostic  procedure  of  choice  in  patients  with  history  or  clinical  symptoms  suggestive  of  esophageal  perforation. Sometimes  the  initial  evaluation  does  not  show  the  extravasation  clearly  and  it\u2019s  possible  only  with  additional  radiography. False  negative  rates  up  to  25%  have  been  reported.\nThe  perfomance  of  CT  is  essential  when  the  usual  clinical  symptoms  are  unrecognized  and  when  the  diagnosis  is  obscure. The  findings  of  mediastinal  fluid  and  more  importantly,  mediastinal  air  on  CT,  are  highly  suggestive  of  perforation  of  the  esophagus. Other  CT  findings  are  esophageal  wall  thickening  and  extraluminal  contrast. When  foreign  body  is  the  cause,  CT  showes  it  correctly. Atypical  CT  findings  are  pneumopericardium,  uncommunicating  mediastinal  effusion and  pleural  effusion. The CT findings of acute mediastinitis include esophageal thickening, extraluminal gas, pleural effusion, single or multiple abscesses and extraluminal contrast medium.  Sometimes  CT  findings  are  not  pathognomonic  for  diagnosis.  Pleural  fluid  can  be  seen  in  a  wide  variety  of  diseases. The  presence  of  mediastinal  air  can  be  due  to  esophageal  perforation,  but  also  to  tracheobronchial  tree  rupture,  penetrating  trauma  and  even  to  perforated  duodenal  ulcer. \n\nCT  scans  obtained  after  per os  contrast  administration,  provide  more  useful  information  than  plain  CT  scans. Even  small  amounts  of  contrast  material  leakage  can  easily be  detected  on  CT.",
    "differential_diagnosis": "Oesophageal, rupture, by, ingested, bone",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001767/000001.jpg?itok=pTlBzS6p",
            "caption": "CT shows normal oesophagus before the perforation site."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001767/000002.jpg?itok=ZqEC_jcy",
            "caption": "CT shows esophageal wall thickening (arrow)."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001767/000003.jpg?itok=t7_I97B9",
            "caption": "CT shows gradual thickening of the wall of the oesophagus."
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001767/000004.jpg?itok=L3g0zDSo",
            "caption": "CT shows gradual thickening of the wall of the oesophagus."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001767/000005.jpg?itok=ySAnxW0Q",
            "caption": "A linear radiopaque foreign body is present in the oesophagus (arrow)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001767/000006.jpg?itok=a9I6G8LQ",
            "caption": "The oesophagus is normal at a lower level. Mediastinal air and a small area of bronchopneumonia are present(arrows)."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001767/000007.jpg?itok=HGcoNBnm",
            "caption": "Air is present in the mediastinum at pulmonary window(arrow)."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT",
      "CT",
      "CT",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/1767",
    "time": "11.11.2002"
  },
  "1801": {
    "case_id": 1801,
    "title": "Pectus excavatum",
    "section": "Chest imaging",
    "age": "20",
    "gender": "male",
    "diagnosis": "Pectus excavatum",
    "history": "Routine pre-employment chest radiograph.",
    "image_finding": "The patient was having a routine pre-employment medical check-up and a chest radiograph was ordered. The plain radiograph PA view showed sloping anterior ends of the ribs with an apparent shift of the heart towards the left side. These and other findings raised the possibility of a pectus excavatum deformity. A lateral view was performed to confirm the diagnosis.",
    "discussion": "Pectus excavatum (funnel chest, depressed sternum) is a condition where the lower half of the sternum is depressed back and there is decreased distance in relation to the dorsal spine. It can occur as an isolated feature or associated with Marfan's syndrome or congenital heart disease especially atrial septal disease. Other syndromes associated with pectus deformity include Ehlers-Danlos syndrome,Fetal alcohol syndrome,homocystinuria and Noonan syndrome.The condition itself can cause a functional systolic murmur.Patient may present with chest pain,easy fatigability,dyspnea on exertion,palpitations and symptoms of restrictive lung disease(tracheal or bronchial compression). It is speculated that the abnormality is probably due to excessive growth of the lowermost cartilages.\n\nPlain films on a PA view show a variety of findings including steep downward slope of the anterior ends of the ribs and a good delineation of the lower dorsal spine through the heart. There is a shift of the heart to the left with apparent cardiomegaly, straightening of the left heart border, and prominence of the main pulmonary artery; there is loss of the descending aortic interface. The right heart border is ill-defined, simulating right middle lobe consolidation. There may be a reduction of space occupied by the left lung. The lateral view of the chest will depict the extent of the depression of the sternum. A pectus index is sometimes used to assess the necessity for surgery. It is derived by dividing the transverse diameter of the chest by the anteroposterior diameter (Haller et al.). The normal value is 2.56 and a figure of more than 3.25 indicates that surgery is necessary.\n\nPatients are usually asymptomatic and in severe cases various surgical procedures(Ravitich,Nuss procedure) have been described. CT or MR best quantify the severity and imaging of the anatomy in severe deformity.CT or MR is useful when surgery is contemplated or in evaluation of complications of surgical repair.",
    "differential_diagnosis": "Pectus, excavatum",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001801/000001.jpg?itok=BvvKIGaV",
            "caption": "Frontal radiograph of chest showing sloping of the anterior ends of ribs,good delineation of the lower dorsal spine,apparent cardiomegaly,loss of right heart border."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001801/000002.jpg?itok=eBz1CFAg",
            "caption": "Lateral view showing the depression of the lower half of the sternum and decrease in distance in between sternum and the dorsal spine."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "Digital radiography"
    ],
    "link": "https://www.eurorad.org/case/1801",
    "time": "06.11.2002"
  },
  "1822": {
    "case_id": 1822,
    "title": "Sj\u00f6gren&#039;s syndrome",
    "section": "Chest imaging",
    "age": "67",
    "gender": "female",
    "diagnosis": "Sj\u00f6gren's syndrome",
    "history": "Patient with xerostomia, keratoconjunctivitis sicca, fatigue and Raynaud's phenomenon; there were no respiratory symptoms.",
    "image_finding": "The patient was diagnosed with xerostomia and keratoconjunctivitis sicca. During follow-up she presented with non-specific manifestations of fatigue and Raynaud's phenomenon; there were no respiratory symptoms.  On chest auscultation bibasilar inspiratory crackles were noted.  Pulmonary function tests showed reduced diffusion capacity. Bronchoalveolar lavage findings showed a reversal of the CD4:CD8 ratio. Her serum contained autoantibodies directed against rheumatoid factor, extractable nuclear antigen and double-stranded DNA; the Waaler-Rose test was also positive. A chest radiograph and HRCT examination of the chest were performed.",
    "discussion": "Sj\u00f6gren's syndrome (1) is a chronic, slowly progressive, autoimmune disease characterised by lymphocytic infiltration of the exocrine glands. The salivary and lacrimal glands are most frequently involved, but extraglandular manifestations occur in 5-10% of cases. The disease can be seen alone (primary  Sj\u00f6gren's syndrome) or in association with another autoimmune disease (RA, SLE or systemic sclerosis). It usually affects women (F:M, 9:1)(2) in the fourth and fifth decades of life. \n\nPulmonary involvement in collagen vascular diseases is common. Pleuropulmonary manifestations (1) of Sj\u00f6gren's syndrome include airways disease, interstitial pulmonary disease, pleural disease and lymphoproliferative disorders. Airways disease results from tracheobronchial desiccation and recurrent infection, and from lymphocytic infiltration of the airways, which causes follicular lymphocytic bronchiolitis. Interstitial lung disease may be due to fibrosing alveolitis or lymphocytic interstitial pneumonitis. Pleural disease consists of pleuritis and pleural thickening or effusion and is more common in secondary Sj\u00f6gren's. In fact lung abnormalities in secondary Sj\u00f6gren's syndrome are often dominated by the associated autoimmune disease, and abnormalities that reflect the associated disease may be difficult to distinguish from those that characterise the Sj\u00f6gren's syndrome itself.  Patients also have an increased risk of lymphoma, which should be suspected in cases of mediastinal lymphadenopathy or/and  in cases of single or multiple areas of consolidation with prominent air-bronchogram, which show little or no change over a prolonged period. \n\nThe advanced disease is easily detectable on chest radiographs. Plain films show primarily a reticular or reticulonodular interstitial pattern in the lower parts of the lungs. Associated airspace shadowing is suggestive of lymphocytic interstitial pneumonitis (LIP). Other radiological features that have been reported are bronchiectasis, pleural effusions or enlarging mediastinal lymph nodes and multiple nodular opacities in cases of pseudolymphoma or lymphoma. (2)\n\nLike other systemic disorders the most common HRCT changes are signs of chronic bronchiolar inflammation alone or in association with the presence of varying degrees of interstitial disease. The spectrum of HRCT findings (3,4,5)in small airways disease includes air trapping, bronchiectasis/bronchiolectasis, bronchial wall thickening and tree-in-bud appearance. An unusual manifestation of airways disease in Sj\u00f6gren's  syndrome consists of  bronchiolitis associated with cystic lung disease, resulting from severe peribronchial infiltrate with air trapping. Signs of fibrosing alveolitis include fibrosis (intralobular interstitial thickening, irregular interfaces, visible intralobular bronchioles, honeycombing and traction bronchiectasis), irregular interlobular thickening, ground-glass opacity, with a peripheral, subpleural, lower lung zone and posterior predominance. Ground-glass opacity can be due to present active inflammation or due to thickening of the intralobular septa.\nThe disease can cause dry eyes, dry mouth, vasculitis, and neurologic disease, and each symptom may be at times correctly attributed to Sjogren's or incorrectly attributed to another disease. The treatment of these symptoms is still mainly symptomatic. The outcome of the patient depends on the evolution of the disease but a standard basic treatment is not available for the moment.",
    "differential_diagnosis": "Sj\u00f6gren's, syndrome",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001822/000001.jpg?itok=s0b2oRe9",
            "caption": "Chest radiograph shows reticulonodular opacities in the lower part of the lungs."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001822/000002.jpg?itok=3EKFs2sU",
            "caption": "Chest radiograph shows reticulonodular opacities in the lower part of the lungs."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001822/000003.jpg?itok=ksq7YiN6",
            "caption": "Inspiratory HRCT scan demonstrates multiple bronchiectasis/bronchiolectasis, thickening of interlobular septa and bronchovascular bundles, subpleural cysts, as well as ground-glass opacities and areas of consolidation, with a lower lung zone and subpleural and peribronchovascular predominance."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001822/000004.jpg?itok=_PfWBPVN",
            "caption": "Inspiratory HRCT scan demonstrates multiple bronchiectasis/bronchiolectasis, thickening of interlobular septa and bronchovascular bundles, subpleural cysts, as well as ground-glass opacities and areas of consolidation, with a lower lung zone and subpleural and peribronchovascular predominance."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001822/000005.jpg?itok=L8VR2Obt",
            "caption": "Inspiratory HRCT scan demonstrates multiple bronchiectasis/bronchiolectasis, thickening of interlobular septa and bronchovascular bundles, subpleural cysts, as well as ground-glass opacities and areas of consolidation, with a lower lung zone and subpleural and peribronchovascular predominance."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001822/000006.jpg?itok=Ym7XPZDJ",
            "caption": "Inspiratory HRCT scan demonstrates multiple bronchiectasis/bronchiolectasis, thickening of interlobular septa and bronchovascular bundles, subpleural cysts, as well as ground-glass opacities and areas of consolidation, with a lower lung zone and subpleural and peribronchovascular predominance."
          },
          {
            "number": "Figure 2e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001822/000007.jpg?itok=cOdtCHxO",
            "caption": "Inspiratory HRCT scan demonstrates multiple bronchiectasis/bronchiolectasis, thickening of interlobular septa and bronchovascular bundles, subpleural cysts, as well as ground-glass opacities and areas of consolidation, with a lower lung zone and subpleural and peribronchovascular predominance."
          },
          {
            "number": "Figure 2f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001822/000008.jpg?itok=LCM7NErx",
            "caption": "Inspiratory HRCT scan demonstrates multiple bronchiectasis/bronchiolectasis, thickening of interlobular septa and bronchovascular bundles, subpleural cysts, as well as ground-glass opacities and areas of consolidation, with a lower lung zone and subpleural and peribronchovascular predominance."
          },
          {
            "number": "Figure 2g",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001822/000009.jpg?itok=NISHPSNR",
            "caption": "Inspiratory HRCT scan demonstrates multiple bronchiectasis/bronchiolectasis, thickening of interlobular septa and bronchovascular bundles, subpleural cysts, as well as ground-glass opacities and areas of consolidation, with a lower lung zone and subpleural and peribronchovascular predominance."
          },
          {
            "number": "Figure 2h",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001822/000010.jpg?itok=Huk9pdE-",
            "caption": "Inspiratory HRCT scan demonstrates multiple bronchiectasis/bronchiolectasis, thickening of interlobular septa and bronchovascular bundles, subpleural cysts, as well as ground-glass opacities and areas of consolidation, with a lower lung zone and subpleural and peribronchovascular predominance."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/1822",
    "time": "30.01.2003"
  },
  "1833": {
    "case_id": 1833,
    "title": "A special case of lung embolism",
    "section": "Chest imaging",
    "age": "70",
    "gender": "female",
    "diagnosis": "Lung embolism by foreign body: cement",
    "history": "An operation was interrupted because of a rapid decrease of the CO2 at the end of expiration; there was no haemodynamic collapse of the patient. A chest X-ray obtained preoperatively was normal.",
    "image_finding": "The patient presented with progressive low back pain, due to an osteoporotic compression fracture of D11-D12, which had manifestly increased over the previous months. A vertebroplasty was planned. During the operation, at the time of cement injection, there was a rapid decrease of the CO2 at the end of expiration (end-tidal CO2)suggesting pulmonary embolism in an intubated patient.  There was no haemodynamic collapse of the patient. The operation was interrupted and the patient was transferred to the intensive care unit.\n  \nThere were no pulmonary complaints pre-operatively and a chest X-ray obtained preoperatively was normal.\nAfter the operation a chest X-ray and a spiral CT of the chest were made.",
    "discussion": "Percutaneous vertebroplasty is an operation where acrylic cement (polymethylmethacrylate) is injected via a transpedicular approach into a diseased vertebral body for partial vertebral remodelling and pain relief. Indications for a percutaneous vertebroplasty are: osteolytic metastases, osteoporotic compression fractures and vertebral haemangiomas.  (The patient in this case suffered from a compression fracture of D11-D12.) Complications of the procedure are infrequent but possible and consist of infection or cement leakage into the spinal canal or into the perivertebral venous system.\n\nCement leakage can occur into the external or internal vertebral venous plexuses.  There is also a potential risk of cement migration into the inferior vena cava and pulmonary embolism. Compression on the spinal cord or on the nerve roots due to leakage of cement in the internal vertebral venous plexuses is mostly asymptomatic.\n\nIn this patient pulmonary embolism occured immediately after the injection of  cement. On chest X-ray the pulmonary arteries in the upper lung areas were more pronounced and had a higher density.  A control chest X-ray showed pronounced arteries in the ventral lung area corresponding to pulmonary arteries filled with cement. The ventral pulmonary arteries were especially affected because the patient was in a prone body position during the operation. Spiral CT showed the migration of cement into the internal and external perivertebral plexuses and confirmed the presence of cement in the ventral pulmonary arteries.\n\nTreatment options are not very clear. Anticoagulants appear to be effective on pulmonary infarction (which was not present in this patient).  When medical treatement is not sufficient, pulmonary embolectomy is a reliable and effective procedure to treat this rare complication of acrylic vertebroplasty.",
    "differential_diagnosis": "Lung, embolism, by, foreign, body:, cement",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001833/000001.jpg?itok=MjymmWLT",
            "caption": "Normal heart contour.  Normal lungparenchyma, there are no parenchymconsolidations. Pronounced vessels in the upper lung areas."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001833/000002.jpg?itok=9JXBmRYb",
            "caption": "Spiral CT of the chest whithout IV contrastadministration.  There are some dense opacities in de pulmonary arteries of the both upper lobes."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001833/000003.jpg?itok=rgABKVkz",
            "caption": "Spiral CT of the chest whithout IV contrastadministration.  There are some dense opacities in de pulmonary arteries of the both upper lobes but also in de left lower lobe."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001833/000004.jpg?itok=XeOcx3BT",
            "caption": "The lungparenchyma is normal.  No evidence for pulmonary consolidation, pulmonary infarct or mosaicperfusion."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001833/000005.jpg?itok=4xvEPSm3",
            "caption": "The lungparenchyma is normal.  No evidence for pulmonary consolidation, pulmonary infarct or mosaicperfusion."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001833/000006.jpg?itok=FqptPjd-",
            "caption": "Pronounced vessels in the upper and ventral lung areas.\nSmall amount of pleural fluid in the left CD sinus."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001833/000007.jpg?itok=Daqt43JM",
            "caption": "Pronounced vessels in the upper and ventral lung areas.\nSmall amount of pleural fluid in the left CD sinus."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001833/000008.jpg?itok=ulJGWAJG",
            "caption": "Spontaneous hyperdense material in the pulmonary arteries, mostly in the ventral lung areas."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001833/000009.jpg?itok=qUxcaCEB",
            "caption": "Spontaneous hyperdense material in the pulmonary arteries, mostly in the ventral lung areas."
          },
          {
            "number": "Figure 4c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001833/000010.jpg?itok=eMyniPkd",
            "caption": "Spontaneous hyperdense material in the pulmonary arteries, mostly in the ventral lung areas."
          },
          {
            "number": "Figure 4d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001833/000011.jpg?itok=NUYIFUYG",
            "caption": "Spontaneous hyperdense material in the pulmonary arteries, mostly in the ventral lung areas."
          },
          {
            "number": "Figure 4e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001833/000012.jpg?itok=-HqJTNeN",
            "caption": "Spontaneous hyperdense material in the pulmonary arteries, mostly in the ventral lung areas."
          },
          {
            "number": "Figure 4f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001833/000013.jpg?itok=or7LVev1",
            "caption": "Spontaneous hyperdense material in the pulmonary arteries, mostly in the ventral lung areas."
          },
          {
            "number": "Figure 4g",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001833/000014.jpg?itok=pKuCBuuD",
            "caption": "Spontaneous hyperdense material in the pulmonary arteries, mostly in the ventral lung areas."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001833/000015.jpg?itok=UgZsJ3B7",
            "caption": "Spontaneous hyperdense material in the perivertebral venous system."
          },
          {
            "number": "Figure 5b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001833/000016.jpg?itok=ntHiG9Ib",
            "caption": "Spontaneous hyperdense material in the perivertebral venous system."
          },
          {
            "number": "Figure 5c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001833/000017.jpg?itok=zar1DM8N",
            "caption": "Spontaneous hyperdense material in the perivertebral venous system."
          },
          {
            "number": "Figure 5d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001833/000018.jpg?itok=FZCANwFk",
            "caption": "Spontaneous hyperdense material in the perivertebral venous system."
          },
          {
            "number": "Figure 5e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001833/000019.jpg?itok=5sW60CHf",
            "caption": "Spontaneous hyperdense material in the perivertebral venous system."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "Digital radiography",
      "CT",
      "CT",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/1833",
    "time": "21.01.2003"
  },
  "1847": {
    "case_id": 1847,
    "title": "Nodular form of pulmonary sarcoidosis",
    "section": "Chest imaging",
    "age": "25",
    "gender": "male",
    "diagnosis": "Nodular form of sarcoidosis",
    "history": "The patient complained of swollen ankles, night sweats and weight loss. A clinical examination revealed crepitations on the right lung base.",
    "image_finding": "The patient complained of swollen ankles, night sweats and weight loss. A clinical examination revealed crepitations on the right lung base. Clinical findings did not imply infection, and antibody tests showed negative serum results against a variety of bacteria.\n\nA chest radiograph was performed, followed by a CT scan of the chest.",
    "discussion": "Diagnosis of sarcoidosis is based on clinico-radiological findings and histological evidence of non-caseating epithelioid cell granulomas.  In this patient histological examination of the biopsy specimens revealed non-caseating epithelioid cell granulomas with giant cells. In clinical practice, the organs commonly scanned are lymph nodes, liver and lung. The majority of cases are diagnosed in patients between 20 and 40 years of age. The aetiology of the disease remains unknown.\nThe chest radiograph is abnormal in 90-95% of patients with sarcoidosis. About 5-15% of patients have a normal chest radiograph at presentation but pulmonary granulomas can be demonstrated on biopsy in these patients despite the absence of radiological change.\nCT scanning is superior to plain chest radiography in showing parenchymal involvement of pulmonary sarcoidosis and in evaluating the lymph node enlargement. \nLymphadenopathy is the most common intrathoracic manifestation of sarcoidosis. It can present alone or in association with parenchymal disease. The classic pattern is symmetrical, bilateral hilar adenopathy and some forms of paratracheal adenopathy. Lymphadenopathy alone is highly suggestive of sarcoidosis, but biopsy is needed, as lymphoma or metastatic disease can also present in this manner. \nLarge parenchymal nodules are an uncommon finding in sarcoidosis and have been noted in up to 4% of patients with this disease. The nodules are usually bilateral and multiple, ranging in size from 0.5cm to 5cm. There is a slight mid-zone predilection. The margins of the nodules tend to be fluffy and ill-defined. Some nodules may contain an air bronchogram. \nRadiological differential diagnosis must include metastatic disease, lymphoma, septic emboli, infectious disease (tuberculous or fungal) and immunological disease (Wegener's granulomatosis, rheumatoid lung).",
    "differential_diagnosis": "Nodular, form, of, sarcoidosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001847/000001.jpg?itok=zAnYz4Re",
            "caption": "The chest X-ray shows multiple large nodular masses, diffuse in both lungs with a predilection for the middle and lower lung areas. The nodules range in size from 1cm to several centimetres. The margins of these nodules are usually ill-defined and hazy. There is bilateral hilar enlargement."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001847/000002.jpg?itok=p8KCI3kO",
            "caption": "The chest X-ray shows multiple large nodular masses, diffuse in both lungs with a predilection for the middle and lower lung areas. The nodules ranging in size from 1cm to several centimetres. The margins of these nodules are usually ill-defined and hazy. There is bilateral hilar enlargement."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001847/000003.jpg?itok=H49WKTcz",
            "caption": "On CT scan there are bilateral hilar and mediastinal enlarged lymph nodes."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001847/000004.jpg?itok=dhheFaLD",
            "caption": "On CT scan there are bilateral hilar and mediastinal enlarged lymph nodes."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001847/000005.jpg?itok=yj3JA3VT",
            "caption": "On CT scan there are bilateral hilar and mediastinal enlarged lymph nodes."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001847/000006.jpg?itok=5yDKOoAe",
            "caption": "On CT scan there are bilateral hilar and mediastinal enlarged lymph nodes."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001847/000007.jpg?itok=oH9z5Oul",
            "caption": "On the lung windows we can visualise the nodular densities. The margins are usually poorly defined, hazy, and fluffy, but some are sharply demarcated. Some of them contain an air bronchogram."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001847/000008.jpg?itok=TIz2DL0W",
            "caption": "On the lung windows we can visualise the nodular densities. The margins are usually poorly defined, hazy, and fluffy, but some are sharply demarcated. Some of them contain an air bronchogram."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001847/000009.jpg?itok=wQbtRwDd",
            "caption": "On the lung windows we can visualise the nodular densities. The margins are usually poorly defined, hazy, and fluffy, but some are sharply demarcated. Some of them contain an air bronchogram."
          },
          {
            "number": "Figure 3d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001847/000010.jpg?itok=S0KgcgVK",
            "caption": "On the lung windows we can visualise the nodular densities. The margins are usually poorly defined, hazy, and fluffy, but some are sharply demarcated. Some of them contain an air bronchogram."
          },
          {
            "number": "Figure 3e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001847/000011.jpg?itok=2Q1ptQW4",
            "caption": "On the lung windows we can visualise the nodular densities. The margins are usually poorly defined, hazy, and fluffy, but some are sharply demarcated. Some of them contain an air bronchogram."
          },
          {
            "number": "Figure 3f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001847/000012.jpg?itok=ytogbaDc",
            "caption": "On the lung windows we can visualise the nodular densities. The margins are usually poorly defined, hazy, and fluffy, but some are sharply demarcated. Some of them contain an air bronchogram."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "Digital radiography",
      "CT",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/1847",
    "time": "09.12.2002"
  },
  "1882": {
    "case_id": 1882,
    "title": "Paracardiac pleural Castleman disease: radiographic and MR findings",
    "section": "Chest imaging",
    "age": "22",
    "gender": "female",
    "diagnosis": "Paracardiac pleural Castleman disease of the hyaline-vascular subtype",
    "history": "A previously healthy young woman complained of right lower chest discomfort for 10 months.",
    "image_finding": "The patient presented with a 10-month history of right lower chest discomfort. Physical examination and laboratory findings were normal. \n\nChest radiography revealed an ovoid mass in the right paracardiac region (Fig. 1a). MR imaging revealed a well-defined mass in the right cardiophrenic region. The mass was slightly hyperintense to skeletal muscle on T1-weighted images, and heterogeneously hyperintense on T2-weighted and enhanced T1-weighted images (Figs 1b-1e). \n\nDuring surgery, a 5cm encapsulated mass originating from the right paracardiac parietal pleura, with blood supplies from the pleural arteries, was found. Adhesion of the mass to the adjacent pericardium, right hemidiaphragm, and right middle and lower lobes was also noted. Radical tumour resection was performed.\n\nMicroscopically, the lesion was composed of germinal follicles with hyalinised vessels surrounded by onion-like layers of small lymphocytes and prominent vascular stroma in the interfollicular tissue with lymphocytic infiltration. The adjacent lung and pericardial tissues appeared normal. The final diagnosis was Castleman disease of the hyaline-vascular subtype. \n\nThe patient has been followed-up for 8 years with no further chest discomfort.",
    "discussion": "Castleman disease (CD) is an uncommon benign lymphoproliferative disorder. Based on biological behavior, CD is currently categorised into the unicentric form and the multicentric form. Most cases of the former are of the hyaline-vascular type and are amenable to surgical treatment, while most of the latter belong to the plasma-cell type and are associated with systemic manifestations. Approximately 70% of cases of CD involve the thorax, 10-15% the neck, and 10-15% the abdomen, retroperitoneum and pelvis. Thoracic CD usually affects the mediastinum and pulmonary hilus along the tracheobronchial tree. Uncommon locations, including the intercostal space and pericardium, have also been described. Interestingly, although CD arises from the lymph nodes, it may affect extra-lymphatic tissues such as the larynx, parotid gland, pancreas or muscle. In contrast to absence of lymph nodes in the pleural space, well developed clusters of lymphoid cells are present in the subpleural space. Therefore, it is plausible to postulate that pleural CD disease may arise from these subpleural lymphoid tissues and then grow into the pleural space. \n\nDue to its rarity, paracardiac pleural CD is difficult to diagnose preoperatively. The plain radiographic findings may mimic pericardial cyst. CT is useful in differentiation between solid and cystic content, and in diagnosis of those cases of CD with the typical findings of a well-defined, strongly enhancing tumour. MR imaging allows multiplanar anatomical delineation of such lesions, a clear demonstration of the relationship to bronchiovascular structures, and occasionally demonstrate the intratumoral vessels as \"signal-void\". Furthermore, the MR signal characteristics of CD, with heterogeneous hyperintensity on T2- and enhanced T1-weighted images, as illustrated in this case, provide clues for preoperative diagnosis of this uncommon tumour.",
    "differential_diagnosis": "Paracardiac, pleural, Castleman, disease, of, the, hyaline-vascular, subtype",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001882/000001.jpg?itok=FAwKhLK4",
            "caption": "Chest radiograph shows an ovoid right paracardiac mass."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001882/000002.jpg?itok=YASWCO9m",
            "caption": "Coronal T1-weighted image shows a well-defined right paracardiac mass with signal intensity hyperintense to chest wall skeletal muscles. \"Signal-void\" intratumoral vessels are also noted."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001882/000003.jpg?itok=x9IXIHtC",
            "caption": "Axial T1-weighted image shows a well-defined right paracardial tumour with partial obliteration of the adjacent pericardial lining."
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001882/000004.jpg?itok=_hJS5LRR",
            "caption": "Axial T2-weighted image shows heterogeneous hyperintensity of the mass."
          },
          {
            "number": "Figure 1e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001882/000005.jpg?itok=3a_4bhOO",
            "caption": "Axial enhanced T1-weighted image shows heterogeneous enhancement of the tumour."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "MR"
    ],
    "link": "https://www.eurorad.org/case/1882",
    "time": "21.01.2003"
  },
  "1885": {
    "case_id": 1885,
    "title": "A case of pulmonary lymphangioleiomyomatosis and renal angiomyolipom",
    "section": "Chest imaging",
    "age": "32",
    "gender": "female",
    "diagnosis": "Pulmonary lymphangioleiomyomatosis and renal angiomyolipoma",
    "history": "A patient with a history of recurrent pneumothoraces underwent chest X-ray and high-resolution chest and abdominal CT scanning, which revealed multiple, bilateral pulmonary cystic lesions, right pneumothorax and a left renal mass.",
    "image_finding": "The patient with a history of recurrent pneumothoraces underwent chest X-ray and high-resolution chest and abdominal CT scanning, which revealed multiple, bilateral pulmonary cystic lesions, right pneumothorax and a left renal mass.\nAP chest X-ray revealed irregular cavities and evidence of prior lung resection (Fig. 1). A lobulated right anterior pneumothorax was also visible inferiorly on the lateral view (not shown).\nA non-contrast high-resolution chest (Fig. 2) and upper abdominal (Fig. 3) CT study  with 5mm sections demonstrated multiple thin walled cysts diffusely involving both lungs. The largest complex cyst abnormality was in the right upper lobe, near the apex, measuring 4.2cm x 4.2cm. There was a small right-sided pneumothorax (Fig. 2b). Post-surgical changes were evident at the right apex. Posterior calcified opacities conforming to the pleural contour, were also seen, and probably related to prior pneumothoraces or prior pleurodesis.\nCT of the upper abdomen revealed distortion of the left renal contour due to the presence of a mass containing fat and a calcification. There was no evidence of mediastinal or hilar lymphadenopathy.",
    "discussion": "Lymphangioleiomyomatosis (LAM) is a rare, idiopathic hamartomatosis characterized by smooth muscle cell hyperplasia along the terminal bronchioles in the lung, the lymphatic and blood vessels of the thorax and the retroperitoneum. The pathogenesis of LAM is still unclear. Pulmonary LAM can occur as part of the tuberous sclerosis complex. Some investigators claim that isolated pulmonary LAM and LAM associated with renal angiomyolipomas are a rough form of tuberous sclerosis. Pulmonary involvement in tuberous sclerosis is very uncommon, occurring in only 0.1%\u20131% of cases. The prevalence of LAM in women with asymptomatic tuberous sclerosis may be as high as 34%. LAM has been rarely described in males with tuberous sclerosis. The majority of patients are women. Patients present with pulmonary symptoms and signs such as increasing shortness of breath, cough, pneumothorax, chylous pleural effusion and haemoptysis. Some patients have abdominal pain or a painless abdominal mass, either in isolation or coincident with chest symptoms. The classic triad of chest radiographic findings includes a reticular interstitial pattern, chylous pleural effusion and recurrent pneumothoraces. The interstitial changes seen on chest radiography represent the superimposition of the thin-walled cysts uniformly distributed throughout the lungs that are a hallmark of LAM on computed tomography (CT). Some authors have described the radiological pattern as a honeycomb appearance of small cysts, while others have described larger cysts. It has been suggested that the size of the cysts tends to be larger in more severe disease.\nThe four major abdominopelvic abnormalities seen in patients with LAM are renal angiomyolipoma (AML), as in this case; lymphadenopathy; lymphangioma; and chylous ascites. \nRenal AML is the most common tumour associated with LAM. AMLs are benign, non-capsulated masses containing varying amounts of abnormal blood vessels, smooth muscle and mature fat. It is frequently associated with tuberous sclerosis. The key to diagnosis of an AML is the demonstration of fat. Because of its sensitivity in detection of small foci of fat, CT is the optimal imaging modality. Careful focal sampling of the low-attenuating regions within the mass must be performed, since the masses are frequently heterogeneous. A major but uncommon complication of renal AML is haemorrhage, which may manifest as flank pain or shock. \nThe recommended management of renal AML is based on tumour size and symptoms. Patients with asymptomatic lesions smaller than 4.0cm in diameter may be followed up with annual US or CT and those with lesions larger than 4.0cm in diameter by semiannual US or CT. Only patients with progressive symptoms should undergo nephrectomy or preferably a partial nephrectomy or embolisation. \nLAM is believed to be hormonally mediated and therapies have been directed towards reducing circulating oestrogen levels. Lung transplantation has recently become an option for patients with end-stage LAM, but it has been associated with increased morbidity owing to unique complications related to the underlying disease, such as intraoperative bleeding due to pleural adhesions, native lung pneumothorax, chylous effusion, and ascites. \nChest and upper abdominal CT scanning is highly capable, as shown in the present case, of achieving an accurate evaluation of both pulmonary LAM and renal angiomyolipoma.",
    "differential_diagnosis": "Pulmonary, lymphangioleiomyomatosis, and, renal, angiomyolipoma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001885/000001.jpg?itok=A764VF_o",
            "caption": "AP chest X-ray revealed irregular cavities and evidence of prior lung resection with minor scarring."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001885/000002.jpg?itok=2WrGKMlp",
            "caption": "Multiple thin walled cysts randomly involving both lungs are evident. The largest complex cystic abnormality is in the right upper lobe, near the apex, measuring 4.2cm x 4.2cm."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001885/000003.jpg?itok=1uEW7p72",
            "caption": "There is a small right-sided pneumothorax."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001885/000004.jpg?itok=6pTEKj0f",
            "caption": "Unenhanced upper abdominal CT revealed distortion of the left renal contour due to the presence of a mass containing fat and a calcification. There was no evidence of mediastinal or hilar lymphadenopathy."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/1885",
    "time": "10.07.2003"
  },
  "1895": {
    "case_id": 1895,
    "title": "Congenital intrathoracic ectopic kidney",
    "section": "Chest imaging",
    "age": "20",
    "gender": "male",
    "diagnosis": "Congenital intrathoracic ectopic kidney",
    "history": "Complaints of non-specific respiratory tract infection such as cough and mild fever. Plain radiographs of the chest revealed a paravertebral soft tissue opacity with regular borders encasing the left heart contour. There was mild leukocytosis (15,500 WBCs/mm3).",
    "image_finding": "The patient presented with complaints of non-specific respiratory tract infection such as cough and mild fever. Plain radiographs of the chest revealed a paravertebral soft tissue opacity with regular borders encasing the left heart contour (Fig. 1). The medical history was unremarkable and there was no previous trauma. Laboratory tests and renal function tests showed no abnormality apart from mild leukocytosis (15,500 WBCs/mm3). Abdominal ultrasound, excretory urography, and computed tomography of the chest were performed to aid in diagnosis.",
    "discussion": "Ectopic kidneys are frequently located in the pelvic region, but intrathoracic renal ectopia is extremely rare (1,2). Most cases are in male patients and the diaphragm is usually intact. Ectopic kidneys mostly occur on the left side (61%) but they may also be right sided (36%) or bilateral (2%) (1). Intrathoracic kidneys are usually asymptomatic, in contrast to pelvic kidneys, and are found incidentally on antero-posterior chest radiography. \nThe embryology of thoracic ectopic kidneys is still unclear. It was first described by Jean Louis Petit in 1970 as the migration of the contents of abdominal and retroperitoneal areas into the thoracic cavity, and was later termed 'evantratio diaphragmatica' by Beclard. It was previously thought that most intrathoracic kidneys were the result of maldevelopment of the pleuro-peritoneal membrane. However, the incidence of intrathoracic kidney with diaphragmatic hernia is low (less than 0.25%). \nSpillane and Prather proposed three criteria in the diagnosis of congenital intrathoracic kidney. They were rotation anomaly, long ureter and anomalous high origin of the renal arteries. Medial deviation of the lower poles of the kidneys was described as in pelvic and horseshoe kidneys. The normal origin of the renal arteries, as seen in this case, has been shown previously with selective arteriography in a few cases (2,3). \nFour basic types of intrathoracic kidney have been described:\nTrue thoracic ectopia with a normally developed dorsal diaphragm; \nEventration of the diaphragm; Diaphragmatic hernia, either a congenital diaphragmatic hernia defect or acquired herniation; \nTraumatic rupture of the diaphragm with renal ectopia (1,2).\n\nThe radiographic appearance of a thoracic kidney may be similar to that of posterior mediastinal masses, such as Bochdalek hernia, sequestration, or neurogenic masses. A smooth rounded mass is seen extending into the chest near the midline on antero-posterior chest radiography and on the posterior aspect of the diaphragm on the lateral view. Sometimes the only radiological finding is elevation of the diaphragm (1). Ultrasound is useful in the diagnosis of juxtadiaphragmatic masses (2). Excretory urography is very useful and it may be necessary for the differential diagnosis (4). Computed tomography (CT) provides not only detection of a posterior mediastinal lesion but also visualisation of its contour, extent and size. The differential diagnosis from other thoracic masses, such as omental hernias through Morgagni's foramen or oesophageal hiatus and mediastinal lipomatosis can be made easily on the basis of low-density fatty components of these structures (1). The typical contrast enhancement of pelvicaliceal structures and the typical appearances of soft tissue density of kidney can be best diagnosed by CT (5). \nApart from its abnormal position, a thoracic kidney is functionally normal. The stretched ureter provides good drainage and so there is no tendency to infection or other complications as in low localised ectopic kidneys. Thoracotomy and nephrectomy are almost always not necessary for diagnosis but may be indicated for associated abnormalities of the reproductive system, pelvis, adrenal glands and lungs. \nIn conclusion, thoracic kidney must be kept in mind whenever a reniform mass lesion with convex upper and lower borders is seen in the posterior sulcus of the thorax in an asymptomatic patient. Excretory urography, ultrasound, and CT best demonstrate the abnormality.",
    "differential_diagnosis": "Congenital, intrathoracic, ectopic, kidney",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001895/000001.jpg?itok=OiGMrw5K",
            "caption": "On lateral chest radiography, a posterior mediastinal mass is seen."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001895/000002.jpg?itok=VKSmN0PZ",
            "caption": "On excretory urography, the right kidney is functional and in the normal location. The left kidney has an intrathoracic location and has a rotation anomaly in the vertical and transverse planes. The renal pelvis and pelvicaliceal structures are normal."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001895/000003.jpg?itok=GjJx72CN",
            "caption": "Contrast-enhanced CT shows the left intrathoracic kidney with normal function."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001895/000004.jpg?itok=iV6dP1pb",
            "caption": "Selective intra-arterial renal DSA shows the normal origin of the left single renal artery and the left kidney in the supradiaphragmatic region."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/1895",
    "time": "12.11.2003"
  },
  "1904": {
    "case_id": 1904,
    "title": "Persistent left superior vena cava draining into the left atrium",
    "section": "Chest imaging",
    "age": "59",
    "gender": "female",
    "diagnosis": "Persistent left superior vena cava draining into the left atrium",
    "history": "Two-day history of dyspnoea at rest, mild hypoxaemia.",
    "image_finding": "The patient was admitted with dyspnoea at rest. The arterial blood gas analysis showed mild hypoxaemia. Chest X-ray demonstrated a light enlargement of the left ventricle and left superior mediastinum.\n\nWith a clinical suspicion of pulmonary embolism (PE), a CT was performed with injection of contrast medium from the left antecubital vein. Axial images showed the opacification of the left anonymous vein draining directly into the left superior vena cava and the subsequent opacification of the left atrium and the left ventricle. CT images also demonstrated mild opacification of the right atrium through a patent foramen ovale; no opacification of the pulmonary arteries was obtained. To rule out PE a contrast injection from the right antecubital vein was performed and no intraluminal defects into the pulmonary arteries were detected. A right SVC draining into the right atrium was also present.",
    "discussion": "The incidence of persistent left superior vena cava (PLSVC) is about 0.3% in the healthy population, reaching over 11% in patients with congenital heart disease. This anomaly results from failure of obliteration of the left anterior cardinal vein during foetal development.\n\nIn the majority of cases the PLSVC opens into the coronary sinus or into the right atrium directly, but in 8% of cases it drains into the left atrium, as in this case. PLSVC draining into the left atrium causes a right-to-left shunt and may appear in isolation or as a part of more complex cardiac anomalies. In this case it is associated with a mild patency of the foramen ovale demonstrated by CT. So, blood from the left upper extremity doesn't reach the pulmonary circulation, but the left-to-right shunt through the patent foramen ovale leads to only a mild hypoxaemia.\n\nLSVC can be seen with or without the presence of right superior vena cava and may be associated with other vascular anomalies such as two azygos veins or the hemiazygos vein opening into the left superior vena cava.\n \nLSVC may often be discovered incidentally or during catheterisation of the left jugular or subclavian veins. This anomaly may be completely asymptomatic if is not haemodynamically significant or not associated with other congenital cardiac anomalies; cyanosis and hypoxaemia may be present when the left superior vena cava drains into the left atrium. The most significant clinical implication of PLSVC associated with congenital heart disease is the presence of alterations of cardiac impulse formation and conduction.\n\nSpiral CT allows evaluation of the course and drainage of the LSVC if the contrast medium is injected into the left cubital or forearm veins. Furthermore multiplanar and three-dimensional reconstructions from the spiral CT data set can help not only radiologists but also clinicians and surgeons in therapeutic planning. \n\nIf the PLSVC represents a haemodynamically significant anomaly, surgical management and repair can be performed by one of four methods: 1) division and reimplantation of the LSVC to the right atrium; 2) an intraatrial baffle to divert flow from the LSVC to the right atrium; 3) simple ligation of the LSVC; 4) anastomosis of the LSVC to the left pulmonary artery.",
    "differential_diagnosis": "Persistent, left, superior, vena, cava, draining, into, the, left, atrium",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001904/000001.jpg?itok=O5IUvrbL",
            "caption": "Frontal chest X-ray demonstrating a slight enlargement of the left ventricle and left upper mediastinum (arrow); no evidence of parenchymal disease or pleural effusion."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001904/000002.jpg?itok=NEZCwVgl",
            "caption": "CT scan at the level of the aortic arch showing an opacified left superior vena cava (LSVC) after injection of contrast medium into the left antecubital vein; a non-opacified right superior vena cava is also present."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001904/000003.jpg?itok=aqhSiETj",
            "caption": "Subsequent CT scan at the level of the main pulmonary arteries showing the opacification of the left atrial appendage; no opacification of the main pulmonary arteries is seen."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001904/000004.jpg?itok=quD9ngre",
            "caption": "Subsequent CT scan showing the opacification of the left atrium."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001904/000005.jpg?itok=7RNf6tbk",
            "caption": "CT scan showing a \"jet\" of contrast medium passing from the left atrium to the right atrium through a patent foramen ovale (arrow); a mild opacification of the right atrium is seen."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/1904",
    "time": "20.01.2003"
  },
  "1910": {
    "case_id": 1910,
    "title": "Pneumoblastoma in an adult",
    "section": "Chest imaging",
    "age": "52",
    "gender": "male",
    "diagnosis": "Pneumoblastoma",
    "history": "Cough, dyspnoea and degradation of health status. Pulmonary mass on imaging studies.",
    "image_finding": "The patient was referred for management of a pulmonary mass. Initially, he presented with cough, dyspnoea and degradation of health status. When he presented he had superior vena cava syndrome. Conventional chest X-rays were obtained (Fig. 1) as well as chest CT scans (Figs 2-4). \n\nHistology revealed a diagnosis of pneumoblastoma. Additional imaging work-up was negative (brain CT, bone scintigraphy, abdominal ultrasound). The patient was treated with chemotherapy with moderate results (Fig. 5).",
    "discussion": "Pneumoblastoma is a rare pulmonary malignant tumour of embryonic origin, which is more frequent in children. Its description in adults is rare [1]. Men are more often (80%) affected than women and the age of the diagnosis is most commonly 30-40 [2]. This tumour is known to have a very  poor prognosis [2].\n\nClinical presentation is varied: mostly, the tumour is asymptomatic for a long time [2]; cough and dyspnoea appear with large tumours. A case of spontaneous pneumothorax has been reported [3]. \n\nImaging is non-specific. On conventional radiographs pneumoblastoma appears as a large peripheral mass [2]. Most of the time CT shows a heterogeneous parenchymal mass, with contrast enhancement. Large tumours contain low density areas corresponding to necrosis. Calcifications are possible [2].\n\nAll kinds of secondary visceral localisations are found, mostly in the liver and brain [2]. Metastases to lymph nodes (in the neck and mediastinum), bone, pancreas and adrenal glands have been described [2]. \n\nVascular extension, as described in this case, is less frequent: only two cases of vascular extension have been described in the literature [4-5], and one case concerns an extension into the left atrium through a pulmonary vein.\n\nDefinite diagnosis of the pneumoblastoma is histological - the presence of cells with blastematous character, very similar to foetal lung, is characteristic - and it is necessary to differentiate pneumoblatoma from carcinoma [1].",
    "differential_diagnosis": "Pneumoblastoma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001910/000001.jpg?itok=k79g1LEW",
            "caption": "A large opacity of the right lung is seen."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001910/000002.jpg?itok=ulOaifDP",
            "caption": "CT shows a large parenchymal mass, which occupies 70% of the right lung, in association with a pleural effusion. The mass is heterogeneous with low density areas, and peripheral contrast enhancement."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001910/000003.jpg?itok=C31_4H3s",
            "caption": "The vena cava and the pulmonary arteries are encased and invaded by the tumour."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001910/000004.jpg?itok=ADh_bBAO",
            "caption": "The extension of the tumour in the left pulmonary artery is depicted."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001910/000005.jpg?itok=eI4E2Rmp",
            "caption": "Chemotherapy resulted in only moderate reduction in tumour size."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "Digital radiography",
      "CT",
      "Digital radiography"
    ],
    "link": "https://www.eurorad.org/case/1910",
    "time": "20.01.2003"
  },
  "1959": {
    "case_id": 1959,
    "title": "CT findings of pulmonary Kaposi&#039;s sarcoma in a patient with AIDS",
    "section": "Chest imaging",
    "age": "45",
    "gender": "male",
    "diagnosis": "Kaposi's sarcoma",
    "history": "A patient with AIDS presented with cough, and increasingly dyspnoea.",
    "image_finding": "A patient with AIDS and known Kaposi of the skin presented with cough, and increasingly dyspnoea. Blood analysis revealed a CD4 count of less than 400/mL.\n\nHigh resolution chest CT revealed ground glass density opacifications, primarily involving the upper lung lobules (Fig. 1), and in the middle right, lingular left, and bilaterally in the low lobes distributed, diffuse, flame-shaped, nodular opacities distributed along the bronchovascular bundles with disease encasing the hilar areas and thickening the interlobular septa (Figs 2,3).",
    "discussion": "More than 30 million people wordwide are infected with the human immunodeficiency virus (HIV), the cause of the acquired immunodeficiency syndrome (AIDS). Chests disease continues to account for the majority of all AIDS-defining illnesses, with lung infections causing significant morbidity and mortality. Kaposi's sarcoma (KS) is the most common tumour identified in AIDS, strongly associated with the homosexual transmission of HIV.\n\nKaposi's sarcoma may involve lymph nodes and internal organs, usually in association with skin lesions. Pulmonary involvement can be observed in up to 50% of patients with typical cutaneous lesions. Pulmonary, pleural, and tracheobronchial involvement occurs in approximately one third of patients with cutaneous lesions. As a malignancy of probable lymphatic endothelial origin, when there is involvement of the pulmonary parenchyma, KS has an obvious distibution along interstitium, and in the peribronchial and perivascular lymphatics. Therefore, computed tomography may demonstrate linear opacities and ill-defined irregular nodules in a peribronchovascular distribution. The typical CT findings include bilateral, symmetric perihilar ill-defined nodules or flame-shaped lesions. Lymphadenopathy is uncommon. Less commonly, large masses, and vocal consolidation, may be observed. These masses, when present, may show surrounding ground-glass density due to haemorrhage in the surrounding lung.\n\nA few diffuse lung diseases are characterised by a distribution primarily along the bronchovascular bundles. These include lymphangitic carcinoma, Kaposi's sarcoma, and sarcoidosis. High resolution CT may demonstrate small irregular nodular opacities adjacent to the bronchovascular structures. \n\nThe CT halo sign, originally described in association with invasive pulmonary aspergillosis, refers to a halo of ground-glass attenuation, due to haemorrhage or oedema, surrounding a variety of infectious and noninfectious nodules, including Kaposi's sarcoma, candidiasis, tuberculosis, and following transbronchial biopsy.",
    "differential_diagnosis": "Kaposi's, sarcoma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001959/000001.jpg?itok=rWDnidzu",
            "caption": "High-resolution CT scan shows ground glass density opacifications involving the upper right lung lobules."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001959/000002.jpg?itok=4sQ3ytyq",
            "caption": "High-resolution chest CT reveals in the middle right, lingular left, and bilaterally in the low lobes distributed, diffuse, flame-shaped, nodular opacities."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001959/000003.jpg?itok=j2Zw2x8L",
            "caption": "High-resolution chest CT reveals in the middle right, lingular left, and bilaterally in the low lobes distributed, diffuse, flame-shaped, nodular opacities."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/1959",
    "time": "10.01.2003"
  },
  "1968": {
    "case_id": 1968,
    "title": "Thoracic ganglioneurom",
    "section": "Chest imaging",
    "age": "10",
    "gender": "male",
    "diagnosis": "Thoracic ganglioneuroma",
    "history": "A huge posterior mediastinal mass.",
    "image_finding": "The patient presented with a 3-month history of cough and dyspnoea. He underwent a chest X-ray (not shown), which detected a huge hyperopaque mass located in the posterior portion of the mediastinal space. A contrast-enhanced CT scan of the chest confirmed the presence of a posterior mediastinal mass. This mass encircled the aorta, and showed  homogeneous attenuation with multiple coarse calcifications on unenhanced examination (not shown), and slight homogeneous enhancement and a thin enhancing capsule on contrast-enhanced examination (Fig. 1). The evaluation of the lung parenchyma did not reveal any other abnormality.",
    "discussion": "Tumours of the sympathetic nervous system include neuroblastomas, ganglioneuroblastomas, and ganglioneuromas. They arise from primitive sympathogonia and are referred to collectively as neuroblastic tumours. They arise wherever sympathetic tissue is present, such as in the neck, posterior mediastinum, adrenal glands, retroperitoneum, and the pelvis. The three tumours are characterised by a different degree of cellular and extracellular maturation; immature tumours are usually more aggressive and occur in younger patients, whereas mature tumours arise in older children and tend to behave in a benign fashion. \n\nGanglioneuroma is a benign tumour with a favourable prognosis. It is rare, since only some reports have been previously published. It is made up of gangliocytes and mature stroma, and characteristically lacks neuroblasts, intermediate cells, or mitotic figures. Ganglioneuroma is usually discovered incidentally since it manifests itself only when it reaches dimensions large enough to cause a mass effect. Presentation depends on the location of the mass; for example, if the mass is located in the posterior mediastinum it can cause cough and dyspnoea, whereas if abdominally located it may present with abdominal pain. In rare cases, ganglioneuroma may cause flushing and other symptoms related to excessive catecholamine production. Ganglioneuroma presents as a homogeneous mass of low attenuation on unhenhanced CT scans, and demonstrates only  slight to moderate enhancement homogeneously or heterogeneously. They are usually well-circumscribed, encapsulated tumours, which may show calcifications, which are usually fine and spleckled but may be coarse. The observation of calcifications within these masses may vary and has been described in 42-60% of cases by some authors, but in only 20% of cases by others. Calcifications are usually fine and speckled but may be coarse like in our case. Their benign appearance is usually manifested by preservation of the surrounding structures. In our case, the huge mass encircled the aorta, but not the surrounding thoracic structures. \nOn  MR imaging the mass is usually characterised by the following features: low signal intensity on T1-weighted images and heterogeneous high signal intensity on T2-weighted images.\nAlthough ganglioneuroma are usually more homogeneous, its imaging findings are similar to those of ganglioneuroblastoma, and neuroblastoma; therefore, they  cannot be discriminated at imaging evaluation except for the presence of metastases, which are rare in ganglioneuroma. \n\nTreatment consists of complete surgical resection to ensure thorough sampling of the tumor, such a confident diagnosis of ganglioneuroma can be made. Local recurrence may be possible, therefore radiologic follow-up is performed.",
    "differential_diagnosis": "Thoracic, ganglioneuroma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001968/000001.jpg?itok=Unzp5sPy",
            "caption": "Contrast-enhanced spiral CT scan shows a huge, well-marginated mass, containing coarse calcifications, located in the posterior mediastinal space. The mass is characterised by slight homogeneous enhancement during the arterial phase."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001968/000002.jpg?itok=Yet-GuqR",
            "caption": "During the portal phase the mass is characterised by slight homogeneous enhancement."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/1968",
    "time": "02.03.2003"
  },
  "1975": {
    "case_id": 1975,
    "title": "Mixed-type hiatal hernia mimicking pulmonary cystic lesion",
    "section": "Chest imaging",
    "age": "60",
    "gender": "female",
    "diagnosis": "Mixed-type hiatal hernia mimicking pulmonary cystic lesion",
    "history": "The patient presented with an intermittent history of chest/epigastric pain, shortness of breath, and nausea/vomiting during or shortly after meals.",
    "image_finding": "The patient presented with an intermittent history of chest/epigastric pain, shortness of breath, and nausea/vomiting during or shortly after meals. All biochemical laboratory study results were negative, and physical examination findings were unremarkable. Abdominal ultrasonography (not shown) and posteroanterior chest radiography (Fig. 1) were performed for evaluation of the thorax. Radiography revealed a smoothly marginated cystic lesion and an irregular mass at the bottom of the cyst in the left paracardiac area. The mass extended from the mediastinal area to the left paracardiac area.\n\nComputed tomography (CT) of the thorax was subsequently performed, and this essentially confirmed the radiographic findings. CT showed a 5cm x 6cm x 6cm cystic mass and a closely related 4cm x 4cm x 4cm solid mass in the left posterior mediastinum (Figs 2a-c). \n\nHiatus hernia produces a mass of soft-tissue density with an eccentric junction with the hernia fundus segment. There is a 180\u00b0 mesentero-axial rotation of a large portion of stomach, so that the great curvature is upward, within the posterior mediastinum. There are numerous coarse thick gastric folds within the suprahiatal pouch and an increase in fat surrounding the distal oesophagus. The oesophagogastric junction is above the diaphragm. \n\nThe patient refused surgery.",
    "discussion": "Hiatus hernias are divided into tree types: \nAn axial hernia (sliding) exists when a loculus of stomach and the gastric cardia pass through the hiatus into the thorax.  \nA paraoesophageal hernia exists when a portion of the stomach herniates through the hiatus but the cardia remains normally located. \nOccasionally a hiatus hernia is demonstrated with both sliding and paraoesophageal components, giving rise to the term mixed hiatus hernia (1). \n\nAbout 99% of hiatus hernias are axial. Only about 1% are paraoesophageal. Hiatus hernia indicates stretching or rupture of the phrenicoesophageal membranes (2). Aetiology is uncertain. They are rarely seen and may be associated with previous trauma. Although a congenital weakness of the oesophageal hiatus may be partly responsible for the development of hiatus hernia, there is little doubt that acquired factors play a significant role, the most important being obesity and pregnancy. The prevalence increases with age (3). Because the hernia is related to the oesophageal hiatus, the stomach is by far the most common herniated structure. \n\nPlain radiographs of the chest often show a retrocardiac mass, usually containing air or an air-fluid level. Differential diagnosis of a cystic lesion with an air-fluid level on chest film includes lung abscess, brochogenic cyst, cystic brochiectasis, oesophageal diverticulum, and hiatal hernia (4). Occasionally large hernias are located predominantly on one side of the hemithorax and mimic a lung abscess cavity on radiography (3). \n\nIn cases in which most of the stomach has herniated through the hiatus, the stomach may undergo volvulus within the mediastinum and present as a large mass, sometimes containing a double air-fluid level. This must be differentiated from mediastinal cysts, hydatid cyst with rupture and cystic adenoid malformation. Most mediastinal cysts are of congenital origin and include foregut-duplication cyst (bronchogenic, duplication, and neurenteric cysts), pleuropericardial cyst and thymic cyst. It must also be differentiated from eventration of the diaphragm and from diaphragmatic hernia (foramen of Bochdalek and Morgagni) (3). \n\nMost patients with oesophageal hiatus hernia do not report symptoms; the abnormality is discovered on a screening chest radiograph or examination of the upper gastrointestinal tract for unrelated complaints. When present, symptoms consist of retrosternal burning and pain, typically occurring after meals and accentuated when the patient lies down. The symptoms are usually chronic because of gastroesophageal reflux or gastric outlet obstruction. The gastroesophageal junction is located high above the oesophageal hiatus (4). The intrathoracic, extrapleural stomach may be dilated or obstructed. \n\nDefinitive diagnosis sometimes requires barium study of the oesophagogastric junction or the use of CT (5).  Elective repair is offered as the treatment of choice in oesophageal hernia. Surgical techniques include hernia reduction, crural closure, and fundoplication (1).",
    "differential_diagnosis": "Mixed-type, hiatal, hernia, mimicking, pulmonary, cystic, lesion",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001975/000001.jpg?itok=fRD4jMbD",
            "caption": "PA chest X-ray showing a smoothly marginated cystic lesion and an irregular mass present at the bottom of the cyst in the left paracardiac area."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001975/000002.jpg?itok=N_0OV6vL",
            "caption": "Mediastinal window, CT slice showing a 5cm x 6cm x 6cm cystic mass and a closely related 4cm x 4cm x 4cm solid mass in the left posterior mediastinum."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001975/000003.jpg?itok=968V8Jln",
            "caption": "Mediastinal window, CT slice showing a 5cm x 6cm x 6cm cystic mass and a closely related 4cm x 4cm x 4cm solid mass in the left posterior mediastinum."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001975/000004.jpg?itok=tQverFci",
            "caption": "Parenchymal window, CT slice showing a 5cm x 6cm x 6cm cystic mass and a closely related 4cm x 4cm x 4cm solid mass in the left posterior mediastinum."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/1975",
    "time": "01.12.2002"
  },
  "1978": {
    "case_id": 1978,
    "title": "Bronchopericardial fistula and pericarditis as complications of invasive pulmonary aspergillosis",
    "section": "Chest imaging",
    "age": "15",
    "gender": "female",
    "diagnosis": "Bronchopericardial fistula and pericarditis complicating invasive pulmonary aspergillosis",
    "history": "Persistent fever for 2 weeks and severe right chest pain after bone marrow transplantation (BMT) for acute lymphoblastic leukaemia (ALL).",
    "image_finding": "The patient, with acute lymphoblastic leukaemia (ALL), received an allogeneic bone marrow transplantation (BMT) from a matched unrelated donor. Immediately after the transplant the patient developed profound pancytopaenia and fever, and empirical treatment with broad-spectrum antibiotics and amphotericin B was started. \n\nThree weeks later the patient was referred for chest radiography because of severe right chest pain and persistent fever. Chest films demonstrated an enlarged cardiac silhouette, pneumopericardium, and a pulmonary cavitated lesion with characteristic \"air crescent\" formation, located  adjacent to the left side of the pericardium (Fig. 1). Based on clinical data and imaging findings, a provisional diagnosis of invasive pulmonary aspergillosis complicated with a bronchopericardial fistula was suggested. \n\nA control chest film one week later revealed progression of the pneumopericardium with an air-fluid level (hydropneumopericardium) (Fig. 2). On the same day, a computed tomography (CT) scan of the thorax was performed (Fig. 3). The patient underwent an emergency pericardiocentesis, and Aspergillus fumigatus was cultured from the pericardial fluid. Bronchoalveolar lavage (BAL) was performed, also revealing Aspergillus on culture. \n\nThe patient had progressive respiratory distress and died a few days later. The suspected diagnosis of invasive pulmonary aspergillosis complicated with a bronchopericardial fistula and pericarditis was confirmed by autopsy.",
    "discussion": "Invasive pulmonary aspergillosis (IPA) is a serious infection that requires severe impairment of host defence mechanisms, usually due to acute leukaemia and granulocytopenia from chemotherapy. Pathologically IPA is characterised by the invasion and thrombosis of small- to medium-sized pulmonary arteries by fungal hyphae, which leads to haemorrhagic infarction with necrosis and cavitation. The diagnosis is difficult and should be suspected when airspace consolidation does not improve with broad spectrum antibacterial therapy. The prognosis is poor (mortality rate as high as 30-90%) and early recognition is imperative to improve survival. \n\nCT plays an important role in early diagnosis (1). Characteristic findings correspond to haemorrhagic infarcts and consist of nodules or pleura-based, wedge-shaped areas of consolidation, surrounded by a halo of ground-glass attenuation. Histologically the \"halo sign\" represents haemorrhage around a focal area of lung infarction; it is best seen with high-resolution CT. This sign is non-specific; similar appearances are seen in tuberculosis, mucormycosis, candidiasis, herpes simplex, cytomegalovirus, Wegener's granulomatosis, Kaposi's sarcoma and haemorrhagic metastases. However, in the appropriate clinical setting, the CT halo sign is highly suggestive of IPA. Cavitation in the nodules or masses is a late finding that occurs with recovery from neutropenia, and it is associated with a better prognosis than consolidation without cavitation. It typically results in a distinctive radiographic appearance, the \"air crescent\" sign. This finding, also described as the \"meniscus\" sign, is an air crescent near the periphery of a lung nodule formed by contraction of infarcted tissue, trapping the air between the necrotic lung and the healthy surrounding parenchyma. \n\nPleural effusion is uncommon in IPA, and chest wall or mediastinal invasion and systemic dissemination can occur. The presence of adenopathy is rare. Pericardial involvement by Aspergillus is also uncommon (2,3). This case illustrates a patient who developed pericarditis and a pneumopericardium as a result of a bronchopericardial fistula following IPA. The pericardium was directly invaded by a necrotic mass with the characteristic \"air crescent\" appearance, creating an abnormal connection (fistula) between the pericardium and the lung. To our knowledge, the literature in English contains only four documented reports of pneumopericardium complicating IPA (2-5). Pneumopericardium is a very rare life-threatening complication, with important therapeutic significance since a large intrapericardial collection producing cardiac tamponade requires emergency pericardiocentesis. The diagnosis is made when air is located in the pericardial space surrounding the heart. The air is sharply defined and, in contrast with pneumomediastinum, is superiorly limited by the lower border of the aortic arch. Aspergillus pericarditis is also an unusual condition with high morbidity and mortality, reflecting the dificulty of diagnosis and treatment and the severity of the underlying disease.",
    "differential_diagnosis": "Bronchopericardial, fistula, and, pericarditis, complicating, invasive, pulmonary, aspergillosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001978/000001.jpg?itok=pVWDgEP9",
            "caption": "The chest film (AP view) shows a radiolucent triangle of free air (black arrow) limited by the pericardium (pneumopericardium), and a left upper lobe cavitated mass-lesion with the typical \"air crescent\" sign (white arrow), located adjacent to the left side of the pericardium. The radiolucency around the mass corresponds to the crescentic gas shadow seen when air is trapped between the necrotic lung tissue (asterisk) and the healthy surrounding lung tissue."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001978/000002.jpg?itok=6zZhN1ZW",
            "caption": "Magnified view of the findings described in Figure 1a. The black arrowheads point to the pericardium."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001978/000003.jpg?itok=A10yhnLN",
            "caption": "Chest film lateral view. Note the round mass (black asterisk) surrounded by air in the upper lung field (white arrows) and the continuity between this air and a posterior and inferior radiolucency correspondig to pneumopericardium (white asterisk). A Hickman catheter with the distal end positioned in the right atrium is seen (black fine arrow)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001978/000004.jpg?itok=92mov8l6",
            "caption": "Chest film AP view. \"Air crescent\" sign (white arrows), enlarged cardiac silhouette and progression of pneumopericardium with a large air-fluid level (black arrow)."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001978/000005.jpg?itok=pwgfrKIM",
            "caption": "Chest film lateral view. Hydropneumopericardium (black arrow) and  \"air crescent\" sign (white arrows). The continuity between the air of the necrotic mass and pneumopericardium is most evident."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001978/000006.jpg?itok=xCrlIVFh",
            "caption": "CT scan (mediastinal window) at the level of the upper lung zone  reveals a soft tissue attenuation mass (asterisk) in the anterior aspect of the left lung, inseparable from the lateral cardiac contour. This mass-lesion corresponds to the necrotic lung or infarcted tissue surrounded by air."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001978/000007.jpg?itok=EnvsIf5P",
            "caption": "The same image as Figure 3a but in the lung window shows the air rim between the infarcted tissue and the adjacent lung parenchyma."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001978/000008.jpg?itok=OiIhHdhF",
            "caption": "The scan at the level of the aortic root (soft tissue window) demonstrates the enhancement of the pericardium (arrow), and beneath it a multiseptated air-fluid collection within the left pericardial space."
          },
          {
            "number": "Figure 3d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001978/000009.jpg?itok=NdnJZZBe",
            "caption": "The same scan as Figure 3c in the lung window is most useful to confirm the multiple cavities. Note an air-fluid level (arrow)."
          },
          {
            "number": "Figure 3e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000001978/000010.jpg?itok=997CCJFM",
            "caption": "CT image at the midventricular level demonstrates loculated pericardial fluid with widening of the pericardial space, most evident on the left. The enhancement of both pericardial layers is well seen (arrows)."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "Digital radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/1978",
    "time": "20.01.2003"
  },
  "2006": {
    "case_id": 2006,
    "title": "Spontaneous rupture of a mediastinal cystic teratom",
    "section": "Chest imaging",
    "age": "27",
    "gender": "female",
    "diagnosis": "Spontaneous rupture of mediastinal cystic teratoma",
    "history": "The patient was admitted as an emergency because of sudden and severe chest pain and dyspnoea.",
    "image_finding": "The patient was admitted as an emergency because of sudden and severe chest pain and dyspnoea. Due to suspicion of a pneumothorax, a chest radiograph of the patient was initially taken (Fig. 1). It showed curvilinear calcification overlapping the heart shadow in the left lower zone, but no pneumothorax was present. There was a suggestion of left pleural effusion. \n\nThen, CT and MRI were performed. On CT (Siemens Somatom Plus 4, Erlangen, Germany), there was a multilocular cystic lesion with a solid component posteriorly, which was heavily calcified, in the left part of the anterior mediastinum (Fig. 2). The mass was about 6cm x 7cm x 11.5cm in size. Left pleural effusion was present. After contrast injection, mild rim enhancement was seen. MR imaging (Siemens Magnetom Open, Erlangen, Germany) showed a large nonhomogeneous mass with areas of both high and low signal intensity, depending on the composition of the tumour (Fig. 3). Fat-suppression T2-weighted images revealed that tumour had little fatty component. Rim-like calcification was barely seen and no invasion to adjacent soft tissues was detected. \n\nThe patient underwent surgery. Histological diagnosis was mature cystic teratoma. In this patient, high levels of amylase and lipase were available in the cystic fluid, 701U/land 2256U/l respectively. However, the levels of CA 19-9 (>50,000U/ml), CA 125 (231U/l) and CEA (107ng/ml) were also high in the cystic fluid. Cultures of the cystic and pleural fluids were negative. The postoperative course was uneventful. After two-year follow-up, no recurrence or metastasis was detected.",
    "discussion": "Mature teratomas are neoplasms consisting of well-differentiated adult tissue of all germinal layers. They occur most commonly in the gonads. Extragonadal teratomas are located along the body midline in such locations as the cranial cavity, mediastinum, retroperitoneum, and sacrococcygeal region [1].\n\nMediastinal mature teratomas usually occur in the anterosuperior mediastinum. They occur in all age groups but are most often diagnosed in young adults. No sex predilection exists. 53% of patients have no symptoms at the time of diagnosis; the tumour is found incidentally on chest radiographs. When symptoms are present, they include chest pain, dyspnoea, and cough [1].  Surgery should be performed whenever complications, such as atelectasis of lung tissue, adhesion to or compression of adjacent structures, rupture, or malignant transformation, are present. Up to 36% of all mediastinal teratomas may rupture, most frequently into the lungs and bronchial tree, followed by the pleural space, pericardial space, or great vessels [1]. The signs and symptoms of a ruptured teratoma vary with the structures involved. \n\nSimilarly, radiological manifestations of ruptured teratomas are variable. CT often shows a combination of fluid-filled cysts, fat, soft tissue, and areas of calcification. This pleomorphic appearance is an important clue to the diagnosis and often makes it possible to distinguish these lesions from thymoma and lymphoma. Calcification is seen in from 20% to 80% of cases, being focal, rim-like, or rarely representing as teeth or bone. Fat is visible on CT in half of cases, a finding that is highly suggestive of this diagnosis. A fat-fluid level within the mass is particularly diagnostic. The fluids within the cystic parts of the tumors also vary in their CT density and may reach soft-tissue density. Teratomas are typically encapsulated and well-demarcated, and rim enhancement can be seen.\n\nMRI can show various appearances, depending on the composition of the tumour. They commonly contain fat, which is intense on T1-weighted images and cystic areas, which are low in intensity on T1-weighted images, but increase with T2-weighting.\n\nDifferential radiological diagnosis between benign and malignant teratomas is sometimes difficult, especially when the mature teratoma has ruptured. In malignant teratomas, CT or MRI may reveal lesions with spiculated borders, thick capsules, heterogeneous contents, fat plane obliteration around the tumour, or direct invasion into the adjacent structures with or without effusion. These findings are sometimes mimicked by ruptured teratomas; however, a sudden onset of symptoms after rupture may be a clue in making the correct diagnosis.\n\nRegarding the rupture process of mature teratomas, several hypotheses have been proposed [2]. The most acceptable one has been attributed to the presence of digestive enzymes secreted by pancreatic tissue, salivary gland tissue, or intestinal mucosa within the tumours leading to rupture into adjacent structures. High amylase activity in pleural effusion or in the tumour contents was reported [2]. The other hypotheses of chemical inflammation, ischaemia, pressure necrosis and infection seem unlikely causes of mediastinal tumour rupture. In this case, high levels of amylase and lipase were detected in the cystic fluid, which might lead to noninfectious inflammation and rupture. Cultures of the cystic fluid and pleural effusion were negative. However, some tumour markers, especially the CA 19-9 level, were high in the cystic fluid.\n\nCA 19-9 has been established as a sensitive tumour marker in a variety of malignant diseases, especially in carcinomas of the exocrine pancreas. But, many benign diseases causing abnormal values, such as pulmonary sequestration, mediastinal bronchogenic cysts, and mediastinal mature teratomas, limit the specificity of CA 19-9. Also, high levels of serum CA 19-9 are reported in idiopathic interstitial pneumonia [3] and in Mirizzi's syndrome [4].\nTakayama et al. [5] speculated that examination of the serum CA 19-9 level helped in diagnosis of the cystic lesion. Conversely, Matsuoka et al. suggested that CA 19-9, CA 125 and CEA were not specific indicators of abnormal cellular activity, and they were synthesised and secreted by normal epithelial cells of the central airways and/or respiratory glands. In this case, the CA 19-9 level in cystic fluid was extremely high (>50,000 U/l) compared with CA 125 and CEA levels. Therefore, we think that a high CA 19-9 level may support the diagnosis of mature cystic teratoma.\n\nIn conclusion, we have presented a case of spontaneous rupture of a mediastinal cystic teratoma into the pleural space. The patient had high levels of amylase and lipase in the cystic fluid. This finding supports the hypothesis of autolysis causing rupture. However, we suggest that a high CA 19-9 level may also help with the diagnosis of cystic teratoma. Rapid diagnosis of this extremely rare complication is important because it may progress to a life-threatening condition. CT and MRI play a significant role in showing the tumour location and tumour tissues, and provide pertinent preoperative information.",
    "differential_diagnosis": "Spontaneous, rupture, of, mediastinal, cystic, teratoma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002006/000001.jpg?itok=JH_teY3K",
            "caption": "On chest X-ray, a curvilinear calcification overlapping the heart shadow was seen in the left lower zone. The left costo-phrenic sinus was obscured."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002006/000002.jpg?itok=igmAAxUb",
            "caption": "On left lateral radiography, a rim-like calcification could not be seen clearly."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002006/000003.jpg?itok=G8D80wTc",
            "caption": "A multilocular cystic lesion with a solid component posteriorly, which was heavily calcified, was depicted in the left part of the anterior mediastinum on thorax CT. Left pleural effusion was present."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002006/000004.jpg?itok=f2nkt0wv",
            "caption": "T1-weighted (gradient echo, TR:198/TE:9ms, flip angle:90) axial scan showed a large non-homogeneous mass with cystic and solid components."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002006/000005.jpg?itok=_MsW86Rq",
            "caption": "Fat suppression T2-weighted inversion recovery (TR:3278/TE:48/TI:110ms) axial image revealed little fatty component of the tumour. In addition to left pleural effusion, no invasion to adjacent soft tissues was detected."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT",
      "MR"
    ],
    "link": "https://www.eurorad.org/case/2006",
    "time": "16.02.2003"
  },
  "2024": {
    "case_id": 2024,
    "title": "Churg-Strauss syndrome",
    "section": "Chest imaging",
    "age": "53",
    "gender": "male",
    "diagnosis": "Churg-Strauss syndrome",
    "history": "Transient pulmonary infiltrates, eosinophilia, history of asthma.",
    "image_finding": "The patient, who had a history of asthma and drug abuse, had been treated for two months in the ICU for meningitis and acute respiratory failure. On transfer to a general ward he was examined and showed pulmonary infiltrates and lower extremity flaccid paralysis with absent reflexes (brain CT and lumbar spine CT were normal). On blood count, WBC was elevated with eosinophilia (20%). The WBC had been elevated for the duration of the patient's stay in ICU with consecutive eosinophil counts of  8%, 12%, 22%, 32% and 30%. Consecutive radiographs showed patchy bilateral pulmonary infiltrates, mostly peripheral in distribution, which proved to be transient over a period of a few months. Chest CT findings included bilateral lung infiltrates.\nSkin tissue biopsy revealed subacute dermatitis with vasculitis and the presence of granulomas, while skeletal muscle biopsy showed mild vasculitis of the small and medium-sized vessels. The final diagnosis, according to the American College of Rheumatology criteria, was Churg-Strauss syndrome. The patient was treated with corticosteroids and had a good outcome with as far a 2-year remission period.",
    "discussion": "Churg-Strauss (CS) syndrome or allergic angiitis and granulomatosis affects mostly the middle age with men being affected twice more frequently than women. It is a form of angiitis, with extravascular or perivascular eosinophilic granuloma formation and parenchymal necrosis. It affects small arteries and veins and less common medium size vessels, which are infiltrated by eosinophils. Most commonly affected organs are the lungs, the heart, the GI tract, the skin, the nervous system, joints and muscles.\nThe etiology is unknown. Asthma, eosinophilia and elevated levels of serum IgE suggest that there is an allergic or immune pathogenesis of the disease (3-4).\nOften there is a history of asthma and allergy which precede the angiitis phase. The onset of asthma is late compared to asthma in general population.\nClinically there are three distinct phases: \n1) a prodromal phase that may persist for many years consisting of asthma often preceded by allergic rhinitis 2) a second phase of marked peripheral blood eosinophilia and eosinophilic tissue infiltrates resembling Lofflers syndrome, or chronic eosinophilic pneumonia which may recover over a period of years and 3) a third, life-threatening vasculitic phase. Common manifestations are fever, loss of weight, dyspnea, multiplex mononeuritis, myalgies, arthralgia, paranasal sinusitis, diarrhea, GI bleeding.(4)\nAccording to Lanham et al the diagnosis is based on the following criteria: asthma, peak peripheral blood eosinophil counts of >1,5 10/L and systemic vasculitis involving two or more extrapulmonary organs (1). According to the American College of Rheumatology the diagnosis can be made with four or more of the six criteria: asthma, eosinophilia>10% on differential WBC count, mononeuropathy or polyneuropathy, transient and fleeting pulmonary infiltrates on radiography, paranasal sinus abnormality and biopsy containing a blood vessel with extravascular eosinophils (2).\nThe lungs are affected most commonly by transient diffuse or patchy pulmonary infiltrates. Less often the infiltrates are nodular. Not so common is pleural effusion in thoracic involvement.\nOn chest radiographs the predominant finding is patchy multifocal peripheral consolidation while multiple nodular lesions with rare cavitation or diffuse interstitial pattern are less found.\nOn CT, findings include suppleural consolidation with lobular distribution, centrilobular perivascular densities with diffuse centrilobular nodules<5mm in diameter often within ground glass lesions, or multiple larger nodules with rare cavitation. In the multiple larger nodules pattern the halo sign is quite feequent where the nodule appears to be within a ground glass opacity. The bronchial wall thickening with or without bronchial dilatation and hyperinflation is related to asthma while the interlobular septal thickening is related to interstitial pulmonary edema due to cardiac and pericardial involvement. Pleural effusion is not very common (4-5).\nFor these radiologic patterns with eosinophilia, differential diagnosis includes chronic eosinophilic pneumonia, acute eosinophilic pneumonia (Loffler syndrome), drug-induced eosinophilic pneumonia, allergic brochopulmonary aspergillosis, hypereosinophilic syndrome, Wegener\u2019s granulomatosis.\nOther clinical manifestations of the syndrome are: cardiomyopathy leading to heart failure, acute pericarditis and constrictive pericarditis, GI involvement with mesenteric vasculitis and submucosal granulomas leading to diarrhea, bleeding, abdominal pain and perforation, skin involvement with macular or papular erythematous rash, purpura, urticaria and subcutaneous nodules, renal involvement with focal segmental glomerular proliferation. Common manifestation is mononeuritis multiplex and less common sensomotory polyneuropathy while CNS involvement is rare (3).\nTreatment of CS syndrome includes the use of corticosteroids, plasma exchanges and immunosuppressive agents (azathioprine, cyclophosphamide) in variable combinations with corticosteroids being the basic treatment (3).\nIn patients with asthma, eosinophilia and CT or radiographs with transient diffuse parenchymal opacification or pulmonary nodules we should always keep in mind Churg-Strauss syndrome as a possible diagnosis.",
    "differential_diagnosis": "Churg-Strauss, syndrome",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002024/000001.jpg?itok=EV_CfQCW",
            "caption": "Bilateral pulmonary infiltrates are seen in the lower pulmonary zones mostly on the left."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002024/000002.jpg?itok=ebO1UerN",
            "caption": "The lesions not only persist but appear to be more abundant."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002024/000003.jpg?itok=fQchpDcB",
            "caption": "The infiltrates are less extensive."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002024/000004.jpg?itok=di6zg6l-",
            "caption": "A few linear atelectasies can be seen, mostly on the left."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002024/000005.jpg?itok=ox-B3pDo",
            "caption": "Bilateral pulmonary infiltrates are present."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002024/000006.jpg?itok=MendkhXr",
            "caption": "Pulmonary infiltrates."
          }
        ]
      },
      {
        "number": "Figure 7",
        "subfigures": [
          {
            "number": "Figure 7",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002024/000007.jpg?itok=lnGd1-vo",
            "caption": "Pulmonary infiltrates."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/2024",
    "time": "10.07.2003"
  },
  "2038": {
    "case_id": 2038,
    "title": "Superior vena cava thrombosis and haemorrhagic mediastinitis as manifestations of angioinvasive aspergillosis",
    "section": "Chest imaging",
    "age": "23",
    "gender": "male",
    "diagnosis": "Superior vena cava thrombosis and haemorrhagic mediastinitis caused by Aspergillus",
    "history": "Persistent fever and severe right chest pain after chemotherapy for acute myeloid leukaemia.",
    "image_finding": "The patient was admitted for therapy of acute myeloid leukaemia in the first haematological relapse. On day 4 he developed fever and severe right chest pain. Blood cultures were negative, and the first chest radiograph and CT revealed no lung pathology. Empirical treatment with broad-spectrum antibiotics was instituted. One week later he also developed abdominal pain, profuse diarrhoea and rectal bleeding. Laboratory examinations showed severe pancytopenia: haemoglobin 8g/dl, neutrophils 0%, and platelets 20,000/mm3. \n\nChest radiography and CT of the thorax were performed. The chest film revealed an infiltrate in the right upper lobe. The CT scan (Figs 1,2) demonstrated multiple nodules in both lung fields, a mass lesion anteriorly in the right upper lobe, bilateral pleural effusion, and diffuse infiltration of mediastinal fatty tissue.\n\nBased on the clinical data and imaging findings, a diagnosis of mediastinitis and invasive pulmonary aspergillosis (IPA) with multiple infarcts was suggested, and empirical therapy with amphotericin B was added. \n\nOn day 27 the fever persisted, and the patient developed a gradual superior vena cava syndrome. Despite intensive therapy he died in respiratory failure a few days later. Autopsy revealed a disseminated angioinvasive aspergillosis involving the kidneys,lungs, pleura and mediastinum, with haemorrhagic infiltration of the mediastinal fat (Fig. 3). Biopsy specimens (Fig. 4) showed septated hyphae that branched at 45\u00b0 angles and were highlighted with silver and PAS stains. Autopsy also revealed a thrombus of Aspergillus occluding the superior vena cava.",
    "discussion": "We illustrate a patient who developed IPA, superior vena cava (SVC) thrombosis and haemorrhagic mediastinitis due to Aspergillus. To our knowledge, this is the first case reported of the coexistence of SVC thrombosis and haemorrhagic mediastinitis complicating invasive aspergillosis, and the third reported case of SVC thrombosis caused by Aspergillus (1,2). \n\nAspergillus fumigatus is the most common cause of infection by Aspergillus in humans. This is a ubiquitous dimorphic fungus that primarily affects the lungs, causing a variety of pulmonary diseases. These can be divided into three groups: aspergilloma, invasive and semi-invasive aspergillosis, and allergic forms of aspergillosis (3). Invasive pulmonary aspergillosis (IPA) is a serious infection that requires severe impairment of host defense mechanisms, usually due to acute leukaemia and granulocytopenia from chemotherapy. Other risk conditions include corticosteroid use, allogeneic bone marrow transplant, solid organ transplantations (kidney, liver, heart), increased use of immunosuppressive regimens for autoimmune diseases, late-stage HIV infection, thoracic surgery and chronic obstructive pulmonary disease(9%). \n\nPathologically IPA is characterised by the invasion and thrombosis of small to medium-sized pulmonary arteries by fungal hyphae, which leads to haemorrhagic infarction with necrosis and cavitation. In tissue, Aspergillus forms septated hyphae that branch at 45\u00b0 angles. IPA typically manifests with fever, cough, pleuritic chest pain, dyspnoea and haemoptysis. The diagnosis is difficult and should be suspected when airspace consolidation does not improve with broad spectrum antibacterial therapy. \n\nComputed tomography (CT) may be useful in certain circumstances, particularly in cases of fever despite intensive therapy with antibiotics, and it plays an important role in early diagnosis. Characteristic findings correspond to haemorrhagic infarcts and consist of nodules or pleura-based, wedge-shaped areas of consolidation, surrounded by a halo of ground-glass attenuation.\n\nHistologically the \"halo sign\" represents haemorrhage around a focal area of lung infarction and it is best seen with high-resolution CT (3,4). This early sign is nonspecific and a similar appearance has been described in tuberculosis, mucormycosis, candidiasis, herpes simplex and cytomegalovirus pneumonias, Wegener granulomatosis, Kaposi sarcoma and haemorrhagic metastases. However, in the appropriate clinical setting, the CT halo sign is highly suggestive of IPA.\n\nCavitation in the nodules or masses is a late finding that occurs with recovery from neutropenia, and it is associated with a better prognosis. It typically results in a distinctive radiographic appearance, the \"air crescent\" or  \"meniscus\" sign. This finding is an air crescent near the periphery of a lung nodule formed by contraction of infarcted tissue, trapping air between the necrotic lung and the healthy surrounding parenchyma. Aspergillus may disseminate beyond the lung by haematogenous spread to the central nervous system, kidney and gastrointestinal tract (25-50%). Chest wall or mediastinal invasion can occur, but pleural and pericardial involvement and the presence of adenopathy are rare. Mortality may exceed 90%, and has not changed significantly over the past decades, despite the introduction of itraconazole and lipid formulations of amphotericin B. At present, invasive aspergillosis is the leading cause of infection-related mortality in many immunocompromised hosts.",
    "differential_diagnosis": "Superior, vena, cava, thrombosis, and, haemorrhagic, mediastinitis, caused, by, Aspergillus",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002038/000001.jpg?itok=6ARYeBO2",
            "caption": "Multiple ill-defined nodular opacities (arrows) in both lung fields, some with the halo sign. A right perihilar infiltrate and mediastinal widening are shown."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002038/000002.jpg?itok=8AzGQnOl",
            "caption": "Multiple ill-defined nodular opacities (arrows) in both lung fields, some with the halo sign. A right perihilar infiltrate and mediastinal widening are shown."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002038/000003.jpg?itok=Gje7LHFW",
            "caption": "Multiple ill-defined nodular opacities (arrows) in both lung fields, some with the halo sign. A right perihilar infiltrate and mediastinal widening are shown."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002038/000004.jpg?itok=4vs7tgOz",
            "caption": "Soft tissue attenuation mass (m) in the anterior aspect of the right lung adjacent to the mediastinum, corresponding to a large pulmonary infarct at autopsy. Diffuse infiltration of mediastinal fatty tissue (white arrows) and bilateral pleural effusion are also seen. A Hickman catheter positioned in the superior vena cava is marked (hollow arrow)."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002038/000005.jpg?itok=HwLxArAp",
            "caption": "Soft tissue attenuation mass (m) in the anterior aspect of the right lung adjacent to the mediastinum, corresponding to a large pulmonary infarct at autopsy. Diffuse infiltration of mediastinal fatty tissue (white arrows) and bilateral pleural effusion are also seen. A Hickman catheter positioned in the superior vena cava is marked (hollow arrow)."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002038/000006.jpg?itok=ZhurStbr",
            "caption": "Soft tissue attenuation mass (m) in the anterior aspect of the right lung adjacent to the mediastinum, corresponding to a large pulmonary infarct at autopsy. Diffuse infiltration of mediastinal fatty tissue (white arrows) and bilateral pleural effusion are also seen. A Hickman catheter positioned in the superior vena cava is marked (hollow arrow)."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002038/000007.jpg?itok=Gj1pV4Fy",
            "caption": "Soft tissue attenuation mass (m) in the anterior aspect of the right lung adjacent to the mediastinum, corresponding to a large pulmonary infarct at autopsy. Diffuse infiltration of mediastinal fatty tissue (white arrows) and bilateral pleural effusion are also seen. A Hickman catheter positioned in the superior vena cava is marked (hollow arrow)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002038/000008.jpg?itok=tfZnDEVD",
            "caption": "An axial slice of the mediastinum shows the trachea (T), and the superior vena cava (outlined in blue), almost totally occluded by a thrombus of <i>Aspergillus</i>. Note two foci of venous lumen not invaded by fungi (white hollow arrows) and the haemorrhagic apperance of the mediastinum surrounding the superior vena cava."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002038/000009.jpg?itok=EmYRlkYz",
            "caption": "Dorsal view of the lungs. The pleural surface shows multiple nodules (arrows), some of them umbilicated. Note the hyperaemic rim surrounding some of the nodules (left lung)."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002038/000010.jpg?itok=7pJnuT0u",
            "caption": "Haematoxylin-eosin stain. Inflammatory exudate consisted of lymphocytes and histiocytes and coagulative necrosis. Note hyphal elements among the necrotic tissue. A  pulmonary vessel (black arrows) full of fungi is shown. This phenomenon is associated with intraluminal thrombi, tissue ischaemia, and infarction."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002038/000011.jpg?itok=HtlBgQIx",
            "caption": "Methenamine silver stain.  Section of the same vessel  shows branching fungal hyphae that invade the vessel wall (red arrows) from the lung parenchyma into the lumen."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/2038",
    "time": "26.02.2003"
  },
  "2046": {
    "case_id": 2046,
    "title": "A primary liposarcoma of the posterior mediastinum",
    "section": "Chest imaging",
    "age": "60",
    "gender": "female",
    "diagnosis": "Pleomorphic liposarcoma of the mediastinum",
    "history": "Adult woman with dyspnoea on exertion but no previous pulmonary disease.",
    "image_finding": "The patient presented with a 2-month history of dyspnoea and mild pain in the entire right hemithorax. There was no history of smoking or of any other previous pulmonary pathology. \n\nChest X-ray showed, on the right, a large lobulated posterior mediastinal mass with relatively well-defined borders. A CT scan confirmed a posterior capsulated mediastinal mass, 110mm in diameter, adjacent to the hilar region and the parietal pleura, of heterogeneous density with microcalcifications, little ipsilateral pleural effusion and no lymph node involvement. Cerebral and abdominal CT, and scintigraphy, were negative. \n\nSurgical excision of the mass showed that the lung was compressed and shifted to the left in the anterior mediastinum without infiltration. The vascular peduncle arose from the posterior mediastinum near the 5th vertebral rib joint. Histological diagnosis: pleomorphic liposarcoma. The post-surgical course was good.",
    "discussion": "Liposarcoma of the mediastinum is a rare tumour accounting for only 1% of all tumours in this location and 15-20% of sarcomas; it occurs most commonly in men between the 2nd and 7th decades; the thigh and the retroperitoneum are the most frequent locations.\n\nIt is a neoplasia in which cells tend to differentiate into lipoblasts and lipocytes and it may be divided into 4 types, differing in grade, stage, treatment and prognosis: 1) well-differentiated; 2) myxoid; 3) round-cell; 4) pleomorphic.\n\nPrimary mediastinal pleomorphic liposarcomas are extremely rare malignancies that remain asymptomatic until they have reached a large size and, even then, initial symptoms are not specific.\n\nPlain x-ray does not usually show a uniformly translucent and sharply defined mass (as is typical of a lipoma). \n\nCT clearly delineates the anatomical origin of the lesion and its fatty composition (from -50HU to 100HU). Lipomas have a uniform fatty density, although linear soft tissue strands due to fibrous stroma may be present; when the tumour is heterogeneous and has an attenuation greater than \u201350 HU, a liposarcoma should be suspected. The CT diagnosis of malignant fatty neoplasms may be extremely difficult. The CT findings suggestive of liposarcomas include: inhomogeneous attenuation with evidence of a significant amount of soft tissue within the fatty mass, poor definition of adjacent structures and evidence of infiltration or invasion of medistinum or chest wall structures. \n\nMR is the primary imaging modality after chest radiograph for attempting  characterisation (percentage of fat composition) and for assessing the extent of mediastinal masses localised in the posterior mediastinum, because of its superior ability in evaluating the relationship with the adjacent spine. In any case, a tissue biopsy is needed for final diagnosis.\n\nThe differential diagnosis of pleomorphic liposarcoma is with malignant fibrous histiocytoma and pleomorphic rhabdomyosarcoma. Local recurrences are frequent within the first 2 years after excision, as are metastates, which occur by the haematogenous route to the lungs, skeleton, etc.\n\nThe long-term survival at 5 years depends on histological type: the range is between 70% for the well-differentiated to 33% for the pleomorphic liposarcoma.",
    "differential_diagnosis": "Pleomorphic, liposarcoma, of, the, mediastinum",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002046/000001.jpg?itok=DTqR9IFn",
            "caption": "Postero-anterior chest film: lobulated and homogeneous opacity involving the upper half of the right lung. The heart and the trachea are not displaced."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002046/000002.jpg?itok=3bpHRA4J",
            "caption": "Lateral chest film: large posterior mass adjacent to the parietal pleura."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002046/000003.jpg?itok=CyMCkHAC",
            "caption": "Postero-anterior chest film: the re-expansion of the lung is evident after the excision of the mass."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002046/000004.jpg?itok=Vp3OAy-K",
            "caption": "Unenhanced CT scan confirms the presence of a posterior mediastinal mass with microcalcifications."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002046/000005.jpg?itok=N_yZgC45",
            "caption": "Contrast-enhanced CT scan shows the capsulated mass with heterogeneous density. Minimal pleural effusion is also present. Normal-sized lymph nodes."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002046/000006.jpg?itok=mnVI9WGR",
            "caption": "Contrast-enhanced CT scan: the density of the tumour is primarily solid (+18.9HU to +60.2HU)."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/2046",
    "time": "10.07.2003"
  },
  "2093": {
    "case_id": 2093,
    "title": "Pleomorphic liposarcoma of the posterior mediastinum",
    "section": "Chest imaging",
    "age": "58",
    "gender": "male",
    "diagnosis": "Pleomorphic, spindle-cell liposarcoma of the posterior mediastinum",
    "history": "The patient reported weight loss, fever and edema of the malleoli. The chest radiographs revealed a right oval mass of the posterior mediastinum.",
    "image_finding": "The patient reported a weight loss of 10 kg over the last two months, fever (38-39\u00baC) of 15-day duration and edema of malleoli for a week and had no history of tobacco use. Chest radiographs revealed widening of the mediastinum due to a right oval mass located in the posterior mediastinum. The tumoral shadow featured a smooth right edge and showed obtuse angles at its margins.  Neither the right heart border nor the right hilum were obscured. No lymphadenopathy was depicted. The patient was admitted to hospital for futher evaluation. Laboratory data diagnosed anemia (Hct: 27.3%, Hgb: 8,9 g/dl) and high ESR levels (130). Chest CT revealed a solid and homogeneous, 8,5cm x 6,5 cm  lesion with a broad base on the mediastinum which projected into the lung with regular edges. An enhanced capsule was demonstrated. The mass had no foci of calcification or necrosis.MRI demonstrated the heterogeneous enhancement of the mass. The capsule was intensely enhanced as well. Intraspinal extension was excluded. A malignant neural tumor was suspected due to clinical and radiological findings. The mass was surgically resected.",
    "discussion": "Liposarcoma takes it origin from lipoblast and cytogenic analysis has revealed a translocation between chromosomes 12 and 16 [t(12;16), (q13;p11)] that is partially considered responsible for its etiology. It is the second most common soft tissue sarcoma encountered in adults but primary mediastinal involvement by liposarcoma is distinctly rare. Patients with mediastinal liposarcoma are usually older than 30 years of age and mainly males. \nLiposarcomas are classified into four histological subtypes:  - well-differentiated (or atypical lipoma),  - myxoid (accounts for 50% of all cases),  - round cell and  - pleomorphic. The demonstration of fat on CT and MRI occurs in all cases of well-differentiated  liposarcomas (which consist of more than 75% of fat) but in less than 30% of round cell or pleomorphic ones that contain little or no fat at all. Liposarcoma is indistinguishable from other sarcomas when fat is not revealed on imaging modalities (1). Mediastinal liposarcoma is mainly situated anteriorly. \nThe predominant finding of mediastinal liposarcoma on chest radiography is a widened mediastinum. Tracheal or vessel deviation may also be present (2).\nCT and MRI demonstrate liposarcomas as inhomogenous fat-containing masses that vary in appearance depending on the amount of soft tissue and fibrous bands in the tumor. Solid components may enhance and surrounding structures may be infiltrated or displaced (2). Thus, liposarcomas vary in appearance depending on if they predominantly contain fat or if they are solid (3).\nLiposarcomas tend to be well circumscribed or encapsulated and usually show a macroscopic distinct multilobular pattern (4).\nWell-differentiated liposarcomas demonstrate signal characteristics similar to subcutaneous fat except for a scattering of broader septa or more nodules than those seen in lipomas(5). These tumors show minimal or no enhancement. Because of the high signal intensity (SI) of fat on T1-weighted images, the enhancement pattern can best be seen on fat-suppressed images (4).\nMyxoid liposarcoma reveals relatively homogeneous internal structure, isointense with muscle on T1-weighted images and of homogeneously high SI with linear septae dividing the lobules on T2-weighted images. The enhancement pattern is mildly heterogeneous with non-enhancing areas. Some cases of this liposarcoma type contain small amounts of fat due to increased lipid depositions in lipoblasts (4).\nPleomorphic and round cell liposarcomas often do not contain fat.\nPleomorphic liposarcomas are the most aggressive high-grade sarcomas. MRI appearance of these liposarcomas is mostly low SI on T1-weighted images and high SI on T2-weighted images. Areas of hemorrhage may also be depicted. Markedly heterogenous enhancement may be also demonstrated and necrotic components of the lesion may then be diagnosed (4).\nRound cell liposarcomas present moderate to markedly heterogeneous MRI features which are indistinguishable from other high-grade liposarcomas and not different from those of other malignant soft-tissue tumors (4).\nPatients may have vague symptoms (dyspnea, cough, pain, weight loss, superior vena cava obstruction) or may be asymptomatic. Pleomorphic liposarcomas often demonstrate polymorphonuclear infiltrations (inflammatory liposarcomas) and are accompanied by fever. Therapeutic approaches consist of surgical resection (or debulking) combined with radiotherapy and/or chemotherapy. Local recurrence is frequent although metastases (lungs, liver, bones) are rare.",
    "differential_diagnosis": "Pleomorphic,, spindle-cell, liposarcoma, of, the, posterior, mediastinum",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002093/000001.jpg?itok=-pwM8R1N",
            "caption": "Note widening of the mediastinum due to a right oval mass featuring a smooth right edge and showing obtuse angles at its margins.  Neither the right heart border nor the right hilum are obscured. No lymphadenopathy was depicted. Pulmonary parenchyma is normal."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002093/000002.jpg?itok=oNhomE8f",
            "caption": "The posterior mediastinal location of the mass is confirmed in the lateral view."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002093/000003.jpg?itok=I2WxB1pf",
            "caption": "The 8,5 cm x 6,5 cm lesion is solid and homogeneous with no foci of calcification or necrosis. The mass has a broad base on the mediastinum which projects into the lung with regular edges The density of the mass is similar to muscle. The adjacent bone structures are not destructed."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002093/000004.jpg?itok=vH14w_zY",
            "caption": "After I.V. contrast administration, note the moderate enhancement of the mass and the demonstration of the enhanced capsule (arrowheads)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002093/000005.jpg?itok=GdgUGaA5",
            "caption": "Gadolinium-enhanced coronal T1-weighted image. Heterogeneous enhancement of the mass in contrast to a portion which shows no enhancement at all. The capsule is intensely enhanced (arrowheads)."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002093/000006.jpg?itok=_FaVEVFL",
            "caption": "Axial T2-weighted image shows the heterogeneous mass with areas of low and intermediate signal intensity. The presence of a capsule with mainly low signal intensity is demonstrated (arrowheads). Intraspinal extension is excluded."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002093/000007.jpg?itok=T2PNvuNp",
            "caption": "The tumour after surgical resection. There is no macroscopic evidence of fat."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT",
      "MR"
    ],
    "link": "https://www.eurorad.org/case/2093",
    "time": "15.09.2003"
  },
  "2124": {
    "case_id": 2124,
    "title": "Primary intrathoracic extrapulmonary haemangiopericytoma with multiple recurrences",
    "section": "Chest imaging",
    "age": "53",
    "gender": "female",
    "diagnosis": "Primary intrathoracic extrapulmonary haemangiopericytoma with multiple recurrences",
    "history": "The patient initially presented 14 years previously with a history of pain of the left shoulder. A chest radiograph showed an abnormal shadow with an extrapleural sign located in the left upper lung field. A disease-free course of 9 years followed. Over the past 4 years multiple intrathoracic and extrathoracic recurrences occurred.",
    "image_finding": "The patient initially presented 14 years previously with a history of pain of the left shoulder. She had no history of shortness of breath, coughing, fever or haemoptysis. A chest radiograph showed an abnormal shadow with an extrapleural sign located in the left upper lung field. A detailed full blood count and biochemical tests showed results within normal range. Chest CT revealed a well-demarcated soft tissue mass in the chest wall adjacent to the second left rib. The diagnosis of haemangiopericytoma was established by percutaneous needle biopsy. The mass was successfully resected and a disease-free course of 9 years followed. \nOver the past 4 years multiple intrathoracic recurrences had occurred, as shown in multiple spiral CT examinations, including: soft tissue masses involving the 4th-6th left rib and the 6th-8th right rib, one left epidiaphragmatic pleural soft tissue mass and a pulmonary mass at the left pulmonary ligament.  Additionally, extrathoracic recurrences were diagnosed at the sacroiliac joints, the left iliac wing and the diaphysis of the right radius. Histological diagnosis and immunochemical studies were obtained at each stage.",
    "discussion": "Incidence and location\nHemangiopericytoma is a rare tumor of high vascularity belonging to the group of sarcomas. Stout and Murray first described this entity in 1942 (1). The tumor arises from the capillary pericyte of Zimmermann, which is a contractile cell normally found spiraling in an incomplete layer around the capillaries and postcapillary venules. \nIt generally presents in middle and late adulthood. Because of its vascular origin, it may be found anywhere in the body. Principal sites of the tumour include lower limb and the retroperitoneal space. Hemangiopericytomas rarely arise in the chest wall. There seems to be a predominance for women in the case of hemangiopericytomas originating in the chest wall (2).\nClinical behaviour\nSymptoms depend on the location of the tumour and are mostly due to pressure effects on the surrounding structures. Thoracic hemangiopericytomas may be discovered incidentally, presenting without any symptoms. \nThe rate of recurrence is given as 50%. Adult cases usually follow a benign course but 20\u201330% of cases behave in malignant fashion. Distant metastases occur via hematogenous route. Local or distant recurrences have been reported to occur at long intervals after the initial diagnosis. \nHistological features\nThe natural history of hemangiopericytoma is associated with cellularity, mitotic activity, necrosis, and hemorrhage. Four or more mitoses per high-power field, foci of necrosis, and increased cellularity are suggestive of malignancy and poor prognosis. The histology of adult hemangiopericytoma usually shows a well demarcated but multinodular mass. Positive reticulin stain is the criterion for the diagnosis of hemangiopericytoma (3). The tumor seems to have a low tendency to infiltrate into surrounding tissue rather than to form a fibrotic capsule against displaced tissue.\nImaging appearance\nHemangiopericytomas, at any location, are difficult to diagnose on the basis of imaging findings alone. Such findings are nonspecific in the majority of cases and may suggest only a soft tissue origin or marked hypervascularity of the tumor. Contrast-enhanced CT scan, angiography, and magnetic resonance imaging can be employed preoperatively, as well as during the follow-up.\nIn a case of an intrathoracic extrapulmonary hemangiopericytoma, cross-section imaging modalities may suggest the diagnosis. A chest radiograph is an essential tool in the diagnostic workup. In the chest radiograph the size and contour of the tumor are initially evaluated, which may vary from a sharply delineated round or lobulated mass, as well as the presence or absence of pleural effusion. The CT findings of a thoracic hemangiopericytoma may include a large, well-circumscribed, lobulated, soft tissue mass with cystic low attenuation zones and speckled calcifications. After intravenous administration of contrast agent, there is enhancement of solid areas or septations (4). CT sometimes shows capsular like appearance, contrast enhancement of the \u201ccapsular\u201d margin, without signs of surrounding compression atelectasis. A heterogeneous matrix is usually noted in large tumors. The differential diagnosis includes other soft tissue sarcomas of the lung (i.e. an angiosarcoma, fibrosarcoma, leiomyosarcoma, primary liposarcoma or a Kaposi\u2019s sarcoma in immunocompromised patients), as well as other unusual lung tumors (of vascular origin, i.e. a hemangioendothelioma and sclerosing hemangioma, of other mesenchymal tissue, i.e. solitary fibrous tumor, malignant thoracopulmonary small cell tumor -\"Askin\" tumor-, or plasma cell granuloma).\nMRI is the most sensitive instrument to exclude invasion of neighboring structures. It defines the extent of the tumor more clearly and provides better tissue characterization. MRI shows intermediate signals on T1-weighted images and increased signal on T2-weighted images (4). Nevertheless, compared to MRI, CT scan may offer a more detailed report of bone involvement in cases of primary or metastatic hemangiopericytomas that arise from osseous structures. Osseous lesions may reveal lysis, or a honeycomb appearance similar to that of hemangioma. In high-grade malignant hemangiopericytomas more aggressive features of marked osseous expansion are frequently present.\nAn angiographic study may detect the feeding vessels of this hypervascular tumor. Preoperative embolization has been suggested in cases of very hypervascular tumors, so as to decrease the risk of uncontrollable bleeding and massive blood loss.\nAs far as recurrences are concerned, CT helps determine the location and features of each new lesion and depicts associated findings, in order to document the extent of disease. Both intrathoracic and extrathoracic recurrences have been discovered many years after the initial diagnosis and long-term follow-up is necessary (5). The CT features of recurrences include soft tissue masses, round or lobulated, with contrast enhancement in solid areas or in septations, and with osseous destruction in cases of osseous involvement.\nThe radiologic appearance of primary intrathoracic extrapulmonary hemangiopericytoma with multiple intra- and extrathoracic recurrences is rarely cited in current literature. The clinical course of this entity may be long and uneventful unless it involves vital structures and spiral CT may serve as an effective means of recording its progress in sites of recurrence.",
    "differential_diagnosis": "Primary, intrathoracic, extrapulmonary, haemangiopericytoma, with, multiple, recurrences",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002124/000001.jpg?itok=f8r7CQWB",
            "caption": "Chest CT scan showing an extrapleural soft tissue mass invading the second left rib and the adjacent vertebral body. Initial presentation of the extrathoracic intrapulmonary haemangiopericytoma."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002124/000002.jpg?itok=dRyDQ7Oy",
            "caption": "Chest CT scan showing a recurrence of the primary haemangiopericytoma, presenting as a soft tissue mass invading the 4th left rib."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002124/000003.jpg?itok=SqKJOCtr",
            "caption": "Spiral contrast-enhanced chest CT scan, showing a mass-lesion of variable texture and areas of contrast enhancement invading the 6th right rib."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002124/000004.jpg?itok=a5ul-E9m",
            "caption": "Spiral contrast-enhanced chest CT scan showing a recurrence appearing as an inhomogenously enhancing large left epidiaphragmatic mass."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002124/000005.jpg?itok=BQdcVhvc",
            "caption": "Spiral chest CT scan showing a recurrence appearing as a nodular subpleural lesion on the left hemithorax."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002124/000006.jpg?itok=qES2aLUB",
            "caption": "Spiral abdominal CT scan showing multiple soft tissue masses at the iliac bones and left sacral bone, causing osteolysis."
          }
        ]
      },
      {
        "number": "Figure 7",
        "subfigures": [
          {
            "number": "Figure 7a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002124/000007.jpg?itok=p0iboN6K",
            "caption": "Spiral CT scan of the right radius showing new site of recurrence at the diaphysis of the right radius."
          },
          {
            "number": "Figure 7b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002124/000008.jpg?itok=mWa_J5ZN",
            "caption": "Spiral CT scan of the right radius showing new site of recurrence at the diaphysis of the right radius, homogenously enhancing after iv contrast administration."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT",
      "CT",
      "CT",
      "CT",
      "CT",
      "CT",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/2124",
    "time": "18.05.2003"
  },
  "2180": {
    "case_id": 2180,
    "title": "Pulmonary miliary tuberculosis",
    "section": "Chest imaging",
    "age": "70",
    "gender": "male",
    "diagnosis": "Pulmonary miliary tuberculosis",
    "history": "Two-month history of high fever, general malaise, anorexia and progressively increased sedimentation rate without improvement after antibiotic therapy.",
    "image_finding": "The patient presented with a two-month history of high fever (40\u00b0C), general malaise, anorexia and progressively increased sedimentation rate without any improvement after antibiotic therapy. The patient was referred to our hospital because of a fever of unknown origin and a suspected paraneoplastic syndrome. Routine blood parameters were normal apart from the sedimentation rate which had increased from 25mm/h to 67mm/h in the course of one month. Chest radiographs and abdominal ultrasound showed no pathology.  \n\nCT examination of the chest was performed using a single slice helical CT scanner. It demonstrated multiple nodular lesions, 1-2mm in diameter, predominantly in the right upper and middle lobes. A small fibrotic focus (11mm in diameter) was found in the apical segment of the left upper lobe, associated with thickening and calcification of the posterior-lateral pleura. The mediastinal lymphatic nodes were not enlarged. \n\nUltrasound examination of the thyroid, gastroscopy and colonoscopy showed no pathology. \n\nThe correlation of radiographic findings and clinical data, including the absence of a primary tumour and signs of previous exposure to pulmonary and pleural tuberculosis led to the diagnosis of pulmonary miliary tuberculosis. The patient was referred to another hospital and tuberculostatic treatment was started. Clinical improvement was determined two weeks after therapy was started, but the patient died a week later of cardiac infarction. The diagnosis of pulmonary miliary tuberculosis was confirmed histologically.",
    "discussion": "The incidence of acute miliary pulmonary tuberculosis is 2-3% of all tuberculosis infections. The outcome is fatal in 25% of cases. In high prevalence areas, miliary tuberculosis follows shortly after primary infection. In low prevalence areas, miliary tuberculosis occurs mostly in elderly people, representing reactivation. Risk factors are social disorientation, AIDS, diabetes mellitus, history of prior tuberculosis, chronic liver and renal disease, immunosuppressive drug therapy and malignancy. The most common clinical symptoms are fever, malaise, loss of weight and anorexia. The most common laboratory abnormalities are anaemia, lymphopenia and increased sedimentation rate. \n\nCT examination of the chest (especially HRCT) is the method of choice for the evaluation of miliary pulmonary tuberculosis because of the low sensibility of conventional chest X-ray. The diagnosis is based on the presence of randomly distributed micronodular lesions without consistent relationship to structures of the secondary lobule.\n\nThe differential diagnosis includes inhalation diseases, granulomatous diseases and metastases. In the case of inhalation diseases, CT examination demonstrates diffuse or random, centrilobular or subpleural nodules with posterior predominance; the diagnosis can be suggested by job history. Sarcoidosis, the most common granulomatous disease, is associated with existing or previous adenopathy and appears as peribronchovascular and subpleural nodules with upper lobe predominance.  Miliary metastases are well-defined lesions, related to vessels, and are common for thyroid carcinoma, melanoma, and adenocarcinoma of the breast, stomach, colon and pancreas.",
    "differential_diagnosis": "Pulmonary, miliary, tuberculosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002180/000001.jpg?itok=Ules-IxY",
            "caption": "Upper lobes."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002180/000002.jpg?itok=38CBMbvK",
            "caption": "Middle lobe and lingula."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002180/000003.jpg?itok=L1tGJVxN",
            "caption": "Lower lobes."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002180/000004.jpg?itok=exhXz7ty",
            "caption": "Small fibrotic focus (11mm in diameter) in the apical segment of the left upper lobe."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002180/000005.jpg?itok=_cotL0_L",
            "caption": "Thickening and calcification of the posterior-lateral pleura (lung window)."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002180/000006.jpg?itok=XQRdaNUj",
            "caption": "Thickening and calcification of the posterior-lateral pleura (soft-tissue window)."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/2180",
    "time": "01.07.2003"
  },
  "2190": {
    "case_id": 2190,
    "title": "Bronchial carcinoid tum",
    "section": "Chest imaging",
    "age": "25",
    "gender": "female",
    "diagnosis": "Bronchial carcinoid tumor",
    "history": "A one-year history of hirsutism, round facies, telengectasis, weight gain, relapsing mycosis and sty, and unstable mood.",
    "image_finding": "The patient showed the following signs and symptoms for a year: hirsutism, round facies, telengectasis, weight gain, relapsing mycosis and sty, and unstable mood.\nHigh peripheral plasma ACTH levels, increased urinary free cortisol levels, and the lack of overnight cortisol suppression after a dexamethasone test, suggested the presence of Cushing's syndrome.\n\nPituitary MRI did not show any adenoma producing ACTH. Simultaneous bilateral inferior petrosal sinus sampling was also negative.\n\nConsidering the clinical and radiological findings, a CT scan of the abdomen was performed. This showed bilateral adrenal enlargement, which was confirmed by adrenal scintigraphy with radiolabelled cholesterol.\n\nThe scintigraphic finding of bilateral adrenal hyperplasia and the negative MRI  suggested the possibility of ectopic production of ACTH.\n\nThe patient underwent a thoracic CT scan which revealed the presence of a 16mm well-defined nodule, with low, but homogeneous contrast enhancement. \n\nThe lesion, localised in the inferior lobe of the left lung, appeared to be hardly dissociable from pericardial pleura.\n\nIn order to complete the diagnostic work-up, particularly because of the low contrast enhancement of the lesion, SPECT was performed with radiolabelled somatostatin analogues, 111In-pentetreotide, which confirmed the ectopic origin of Cushing's syndrome.",
    "discussion": "Bronchial carcinoid tumours are rare neuroendocrine tumours which represent 1-5% of all lung neoplasms and 25% of all carcinoids. They range from low-grade typical carcinoids to more aggressive atypical carcinoids, both having similar imaging features (1).\n\nSince most of these tumours are located in the central airways, radiological findings are commonly related to bronchial obstruction, such as atelectasis, air trapping, and obstructive pneumonias. On CT, the lesion usually appears either as an endobronchial solitary nodule or a hilar-perihilar mass, well-defined, round or ovoid-shaped and sometimes slightly lobulated. Calcifications may be associated (2). Because carcinoids have a rich vascular stroma, they often demonstrate marked and homogeneous contrast enhancement. However, not all carcinoids enhance with contrast material, and enhancement alone does not allow bronchial carcinoid  to be differentiated from brochogenic carcinoma. In addition, atypical carcinoids may display irregular contours and less uniform contrast enhancement (3,4).\n\nThis case of bronchial carcinoid, which did not show significant contrast enhancement, had a peripheral location and therefore its clinical manifestations were not represented by broncho-pulmonary symptoms, but by Cushing's syndrome.\nIn those cases in which there is no evidence of intra-cranial or abdominal ACTH-secreting lesions, the presence of  hormone-producing bronchial carcinoid should be considered (5). CT should be the first method of choice in the study of these rare neuroendocrine tumours.",
    "differential_diagnosis": "Bronchial, carcinoid, tumor",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002190/000001.jpg?itok=uZU_pWel",
            "caption": "Evaluation of the enhancement of the lesion using an ROI showed an atypically low contrast enhancement; therefore SPECT was performed to confirm the diagnosis."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002190/000002.jpg?itok=lmkJwcR7",
            "caption": "The well-defined nodule viewed with the lung window, showing that the lesion was hardly dissociable from pericardial pleura."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002190/000003.jpg?itok=op4Sa6vi",
            "caption": "Coronal view in Volume Rendering mode obtained using an ADW 4.0 workstation.."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002190/000004.jpg?itok=T36z1uJK",
            "caption": "Coronal view in MIP(thickness 17.6 mm) obtained using an ADW 4.0 workstation."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002190/000005.jpg?itok=i0wjKyhZ",
            "caption": "Volume Rendering Reconstruction obtained using reconstructed slices of 2.5 mm."
          },
          {
            "number": "Figure 5b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002190/000006.jpg?itok=f3XlKDd2",
            "caption": "A particular of the same VR image."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002190/000007.jpg?itok=kMvp0Gqe",
            "caption": "Volume Rendering Reconstruction (particular of the lesion)"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT",
      "CT",
      "CT",
      "CT",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/2190",
    "time": "15.09.2003"
  },
  "2206": {
    "case_id": 2206,
    "title": "Aberrant origin of the right upper lobe bronchus",
    "section": "Chest imaging",
    "age": "15",
    "gender": "male",
    "diagnosis": "Tracheal bronchus",
    "history": "Progressive lung infiltration on chest X-ray after renal transplantation.",
    "image_finding": "The patient presented with respiratory distress, hypoxia and malaise after renal transplantation. There was a history of recurrent respiratory tract infections, dialysis because of renal dysplasia, and cardiac failure. \n\nBecause of progressive lung infiltrations seen on chest X-ray, a spiral CT of the chest without contrast administration was performed, revealing the presence of ground-glass opacifications in the right upper lobe and an anatomic variant by which the right upper lobe bronchus originated from the trachea. Coronal, 3D reconstructions and virtual bronchoscopy were also performed.",
    "discussion": "A tracheal bronchus was first described by Sandifort in 1785 as a right upper lobe bronchus originating from the trachea. In the recent literature, however, the term tracheal bronchus encompasses a variety of bronchial anomalies originating from the trachea or main bronchus and directed to the upper lobe territory.  Many congenital variations of the bronchial tree in number, length, diameter, and position of the bronchi have been described.\n\nClassic descriptions of bronchial anatomy have been made from chest X-rays, conventional tomography, bronchography, CT and MR imaging. Recently, the capacity of spiral CT to explore a complete volume with no gap and excellent multiplanar reconstructions and 3D reformations has been emphasised. Therefore, spiral CT is the preferable technique for studying congenital abnormalities of the tracheobronchial tree. In most cases spiral CT permits a full and correct evaluation of the malformation and its associated anomalies.\n\nContrary to the numerous variations of lobar or segmental bronchial subdivisions, abnormal bronchi originating from the trachea or main bronchi are rare. A prevalence of 0.1%-2% for right tracheal bronchus and 0.3%-1% for left tracheal bronchus has been found in bronchographic and bronchoscopic studies. All bronchial anomalies affecting the upper lobe are seven times more frequent on the right side.\n\nThese bronchial anomalies can be classified by origin or by type (supernumerary vs displaced). \nThe normal right upper lobe bronchus is described as eparterial because it arises above the right pulmonary artery. The normal left upper lobe bronchus is described as hyparterial because it arises below the left pulmonary artery. \nAn anomalous bronchus arising proximal to the origin of the upper lobe bronchus is called pre-eparterial on the right side and eparterial or prehyparterial on the left side. \n An anomalous bronchus arising distal to the origin of the upper lobe bronchus is called posteparterial on the right side and posthyparterial on the left side.  \nThese bronchi are described as supernumerary when they coexist with a normal type of branching of the upper lobe bronchus. They may ventilate normal lung, or end in a communicating or noncommunicating cyst. They are described as displaced when, in addition to the aberrant bronchus, one branch of the upper lobe bronchus is missing. This fact is well demonstrated with high-resolution spiral CT, which can demonstrate that the aberrant bronchus may correspond to a segmental, subsegmental, or subsubsegmental bronchus.\n\nThe displaced type is more frequent than the supernumerary type. A true (displaced) tracheal bronchus is any bronchus originating from the trachea, usually within 2cm of the carina and up to 6cm from the carina. When the entire right upper lobe bronchus is displaced on the trachea, it is also called a \"pig bronchus\" and has a reported frequency of 0.2%.\n\nAlthough these aberrant bronchi are usually asymptomatic, respiratory distress may occur if drainage is impaired or in association with other abnormalities. In the literature, these aberrant bronchi have manifested as recurrent local infections, persistent cough, stridor, acute respiratory distress (especially in children) and haemoptysis. Bronchiectasis, atelectasis, focal emphysema (especially of the left upper lobe), and cystic lung malformations may coexist.\n\nKnowledge and understanding of this congenital bronchial abnormality may have important implications for diagnosis, bronchoscopy, surgery, and intubation!",
    "differential_diagnosis": "Tracheal, bronchus",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002206/000001.jpg?itok=H3s8h1KS",
            "caption": "Ground-glass opacity in the right upper lobe. The ground-glass opacities are due to pulmonary infection (pneumonia). Normal carina."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002206/000002.jpg?itok=xkP8Ulr-",
            "caption": "The upper lobe bronchus is lying next to the trachea."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002206/000003.jpg?itok=Eu6kulYe",
            "caption": "The upper lobe bronchus originates from the distal trachea, proximal to the carina."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002206/000004.jpg?itok=s2bvUTFx",
            "caption": "The upper lobe bronchus originates from the distal trachea, proximal to the carina."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002206/000005.jpg?itok=Mf0RCTNV",
            "caption": "Virtual bronchoscopy shows the aberrant right superior bronchus.  Virtual bronchoscopy passes the distal trachea, showing a narrowed carina."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002206/000006.jpg?itok=vt5kGTPY",
            "caption": "Passing along the origin of the tracheal bronchus, virtual bronchoscopy shows the head carina which is narrowed antero-posteriorly.  Virtual bronchoscopy allows passage into the right bronchus which is open and well permeable."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT",
      "CT",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/2206",
    "time": "20.05.2003"
  },
  "2243": {
    "case_id": 2243,
    "title": "A nodular mass as the only presentation of Wegener&#039;s granulomatosis",
    "section": "Chest imaging",
    "age": "52",
    "gender": "male",
    "diagnosis": "Wegener's granulomatosis of the lung.",
    "history": "A 52-years-old male patient (non-smoker) referred to the hospital with a chronic respiratory infection with dyspnea, wheezing and a productive cough. Laboratory tests were normal except for increased ESR and a positive serum test for antineutrophil cytoplasmic antibodies (c-ANCA).",
    "image_finding": "A patient, with a medical history of atopy, hay fever, Crohn's disease (for over 10 years), Bechterew disease and arterial hypertension, presented with a chronic respiratory infection with dyspnoea, wheezing and a productive cough. There was no loss of weight. Laboratory tests were normal except for increased ESR and a positive serum test for antineutrophil cytoplasmic antibodies (c-ANCA).\n\nA bronchoscopy with BAL (bronchio-alveolar lavage) and cytology was performed, but revealed no abnormalities. Skin tests showed a strongly allergic reaction to pollen. The Mantoux test was negative. Chest X-ray and chest CT examinations were performed.\n\nThe differential diagnosis of the lesions seen on chest X-ray and chest CT was: a lung abscess (irregular outer margins), a central necrotising tumour (thick-walled cavity), vasculitis (e.g. Wegener's granulomatosis; mass surrounded by ground-glass opacities).  CT-guided trans-thoracic puncture of a peripheral lesion revealed only some granulation tissue (pleura) with fibrosis (probably encapsulation of a deeper pulmonary lesion). On PET, two areas of intense tracer accumulation with a central cavity were seen in the right upper lobe. A mediastinoscopy was performed, but showed no pathological lymph nodes.  Later, the patient underwent a superior bilobectomy. Histologically the lesion proved to be a nodular Wegener's granulomatosis (necrotising granulomatous vasculitis).\n\nSince no lesions were demonstrated elsewhere in the body, we can concluded that this was a Wegener's granulomatosis restricted to the lung.",
    "discussion": "Wegener's granulomatosis was first established in 1936 by Wegener, a German pathologist. Wegener's disease is a distinct clinicopathological entity characterised by granulomatous vasculitis of the upper and lower respiratory tract together with glomerulonephritis. It is a systemic disease of unknown aetiology. This uncommon disease is extremely rare in blacks compared with whites. The mean age of onset is approximately 40 years. Wegener's disease has a slight male predominance.\n\nIn its earliest form, renal involvement is characterised by a focal and segmental glomerulitis that may develop into a rapidly progressive crescentic glomerulonephritis. Granuloma formation is only rarely seen on renal biopsy. In addition to the classic triad of upper and lower respiratory tracts and kidney disease, virtually any organ can be involved with vasculitis, granuloma, or both (1,2).\n\nThe most common radiographic manifestation of pulmonary Wegener's granulomatosis is bilateral, multiple nodules or irregularly marginated masses with no zonal predominance. The nodules or masses can be solitary in up to 25% of cases. On CT, the nodules typically have irregular margins and often have a peribronchovascular distribution. Peripheral, wedge-shaped areas of consolidation representing infarcts may also be seen.\n\nCavitation of the nodules (>2cm in diameter) occurs in approximately 50% of cases. The cavities usually have irregular, thick walls. CT may also demonstrate nodules and cavitation not apparent in radiographs (3).\n\nWith treatment, the nodules or cavities may resolve completely or result in a scar. Pleural effusions occur in less than 10% of cases. Mediastinal and hilar adenopathy are relatively uncommon. The localised or diffuse areas of air-space consolidation usually represent pulmonary haemorrhage, although pneumonia causes similar findings. A life-threatening acute pulmonary bleeding as a consequence of capillaritis may occur as an exacerbation of a radiological nodular Wegener's granulomatosis (2,4).\n\nEndobronchial disease, either in its active form or as a result of fibrous scarring, may lead to obstruction with atelectasis. Wegener's granulomatosis may also involve the trachea with resultant stenosis.\n\nSpiral CT provides accurate assessment of tracheal lesions and is complementary to bronchoscopy. Involvement of the tracheal or bronchial walls usually consists of mucosal or submucosal granulomatous thickening. CT shows smooth or nodular thickening of the tracheal or bronchial wall. The thickening may become severe, causing narrowing of the lumen and possible eventual calcification.\n\nIn its typical presentation, the classic clinicopathological complex of Wegener's granulomatosis usually provides clear differentiation from other disorders. However, if all the typical features are not present at once, it needs to be differentiated from the other pulmonary vasculitides. Of particular note is the differentiation from lower and upper airway neoplasms.\n\nThe diagnosis of Wegener's granulomatosis is a clinicopathological one made by the demonstration of necrotising granulomatous vasculitis on biopsy of appropriate tissue in a patient with the clinical findings of upper and lower respiratory tract disease together with evidence of glomerulonephritis, but the condition may present characteristic features on imaging by X-rays and CT. Chest X-ray and kidney biopsy are important tools used in diagnosing Wegener's disease. For the most effective treatment, early diagnosis is critical. Asymptomatic patients can be diagnosed by ANCA blood tests and CT scans.",
    "differential_diagnosis": "Wegener's, granulomatosis, of, the, lung.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002243/000001.jpg?itok=GTgKczkD",
            "caption": "Two nodular thick-walled cavities in the right middle and upper lobe. The lesions are well-defined with an irregular inner wall, rather suggesting a lung tumour with central excavation."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002243/000002.jpg?itok=5qxnPSPz",
            "caption": "Two nodular thick-walled cavities in the right middle and upper lobe. The lesions are well-defined with an irregular inner wall, rather suggesting a lung tumour with central excavation."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002243/000003.jpg?itok=FQhZXEVL",
            "caption": "CT showed two nodular masses with thick walls and irregular cavitation in the right lung: posterior middle lobe (7cm) and anterior upper lobe (4cm). The lesions are surrounded by ground-glass opacities."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002243/000004.jpg?itok=4dU1HWuN",
            "caption": "CT showed two nodular masses with thick walls and irregular cavitation in the right lung: posterior middle lobe (7cm) and anterior upper lobe (4cm). The lesions are surrounded by ground-glass opacities."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002243/000005.jpg?itok=fzZ8Wbxx",
            "caption": "CT showed two nodular masses with thick walls and irregular cavitation in the right lung: posterior middle lobe (7cm) and anterior upper lobe (4cm). The lesions are surrounded by ground-glass opacities."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002243/000006.jpg?itok=Y2nlVD5_",
            "caption": "CT showed two nodular masses with thick walls and irregular cavitation in the right lung: posterior middle lobe (7cm) and anterior upper lobe (4cm). The lesions are surrounded by ground-glass opacities."
          },
          {
            "number": "Figure 2e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002243/000007.jpg?itok=Q9Jn1PfQ",
            "caption": "CT showed two nodular masses with thick walls and irregular cavitation in the right lung: posterior middle lobe (7cm) and anterior upper lobe (4cm). The lesions are surrounded by ground-glass opacities."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002243/000008.jpg?itok=ZgxoDfNa",
            "caption": "Pallisaded rim of histiocytes with dying neutrophilic granulocytes;  this lesion is most characteristic of M. Wegener."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "Digital radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/2243",
    "time": "15.09.2003"
  },
  "2275": {
    "case_id": 2275,
    "title": "Alveolar Proteinosis",
    "section": "Chest imaging",
    "age": "16",
    "gender": "female",
    "diagnosis": "Alveolar Proteinosis",
    "history": "We report an interesting respiratory case presenting with acute severe dyspnoea and bilateral air space opacification on chest radiograph in a sixteen year old female. This is followed by a discussion of diagnosis/review of recent literature.",
    "image_finding": "A sixteen year old female presented with a history of pyrexia and rapid onset dyspnoea. She was hypoxic on admission.  A chest radiograph showed bilateral basal consolidation (Figure 1). She was treated for bilateral pneumonia but rapidly deteriorated with no response to antibiotics, steroids or nasal continuous positive airway pressure ventilation(CPAP) and was ventilated and transferred to intensive care unit.\nBroncho alveolar lavage(BAL) showed possible acid fast bacilli (this was subsequently  negative after 6 weeks incubation). High resolution CT of the chest showed widespread interstitial thickening with ground glass opacities (Figures 2 & 3).  A lung biopsy confirmed a diagnosis of alveolar proteinosis showing alveolar spaces distended with eosinophilic granular material containing macrophages, degenerate cells and neutrophils. There was also prominence of type 2 pneumocytes and occasional bronchioles were filled with similar eosinophilic granular material . The surrounding lung parenchyma contained lymphoid aggregates. She had numerous other investigations including an autoimmune screen, nasopharyngeal aspirates for Respiratory syncitial virus (RSV), Influenza virus, Parainfluenza virus, adenovirus, antibody titres for influenza A,B, Adenovirus, RSV and  screens for Ebstein Barr virus and cytomegalovirus. Furthermore she was screened for atypical bacterial infections, HIV, Aspergillus and Lyme serology. These were all found to be negative. A bone marrow examination was also normal. \nThe patient received extracorporealmembranous oxygenation(ECMO) and twice daily BAL for 9 days, draining thick secretions. She had been started on a  course of antituberculous treatment but this was terminated after deranged liver function tests and  negative culture results. She gradually improved. After a course of steroids  ECMO was stopped, she was extubated, continued on overnight CPAP and daily physiotherapy. She was discharged 6 weeks after admission with a clear chest, oxygen saturations of  96% on air, and low flow overnight home oxygen. Follow up in chest clinic is planned",
    "discussion": "Alveolar proteinosis is a rare clinical syndrome that is characterised by the accumulation of surfactant components within the alveoli first described by Rosen et al in 1958 (1). The aetiology of the disease is not entirely clear but it can be understood as an abnormality of surfactant homeostasis, leading to a pathological accumulation of surfactant. There are congenital and acquired forms of alveolar proteinosis and recent research has shown that in the congenital form the disease is attributable to mutations in surfactant protein genes or granulocyte-macrophage colony-stimulating factor (GM-CSF) receptor defects (2). In the acquired form it may result from inhibition of action of GM-CSF receptors by autoantibodies. In some cases the altered homeostasis may be caused by pulmonary insults such as exposure to inorganic dust or by another condition such as immunodeficiency states in children, haematological malignancy, chemotherapy, infection or AIDS. \n\nThe disease usually affects adults aged 30-50 years but can occur in childhood, when the prognosis is generally worse. Males are affected more frequently (3:1). The clinical features of alveolar proteinosis are variable being asymptomatic in the minority (10-20%). The commonest presentation is with exertional dyspnoea and non-productive cough. Other symptoms include pyrexia, chest pain and haemoptysis. Patients may be clubbed, cyanosed and have inspiratory crackles on auscultation , however there may be minimal clinical signs despite extensive disease. \n\nLung function tests show evidence of restriction and a defect in diffusing capacity. Chest radiograph changes in alveolar proteinosis are variable and largely non specific. There can be diffuse or patchy bilateral air-space opacification with either a central or peripheral distribution which may be mistaken for infection or pulmonary oedema initially as in this case. Unilateral involvement is rare, interstitial changes may occur in long standing cases. The CT features of alveolar proteinosis are more specific. Recent research has shown a wide variation in the CT pattern of disease (3) ranging from air-space disease to ground-glass opacity to interstitial disease. However, the most common and more typical HRCT pattern in alveolar proteinosis is a combination of a striking geographical distribution of ground-glass opacification and thickened interlobular septa, the so-called \u201ccrazy paving pattern\u201d (4)(Figure 2). This appearance is characteristic but not pathognomonic of the disease and can be associated with other conditions such as cardiogenic pulmonary oedema, alveolar haemorrhage, hypersensitivity pneumonitis and ARDS(5). Fortunately these other conditions often have characteristic presentations and are unlikely to be confused with alveolar proteinosis. In a small number of patients, pulmonary fibrosis is the dominant feature but this may be a coincidental finding. Bulky lymph node enlargement is rare in alveolar proteinosis and should prompt consideration of underlying infection or malignancy. Likewise large focal areas of air-space disease and pleural effusions are uncommon in this condition and suggest the possibility of superimposed infection. The diagnosis is supported by microscopic analysis of lung tissue, lavage samples and/or sputum. \n\nThe most effective proven treatment is whole-lung lavage which has substantially improved patient morbidity and mortality, in some patients a single treatment is sufficient but in others as in this case repeated treatment is required.",
    "differential_diagnosis": "Alveolar, Proteinosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002275/000001.jpg?itok=HQXTrRJ0",
            "caption": "Chest Radiograph showing bilateral air space opacification"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002275/000002.jpg?itok=evzVaB3Z",
            "caption": "HRCT showing smooth interlobular septal thickening and ground glass change"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002275/000003.jpg?itok=pDfE-KLV",
            "caption": "HRCT showing patchy ground glass change"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/2275",
    "time": "27.11.2003"
  },
  "2325": {
    "case_id": 2325,
    "title": "Invasive tracheal aspergillosis",
    "section": "Chest imaging",
    "age": "72",
    "gender": "male",
    "diagnosis": "Invasive tracheal aspergillosis.",
    "history": "A patient presented with neutropenia and a thickening of the tracheal wall.",
    "image_finding": "A patient with acute myelogenous leukemia was admitted to our hospital for undergoing intensive chemotherapy. Some days later, he developed severe neutropenia, fever and cough. A computed tomography\n(CT) scan revealed an irregular nodular thickening of the tracheal wall with a marked narrowing of the lumen (Fig. 1). Invasive tracheal aspergillosis was confirmed after a bronchoscopy and a biopsy\n(Fig. 2) were performed. Despite intensive therapy with amphotericin B, the patient died a few days later.",
    "discussion": "Aspergillus fumigatus is a ubiquitous dimorphic fungus and the most common cause of infection by Aspergillus in humans. The inhalation of the airborne spores causes a variety of pulmonary infections,\nranging from saprophytic to invasive (1). The term \u201cinvasive aspergillosis\u201d is generally used to define a histopathologically demonstrated invasion of tissues by septated hyphae that\nbranch out at 45\u00ba angles. Most cases of invasive pulmonary aspergillosis present in an angioinvasive form, but less commonly an airborne form of invasive aspergillosis can also be present (2,3).\nThis represents an important cause of morbidity and mortality in immunocompromised patients. In our case, primary aspergillosis involving the trachea developed during treatment of an acute myeloid\nleukemia. A bronchoscopy and a biopsy when performed demonstrated an extensive necrotic thickening of the trachea wall leading to the destruction of the tracheal cartilage by septated hyphae. A CT\nexamination showed an extensive thickening of the tracheal wall with a marked narrowing of the lumen. To our knowledge, this is the second case of tracheal involvement documented radiologically on CT\n(2). Although bronchoscopy may be useful in revealing the pathology (3), an antemortem diagnosis is difficult to make due to the low sensitivity of sputum cultures and the fulminant nature of this\ncondition, and tracheal involvement is usually recognized on autopsy. Invasive tracheal aspergillosis is a potentially lethal disease, and it should be considered in immunosuppressed patients.",
    "differential_diagnosis": "Invasive, tracheal, aspergillosis.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002325/000001.jpg?itok=tALOa-mG",
            "caption": "A CT scan of the thorax targeted at the trachea (mediastinal window). Irregular nodular thickening of the tracheal wall (yellow arrows) with a marked reduction of the lumen. The white arrows point to aortopulmonary window lymphadenopathies. The red arrowhead shows the esophagus. aa: ascendent aorta, da: descending aorta, L: tracheal lumen."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002325/000002.jpg?itok=Y6E-NKCQ",
            "caption": ""
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002325/000003.jpg?itok=vu_GColw",
            "caption": "Hematoxylin-eosin staining at a magnification of x400. Destruction of the tracheal cartilage by septated hyphae that branch out at 45\u00b0 angles (arrows)."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/2325",
    "time": "14.04.2005"
  },
  "2358": {
    "case_id": 2358,
    "title": "ctopic hyperparathyroidism",
    "section": "Chest imaging",
    "age": "32",
    "gender": "male",
    "diagnosis": "Mediastinal ectopic parathyroid adenoma",
    "history": "The patient with a 9 year history of chronic renal failure developed increasing malaise and myalgia. Past medical history included a negative neck exploration for parathyroid adenoma. Biochemical assays revealed corrected serum calcium of 3.2 mmol/l and a parathyroid level of 392 ng/l (normal range 10-50ng/l).",
    "image_finding": "The patient with a 9 year history of chronic renal failure developed increasing malaise and myalgia. Past medical history included a negative neck exploration for parathyroid adenoma. Biochemical assays revealed corrected serum calcium of 3.2 mmol/l and a parathyroid level of 392 ng/l (normal range 10-50ng/l).\nParathyroid imaging was performed using metastable technetium 99 (Tc-99m) pertechnetate subtracted from Sestamibi labelled with metastable technetium 99 (Tc-99m) images, which demonstrated focal increased uptake within the superior mediastinum, to assist in the preoperative localisation of the parathyroid gland (Figure 1).\nThoracic contrast enhanced CT was subsequently performed and revealed an enhancing 2 cm mass within the anterior superior mediastinum (Figure 2).",
    "discussion": "Patients with renal failure often develop secondary hyperparathyroidism in order to attempt control of their hypocalcaemia. Occasionally tertiary hyperparathyroidism develops in which the parathyroid effectively becomes a self-regulating parathyroid adenoma with elevated serum calcium and parathyroid hormone levels.\nDiagnosis of hyperparathyroidism is essentially by biochemical assay of corrected serum calcium levels and parathyroid levels. Preoperative imaging localisation is beneficial in enabling a miniparathyroidectomy to be performed; which has been show to have improved cosmetic results, and a reduced length of hospital admission. Preoperative localisation is often with ultrasound or radioisotope imaging either alone or in combination.\nSubtraction imaging with the Sestamibi / pertechnetate technique is effective with both sensitivity and accuracy of 90-95% for the detection of parathyroid adenomas. False negative results with the Sestamibi technique is often due to poor uptake of Sestamibi by clear cell adenomas, which have a reduced oxyphil cell content and have a prevalence of in 5 -10%. Hence ultrasound in these instances can reduce the overall imaging false negative rate.\nRadiologically ectopic parathyroid adenomas can be difficult to localise. With CT, a meticulous technique is advised with thin slices at least 5mm performed following intra-venous contrast. The small parathyroid adenoma can be difficult to distinguish from normal sized lymph nodes.\nMRI has advantages since on STIR or fat suppressed T2 weighted sequences from the skull base through the mediastinum it should demonstrate parathyroid adenomas as hyperintense foci. Correlation of CT or MRI with sestamibi SPECT images improves anatomical localisation and hence surgical planning.\nHyperparathyroidism often has radiographic manifestations such as renal stones or pancreatic calcification on the abdominal radiograph, osteopenia with subperiosteal resorption of the radial aspects of the index and middle finger\u2019s phalanges, and often vascular calcification. Ectopic parathyroid glands are quite common with an incidence of between 1 to 5%. In the embryo the inferior glands start in the third (higher) pharyngeal pouch and the superior glands in the fourth (lower) pharyngeal pouch crossing during development. Most individuals have 4 glands although there reports of between 2 to 8 parathyroid glands. The radiological differential diagnosis for an anterior mediastinal mass of this size in addition to a parathyroid adenoma would include thymoma, teratoma, intrathoracic thyroid gland and lymphadenopathy due to lymphoma, metastasis or granulomatous disease. Our case illustrates the benefit of routinely acquiring fields of view of the neck and the thorax during Sestamibi imaging of the parathyroid glands.",
    "differential_diagnosis": "Mediastinal, ectopic, parathyroid, adenoma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002358/000001.jpg?itok=KcVSBDaz",
            "caption": "Tc-99m Sestamibi / Tc-99m pertechnetate subtraction parathyroid imaging demonstrates increased focal uptake in mediastinum"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002358/000002.jpg?itok=SQpCgbdO",
            "caption": "Tc-99m Sestamibi / Tc-99m pertechnetate parathyroid imaging of thorax with early and delayed images confirms focal increased uptake in mediastum"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002358/000003.jpg?itok=kEgV0Fl0",
            "caption": "Enhancing 2 cm mass in anterosuperior mediastinum"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "Nuclear medicine conventional",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/2358",
    "time": "26.01.2004"
  },
  "2364": {
    "case_id": 2364,
    "title": "Radionuclide noninvasive determination of lung cance",
    "section": "Chest imaging",
    "age": "61",
    "gender": "female",
    "diagnosis": "Bronchogenic adenosquamous carcinoma",
    "history": "Former smoker with past history of rheumatoid arthritis presented with a solitary pulmonary nodule on chest radiograph.",
    "image_finding": "The patient, a former smoker with past history of rheumatoid arthritis, presented with a solitary pulmonary nodule on chest radiograph (Figure 1) Thorax CT (figure2) was performed to categorise the lesion further. A percutaneous CT guided lung biopsy revealed inflammatory changes alone, hence SPECT radionuclide imaging was performed with a somatostatin receptor types 2, 3 and 5 analogue depreotide labelled with technetium-99m (figure 3).\nChest radiograph demonstrated a 3cm solitary pulmonary nodule (SPN) in the left mid zone (figure 1). Thoracic CT confirmed that the SPN was in the apical segment of the left lower lobe and demonstrated lymphadenopathy at the left hilum with minor small volume nodes within the mediastium (figure 2). Depreotide study showed avid uptake within the SPN, the left hilum and mild increased uptake within the subcarinal area. Hence upstaging on imaging from T2 N1 MO on CT to T2 N2 MO following the depreotide study. Subsequent surgical histology following left lower lobe lobectomy confirmed bronchogenic carcinoma (adenosquamous) with involvement of the left hilar, subcarinal and subaortic arch lymph nodes.",
    "discussion": "99 m Tc depreotide was in this case able to predict the involved hilar and mediastinal lymph nodes, this has the potential advantage in anticipating when chemotherapy for non-small cell carcinoma will be needed in addition to surgical treatment. Depreotide is a somatostatin receptor analogue that selectively attaches to receptor types 2,3 and 5. These receptors in particular type 2 have been demonstrated on a range of tumours including bronchogenic carcinoma, lymphoma and breast carcinoma in addition to neuroendocrine tumours such as carcinoid. Benign processes such as lung granuloma only rarely express them. Hence 99 m Tc depreotide has potential for accurate non-invasive diagnosis of the SPN with a reported accuracy of 91% similar to fluoride-18 FDG PET. Depreotide has been suggested as having a role in the determination of associated thoracic lymphadenopathy and pulmonary metastases although such a technique would be currently limited by the spatial resolution of dual head gamma camera systems of approximately 5 to 8mm. Fluoride-18 2-fluoredeoxglucose (FDG)is more effective in the determination of extrathoracic disease than depreotide. However interest in somatostatin receptors analogues continues with the development of fluoride-18 analogues of octreotide. This enables assessment of potential somatostatin receptor analogue therapy and to monitor response to therapy once commenced. These fluoride labelled agents may have a role in the future characterisation of the SPN.",
    "differential_diagnosis": "Bronchogenic, adenosquamous, carcinoma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002364/000001.jpg?itok=Pxn7q0DJ",
            "caption": "3 cm solitary pulmonary nodule in left midzone"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002364/000002.jpg?itok=JLYY7BNu",
            "caption": "1 cm left hilar lymph node"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002364/000003.jpg?itok=cQ5nqchs",
            "caption": "3 cm solitary pulomonary nodule in apical segment left lower lobe"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002364/000004.jpg?itok=VFxG1PNo",
            "caption": "Coronal reference image and axial reconstructions demonstrate avid increased uptake in the SPN in the left lower lobe and the left hilum. Milder increased uptake with the subcarinal region (slice 23)"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT",
      "SPECT"
    ],
    "link": "https://www.eurorad.org/case/2364",
    "time": "15.09.2003"
  },
  "2372": {
    "case_id": 2372,
    "title": "Primary lymphoepithelioma-like carcinoma of the lung",
    "section": "Chest imaging",
    "age": "54",
    "gender": "male",
    "diagnosis": "Primary lymphoepithelioma-like carcinoma of the lung",
    "history": "The patient, asymptomatic smoker, visited our hospital for a routine check up. The subject decided to participate in a low-dose CT based early lung cancer detection program.",
    "image_finding": "An asymptomatic Caucasian man visited our hospital for a routine check up. Clinical history revealed cigarette smoking (>20 cigarettes/day) for more than 20 years. On physical examination there were no signs of dyspnea or cyanosis. Laboratory tests were normal. Pulmonary function tests were also normal. The patient had no history of previous cancer.\nBesides routine exams, a low-dose spiral computed tomography (CT) (120 kVp, 43 mAs) of the chest was performed as part of a lung cancer-screening trial that is currently being developed in our hospital.\nA FDG-positron emission tomography (FDG-PET) was obtained to correlate CT findings. Excisional biopsy revealed the final diagnosis.",
    "discussion": "Lymphoepithelioma-like carcinoma (LELC) is a rare tumor that occurs most commonly in the nasopharynx. Less frequently it may develop in different anatomic sites in pharyngeal and foregut remnants, such as the oral cavity, salivary gland, esophagus, stomach, colon, larynx, thymus, and lung.\nA strong association between Epstein-Barr virus (EBV) and LELC has been observed. This association is almost invariable in the nasopharynx, and variable in other locations, including lung, with notable geographic and ethnic variations. However, there is no known association with EBV infection for LELC arising in skin, vagina or urinary bladder. The relationship between EBV and LELC of the lung has been demonstrated in Asian, but is lacking in Caucasian, as in the case we report. Similar findings happen in cases of Burkitt\u00b4s lymphoma in Africans and nasopharyngeal carcinoma and nasal T-cell lymphoma in Chinese [1]. On the other hand, EBV has also been implicated in the etiology of other neoplasms, including Hodgkin lymphoma and post-transplant lymphoma.\nIn 1987 Begin et al. [2] first described primary LELC of the lung, as a subset of undifferentiated large cell carcinoma with prominent lymphoid infiltration. Pulmonary LELC is currently considered a subtype of large cell carcinoma of the lung, according to the World Health Organization (WHO) histologic typing of lung and pleural tumors.\nLELC occurs predominantly in adults, without sex predilection. Although patients may be asymptomatic, other present with various pulmonary symptoms, including bloodstained sputum [3]. Radiologic exams demonstrate unilateral ill-defined, solitary solid nodule of peripheral location. \nIn contrast to other lung cancers, there is low association with cigarette smoking in LELC of the lung. This feature may suggest that smoking probably does not play an important key role in the etiology of this cancer. Furthermore, the strong association with EBV and the low frequency of cigarette smoking in patients with LELC of the nasopharynx and lung, make it important to determine whether primary LELC of the lung has a biologically distinct behavior from other non-small cell carcinoma of the lung [4]. On the other hand, some authors conclude that the absence of the EBV genome in LELC strongly suggests  that EBV is not an important factor in the pathogenesis of LELC of the lung.\nCT features of primary LELC of the lung have been reported in several case reports. This tumor can be central or peripheral. Solitary LELC of the lung tend to manifest as oval or round circumscribed nodules with mean diameter <4 mm and are located in the peripheral areas of the lung, as shown in this case. CT features of advanced LELC of the lung have been recently reported [5]. They manifest as large tumours affecting the central regions of the lung in close proximity to the mediastinum with well-defined borders. A predilection for peribronchovascular nodal spread and vascular encasement has been described.\nSince its introduction into clinical routine the accuracy of FDG-PET (FDG-positron emission tomography) in detecting and staging several different malignancies has been highlighted.\nFDG-PET imaging is very accurate in determining if an indeterminate solitary pulmonary nodule is malignant and has become a very useful tool for lung cancer staging. As said above, the patient decided to participate in an ongoing low-dose CT-based lung cancer screening trial. In this particular trial the FDG-PET is employed for the characterization of potentially malignant pulmonary nodules and according to the protocol the participant underwent a FDG-PET scan, which resulted positive. The qualitative analysis was considered instead of the semiquantitative one as the latter showed an indetermined result. According to the CT and FDG-PET positive results, surgical excision of the nodule was performed. Histologically a primary LELC of the lung was confirmed.\nThe differential diagnosis of LELC of the lung includes metastasis from nasopharyngeal carcinoma, malignant lymphoma, and malignant melanoma. Clinical history, negative findings in biopsy of the nasopharynx and the presentation of the tumor as a solitary nodule, without lymph node metastases, make probable to consider LELC a primary cancer of the lung. Nevertheless, the disease may involve other sites, such as bone, liver, lymph nodes, and pleura. Recurrences in lung have also been reported [4].\nTherapeutic approach includes surgery, radiotherapy, chemotherapy, or a combination of these techniques. The best survival appears to result from radical surgery followed by adjuvant chemotherapy and/or radiotherapy [4].\nTumor recurrence and necrosis are associated with significantly poor prognosis [3].",
    "differential_diagnosis": "Primary, lymphoepithelioma-like, carcinoma, of, the, lung",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002372/000001.jpg?itok=hvNz960u",
            "caption": "An ill-defined, peripheral round non-calcified pulmonary nodule was observed in the right upper lobe."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002372/000002.jpg?itok=D5DaywJa",
            "caption": "High resolution CT confined to the nodule demonstrated a 10 mm peripheral solid lesion with spiculations and ill-defined margins. No calcification was observed. Radiologic features suggested malignancy and, according to our early lung cancer detection protocol, FDG-PET was recommended."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002372/000003.jpg?itok=cgPBe327",
            "caption": "FDG-PET was performed for further characterization of this solitary pulmonary nodule. After qualitative and semi-quantitative analysis (maximum standardized uptake value \u2013 SUVmax 1.6) excisional biopsy of the nodule was recommended."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT",
      "PET"
    ],
    "link": "https://www.eurorad.org/case/2372",
    "time": "28.07.2004"
  },
  "2417": {
    "case_id": 2417,
    "title": "Thoraco-Abdominal Aortic Aneurysm",
    "section": "Chest imaging",
    "age": "71",
    "gender": "female",
    "diagnosis": "Thoraco-Abdominal Aortic Aneurysm",
    "history": "71 year old female patient with acute chest pain radiating to the back.",
    "image_finding": "Patient presented with left parasternal chest pain radiating to the back with associated vomiting.   She was a known hypertensive patient with ischaemic heart disease.  On examination she was unwell, pale, clammy and tachycardic.  Upper limb blood pressures were equal bilaterally.  There were no other specific findings on examination.\nChest radiograph [Fig. 1] demonstrated a widened mediastinum due to an extensive aneurysm involving the length of the thoracic aorta with tracheal deviation to the right.  The lungs were clear of acute pathology.  Spiral CT of the thorax and abdomen with contrast [Fig. 2] demonstrated a thoraco-abdominal aortic aneurysm (TAAA) beginning in the ascending aorta just above the aortic valve involving the entire thoracic aorta and extending into the abdominal aorta to end just proximal to the celiac artery.  The widest diameter measured 9cm in the ascending thoracic aorta at the same level as the pulmonary trunk.",
    "discussion": "Thoraco-abdominal aortic aneurysms (TAAA) are when thoracic aortic diameter is over 4cm and abdominal aortic diameter over 3cm.  They are relatively common, being found in as many as 10% of patients at autopsy [1] and with an incidence of 5.9% per 100 000 person-years [2].  Men are affected more commonly than women.  The most common cause is atherosclerotis. Other causes include cystic medial necrosis such as in Marfans, infection, and aortitis.  Treatment is indicated when the diameter of the ascending aorta reaches 5.5cm or the descending aorta reaches 6.5cm.  This is because the risk of rupture or dissection increases significantly above these sizes.\nTAAA are often picked up incidentally on chest radiographs in elderly patients without symptoms. If symptomatic, there may be a variety of symptoms including chest or back pain (especially with acute rupture or dissection), aortic valve incompetence, superior vena cava compression, as well as hoarse voice (left recurrent laryngeal nerve compression), dysphagia (oesophageal compression) or left lower lobe pneumonia (left lower lobe bronchus compression).\nImaging is important in order to define the extent and size of the TAAA as well as the state of the aortic wall and any complications.  Chest radiography helps to demonstrate the presence of an aneurysm.   If there is a focal aneurysm (usually involving the proximal aorta) a chest radiograph may demonstrate focal mediastinal widening with displacement of which mediastinal structures.  This may be difficult to distinguish from a primary lung carcinoma adjacent to the mediastinum.  If the aorta is diffusely aneurysmal involving the descending aorta the chest radiograph will demonstrate widening of the mediastinum.  There may be difficulty in distinguishing this from a tortuous aorta in an elderly patient but the large size usually helps [3].  Occasionally there may be signs of complication including pleural effusions with rupture and displacement of the wall calcification into the lumen with dissection.  However, more complex imaging techniques are necessary to provide the detailed information required to plan management.  These include Computed Tomography (CT), Magnetic Resonance Imaging (MRI), Trans-Oesophageal of Trans-Thoracic Echocardiography (TOE or TTE), as well as conventional angiography.\nCT is most often used because it is able to provide all necessary information in most cases (particularly with new advanced scanners with multiplanar imaging and CT-angiography) and is quick and readily available [4].  There are drawbacks particularly with contrast reactions and nephrotoxicity of iodine based contrast agents in already seriously ill patients.  MRI is better in this respect because gadolinium contrast agents are much less nephrotoxic and contrast reactions are much less frequent [2].  MRI can demonstrate the structure of the aneurysm better than CT helping to characterise the aetiology of the aneurysm, and it can demonstrate function in the same study [2].  The problem with MRI is that it is not as readily available as CT, takes longer, and patient tolerance is less.  If patients are unable to get to CT or MRI or are unsuitable for these imaging techniques TOE or TTE can be used.  These techniques also have advantages in that they demonstrate function of valves and blood flow much better.  They can also localise a site of a rupture by detecting high velocity jets of blood and intimal flaps that may not be seen on CT or MRI [5].  Unfortunately TOE and TTE like all ultrasound techniques are operator dependent and there is a limited field of view.  Also most patients need sedation which may create complications and, finally, angiography is not often used in the diagnosis of TAAA being it reserved for when other techniques have failed.  It may be needed in the planning of some stent grafts.",
    "differential_diagnosis": "Thoraco-Abdominal, Aortic, Aneurysm",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002417/000001.jpg?itok=DF6T63ws",
            "caption": "A widened mediastinum is seen due to an aneurysm affecting the whole of the thoracic aorta.  Marked tracheal deviation to the right is seen."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002417/000002.jpg?itok=j15uSPdb",
            "caption": "The aortic valve and root of the aorta were normal."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002417/000003.jpg?itok=zpkCHwck",
            "caption": "Marked dilatation of the ascending aorta begins just distal to the aortic valve"
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002417/000004.jpg?itok=i4ywJ17t",
            "caption": "The ascending aorta was widest at the level of the pulmonary trunk with a diameter of 9cm.  This had increased from 6cm the year previously.  There was little thrombus visible here or throughout the rest of the aneurysm."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002417/000005.jpg?itok=rD7Y7jrP",
            "caption": "The descending aorta had a maximum diameter of 4.5cm at a level 5 cm proximal to the celiac artery."
          },
          {
            "number": "Figure 2e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002417/000006.jpg?itok=XNUv02BI",
            "caption": "The aneurysm continued down to the level of the celiac artery."
          },
          {
            "number": "Figure 2f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002417/000007.jpg?itok=NoCcAON6",
            "caption": "It begins to become normal at the level of the superior mesenteric artery."
          },
          {
            "number": "Figure 2g",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002417/000008.jpg?itok=i-RcWEHY",
            "caption": "The aorta is of normal diameter at the level of the left renal vein."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/2417",
    "time": "15.09.2003"
  },
  "2424": {
    "case_id": 2424,
    "title": "Mounier-Kuhn syndrome",
    "section": "Chest imaging",
    "age": "52",
    "gender": "female",
    "diagnosis": "Mounier-Kuhn syndrome.",
    "history": "A 52-year-old woman presented with cough and bloody sputum.",
    "image_finding": "A 52-year-old woman presented to our emergency department with cough and bloody sputum. She denied of having fever, chest pain, dyspnea or weight loss. Her expectoration was declining gradually. The\npatient had a 150 pack-year history of tobacco use several years ago and also had multiple prior episodes of pneumonia, sometimes with bloody sputum. A physical examination done revealed a\nwell-nourished patient. The results of blood analysis were within normal limits. A chest radiograph (Fig. 1) and a helical CT scan (Fig. 2) were performed, which showed tracheomegaly with a\ntransversal diameter of 30 mm. Many diverticular outpouchings were present from membranous parts of the trachea. Dilatation of central airways and cystic bronchiectasis involving both lower lobes\nwere additional findings.",
    "discussion": "Mounier-Kuhn syndrome is a rare disorder characterized by a marked dilatation of the trachea and main bronchi, sometimes with diverticulosis (1/3 patients), bronchiectasis, and recurrent lower\nrespiratory tract infections (1). The airways distal to the fourth-order and fifth-order division are usually normal in diameter. The etiology of this syndrome remains unknown. Autopsy studies\nsuggest a congenital defect or atrophy of the internal elastic membrane and smooth muscle tissue of the trachea and main bronchi, which results in dilatation of the cartilaginous skeleton and\nexternal protrusion of the intercartilaginous parts of the tracheal wall, inducing diverticula (2). Flaccidity of the trachea and main bronchi results in a marked dilatation on inspiration, with\nnarrowing or collapse on expiration. Although the majority of cases appear to be sporadic, a familial form has been described. Secondary tracheobronchomegaly was also described in association with\nEhlers-Danlos syndrome, Marfan syndrome, cutis laxa in children, Kenney-Caffe syndrome, and connective tissues diseases (3). The symptoms of this entity are non-specific, with sputum production\nsecondary to bronchiectasis and lower respiratory tract infection. Almost 50% of the patients show no symptoms until the third decade of life (4). The dilatation of the trachea and the main bronchi\nis visible on the chest radiograph. A tracheal diameter superior to 25 mm in men and 21 mm in women on a posteroanterior view is required for the diagnosis (5). Tracheal diverticulosis may result in\nan irregular corrugated or scalloped appearance of the trachea and, occasionally, the main bronchi, which is best seen in the lateral view. Tracheal changes are well appreciated on a CT scan. The\ntreatment is limited to physiotherapy to assist in clearing secretions and adequate antibiotics during infectious episodes.",
    "differential_diagnosis": "Mounier-Kuhn, syndrome.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002424/000001.jpg?itok=tfSVV661",
            "caption": "Posteroanterior projection. A tracheal diameter superior to 2 cm  (hollow arrows) is seen."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002424/000002.jpg?itok=CPC68r6S",
            "caption": "Lateral view. Note the characteristically scalloped or corrugated outline of the trachea with posterior diverticula (black arrows). Hollow arrows point to the anterior and posterior margins of the trachea."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002424/000003.jpg?itok=recCQEio",
            "caption": ""
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002424/000004.jpg?itok=zoRukdmK",
            "caption": "Posteroanterior (Fig. 1c) and lateral (Fig. 1d) projections show multiple bronchiectasis in both lower lobes (hollow arrows)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002424/000005.jpg?itok=cyroABQO",
            "caption": "An axial CT scan. Tracheobronchomegaly. The transverse tracheal diameter is 30 mm. Note the posterior tracheal diverticula."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002424/000006.jpg?itok=YC7UyBDF",
            "caption": "Irregular corrugated appearance of both main bronchi and of the anterior segment of the right upper lobe and the posterior segment branch."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002424/000007.jpg?itok=Fw5q21zk",
            "caption": "High resolution CT scan of the lower lobe showing multiple cylindrical bronchiectasis (hollow arrow). See the typical signet ring sign (white arrows) due to a pulmonary artery adjacent to a dilated bronchus."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002424/000008.jpg?itok=aZM6CNGP",
            "caption": "High resolution CT image  showing multiple dilated, thick-walled bronchi bilaterally."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/2424",
    "time": "23.02.2006"
  },
  "2457": {
    "case_id": 2457,
    "title": "A double \u201cscimitar sign\u201d of the congenital pulmonary venolobar syndrome",
    "section": "Chest imaging",
    "age": "18",
    "gender": "female",
    "diagnosis": "Congenital pulmonary venolobar syndrome (Scimitar syndrome).",
    "history": "An asymptomatic patient was referred for a chest radiograph on routine examination. Two large curvilinear shadows were demonstrated in the right lung descending to the right costophrenic angle. CT,\nCT-angiography, MR-angiography and echocardiography when performed confirmed the initial diagnosis and further demonstrated hypoplasia of the right lower lobe, dextrocardia and a stunted right lower\nlobe bronchus.",
    "image_finding": "The asymptomatic patient was referred for a chest radiograph on routine examination. Two large curvilinear shadows were demonstrated in the right lung descending to the right costophrenic angle.\nHypoplasia of the right lung secondarily causing dextrocardia was also depicted. CT obtained after administering a bolus injection of the contrast medium confirmed partial hypoplasia of the right\nlower lobe and dextrocardia. Enlarged aberrant vessels starting from the right upper lobe-right lower lobe border united at the base of the right lung, and this curvilinear tubular vessel drained to\nthe inferior vena cava. The inferior vena cava and the hepatic veins were observed to be thick. A right lower lobe bronchus was stunted. No right lung fissures were visualized. The patient was told\nto undergo CT-angiography and MR-angiography which confirmed the diagnosis of a right lung bicornuate venous entity. One anomalous vein connected the right pulmonary artery to the inferior vena cava\nabove the level of the diaphragm, and the other vein finished at the right upper lobe. The right pulmonary artery was smaller than the left and had smaller branches. The echocardiography results\ndisclosed a slight enlargement of the right chambers and of the trunk of the pulmonary artery and depicted the insertion of the anomalous vein into the inferior vena cava adjacent to the right\natrium.",
    "discussion": "The scimitar syndrome or congenital pulmonary venolobar syndrome is believed to be a rare and complex syndrome characterized by anomalous connections of most, if not all, pulmonary veins to the\ninferior vena cava below the diaphragm or the junction of the inferior vena cava at the right atrium (less commonly into the right atrium, to the hepatic, azygous or portal vein). The anomalous vein\ncourses parallel to the right atrium and due to its gentle curvature, the vein resembles a curved Muslim sword (\u201cscimitar sign\u201d). The scimitar sign consists of the most constant\nabnormality. More than one anomalous vein can be present as in our case. Manifestations and clinical course of the syndrome are variable. Asymptomatic cases are usually detected first on routine\nchest radiography, while symptomatic cases often suffer from repeated chest infections or dyspnea due to associated congenital disease or lung hypoplasia. 25% of affected patients have associated\ncongenital heart disease (secundum type atrial septal defect). Therefore, symptomatic cases are more likely to have the Scimitar syndrome diagnosed in infancy or in childhood. The Scimitar syndrome\noccurs almost only on the right side. The lung is usually hypoplastic, and shifts the heart to the right. Displacement of the heart to the right is the second most common manifestation. Errors of\nsegmentation and lobation are frequent, contributing to the absence of one or both fissures. The bronchial tree on the involved side is stunted and bronchiectasis or tracheal diverticula may coexist.\nOther anomalies include Bochdalek hernia, accessory right hemidiaphragm and a horseshoe lung. Although a chest X-ray examination often suggests a diagnosis, a variety of imaging techniques have been\nintroduced to better define the aberrant vein and associated anomalies and to confirm the diagnosis. CT provides a non-invasive method of confirming the diagnosis of the scimitar syndrome. The\nabnormal vein, as well as its course and termination, can be clearly shown. CT delineates tracheobronchial anomalies and detects hypoplasia of the lung, possible absence of fissures and associated\nabnormalities. CT cannot however always confirm whether the point of insertion is above or below the diaphragm. Echocardiography can determine the exact insertion site relative to the inferior vena\ncava and verify the presence of venous flow. The anomalous vein in our case was depicted connecting to the inferior vena cava below the level of the diaphragm. Pulmonary angiography is a definite\ntest for visualizing all pulmonary veins, and it allows a catheter-based measurement of pulmonary artery pressure. Pulmonary angiography makes use of ionizing radiation and contrast agents. The\nassociated potential complications necessitate the need for diagnosis to be confirmed by non-invasive techniques such as CT-angiography and MR-angiography, especially in the majority of cases which\nare asymptomatic. CT-A and MR-A can clearly depict the course of the anomalous vein and demonstrate the exact junction point. Cine-MR can measure the degree of shunt as well as pulmonary angiography\ncan. MR-A provides a 3D perspective of the Scimitar syndrome. MR angiography is a non-invasive technique that offers an excellent vessel contrast and can be performed easily and quickly in children\nwho are cooperative and within a breath-hold period.",
    "differential_diagnosis": "Congenital, pulmonary, venolobar, syndrome, (Scimitar, syndrome).",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002457/000001.jpg?itok=iwhGwBA0",
            "caption": "A P-A chest radiograph. Note the dextropositioned heart, the hypoplasia of the right lung and the two scimitar veins (arrowhead and arrow) coursing through the right lower zone toward the right costophrenic angle."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002457/000002.jpg?itok=CiasvAlI",
            "caption": "A lateral chest radiograph. The two anomalous veins (arrowheads and arrow) clearly projecting in the posterior part of the right lung."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002457/000003.jpg?itok=zOB9JhA2",
            "caption": "A CT scan at mediastinal window settings after a bolus administration of the contrast medium.The scimitar vein (arrow) runs to the dilated inferior vena cava (arrowhead)."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002457/000004.jpg?itok=ddlDBFhj",
            "caption": "A CT scan at lung window settings. The two scimitar veins (arrowheads) before joining to form the anomalous vein which inserts to the inferior vena cava. Note the diminished vasculature of the right lung and the stunted bronchus (arrow)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002457/000005.jpg?itok=O-7qaEvE",
            "caption": "A reformatted CT-A scan (oblique section). The upper anomalous vein (long arrow) joins the lower vein (short arrow) to form (arrowhead) the major venous draining vein."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002457/000006.jpg?itok=CX6Fw3xB",
            "caption": "A reformatted CT-A scan (transverse section -- the heart on the bottom and right lung on the left of image). The upper anomalous vein (grey arrow) uniting with the lower vein (white arrow)."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002457/000007.jpg?itok=JhjOUHQX",
            "caption": "The upper anomalous vein and the lower vein (arrowheads) uniting (arrow) can be noted again."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002457/000008.jpg?itok=Fybdz3_O",
            "caption": "The abnormal pulmonary vein (arrow) drains to the intrahepatic level of the inferior vena cava."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "Conventional radiography",
      "CT",
      "CT",
      "MR-Angiography",
      "Ultrasound-Colour Doppler"
    ],
    "link": "https://www.eurorad.org/case/2457",
    "time": "03.03.2005"
  },
  "2465": {
    "case_id": 2465,
    "title": "xtramedullary haematopoiesis",
    "section": "Chest imaging",
    "age": "51",
    "gender": "female",
    "diagnosis": "Extramedullary haematopoiesis with haemochromatosis.",
    "history": "A 51-year-old female presented with hereditary spherocytosis and she had had multiple blood transfusions. She was found to be increasingly short of breath.",
    "image_finding": "Patient was known with hereditary spherocytosis and had received multiple blood transfusions over many years. She now presented with anemia and shortness of breath. Chest radiography was performed\n(Figure 1A and 1B), which showed large well-defined masses in the posterior mediastinum and paravertebral regions. Subsequently, unenhanced CT of the thorax and upper abdomen was performed, which\nconfirmed the presence of soft-tissue masses in the paraspinal region with mixed high and low attenuation (Figure 2). However, the upper abdomen also showed high attenuation of the spleen and liver,\nmild hepatosplenomegaly, enlargement of the right adrenal gland and low attenuation of the aorta (Figure 3).",
    "discussion": "A differential diagnosis of lymphoma was contemplated, but the combination of the findings favoured the diagnosis of extramedullary haemopoeisis in response to underlying chronic anaemia (notice the\nlow attenuation of the abdominal aorta) and haemochromatosis of the liver due to multiple blood transfusions. The commonest presentation of extramedullary haemopoeisis includes soft tissue paraspinal\nmass, rib expansion and hepatosplenomegaly. Some may present with spinal cord compression. These findings are not specific for extramedullary haemopoeisis and there is a wide radiological\ndifferential for each of these findings. More rare involvement has been described in kidneys, adrenal glands, the middle ear, skin and uterus. Finally, any site of lymph node chains can produce soft\ntissue masses. Low attenuation of aorta on a non-enhanced CT scan can be seen in severe chronic anaemias due to any cause. Thus, it has a wide differential of several primary haematological disorders\ncausing anaemia but also may acutely be seen in severe blood loss following trauma or exsanguination following trauma. Furthermore the use of artificial blood, tissue expanders and major fluid\noverload (for instance, rapid infusion of a large amount of clear fluids) can cause decrease in the attenuation values in the aorta. A special mention must be made about repeated blood transfusions\nin patients with congenital haemolytic anaemias, such as hereditary spherocytosis as in this case. This leads to excessive iron loading and haemochromatosis, which increases the attenuation in liver.\nMRI is the investigation of choice for evaluation of posterior mediastinal and paraspinal masses, and is well suited to demonstrate the extent of disease. In cases of cord compression, use of steroid\nwith external beam radiation has a favourable response, and MRI can assist in planning of radiation field and assess therapeutic response. The hallmark of MRI findings is a soft-tissue mass in any of\nthe locations described above, which tends to be low to iso-intense on T1 and heterogenous to hyper-intense on T2, with only minimal Gadolinium enhancement. Bone marrow replacement is also dominant,\nas fatty bone marrow is replaced by red bone marrow (in later stages, this may reverse and indeed bone marrow fibrosis/sclerosis may develop). The liver, however, tends to show signal void in cases\nof excessive iron loading. Indeed, quantification of iron load using MR methods is feasible. Thus, it can be concluded that there is no single imaging finding, which uniquely suggests extramedullary\nhaemopoeisis, but a constellation of findings in the right clinical setting is very suggestive. Familiarity with cross-sectional imaging manifestations together with history and clinical features of\nthe patient is vital in diagnosing extramedullary haemopoeisis. Some of the rare manifestations may need biopsy for definitive diagnosis. The importance of differentiating extramedullary haemopoeisis\nfrom a neoplastic process is crucial because of the favourable response to steroids and external beam radiation of the former and cross sectional imaging with CT (and MRI) is crucial in this regard.",
    "differential_diagnosis": "Extramedullary, haematopoiesis, with, haemochromatosis.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002465/000001.jpg?itok=kpTnCm1b",
            "caption": "A plain chest radiograph (PA view) at the time of admission demonstrating  demonstrating double contours with widening of the paraspinal lines indicating masses. The heart configuration appears enlarged, but the heart itself is actually within normal limits (in this case)."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002465/000002.jpg?itok=y_dEjgJi",
            "caption": "A lateral chest radiograph demonstrating the paravertebral extent of the soft tissue masses."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002465/000003.jpg?itok=2ZvgKbJW",
            "caption": "An axial CT image of the lower thorax demonstrating extensive soft tissue masses in a paravertebral position. Small pleural effusions are also present."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002465/000004.jpg?itok=-XwZ5wp8",
            "caption": "An axial CT image of the upper abdomen demonstrating a mass in the right adrenal. The high attenuation of the liver and the spleen is striking, as is the low attenuation of the abdominal aorta."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/2465",
    "time": "16.11.2006"
  },
  "2490": {
    "case_id": 2490,
    "title": "Spontaneous pneumomediastinum in a patient with an asthma attack",
    "section": "Chest imaging",
    "age": "20",
    "gender": "male",
    "diagnosis": "Spontaneous pneumomediastinum in a patient with an asthma attack.",
    "history": "A 20-year-old male patient complained of severe dyspnea, with a three-day history of a common cold and headache. Serial chest radiographs and CT scans were obtained, which demonstrated a linear band\nof gas splaying the mediastinal pleura from the descending aorta. Air was also found outlining the left main bronchus wall, the medial extent of the left diaphragm, the aortic knob, the left border\nof the heart, the pulmonary arteries, the esophagus and trachea and the perivascular and peribronchial sheaths. The patient was treated conservatively and had good clinical outcome.",
    "image_finding": "The patient visited our hospital\u2019s emergency room for severe dyspnea. He had a clinical history of bronchial asthma. He also had a three-day history of a common cold and headache. Laboratory\ntests revealed low F\u0395V1 and FVC rates indicative of obstructive pulmonary disease. The initial chest radiograph demonstrated a linear band of gas splaying the mediastinal pleura from the\ndescending aorta. Air was also found outlining the left main bronchus, allowing a clear depiction of the bronchial wall. The entire extent of the left diaphragm was visible, without obscuration by\nthe heart. A follow-up radiograph, obtained the following day, revealed a lifting of the mediastinal pleura from the aortic knob and the left border of the heart. Both the PA and the lateral\nradiographs showed linear streaks in the superior mediastinum extending into the neck. Lucent bands outlining the spine and the pulmonary arteries (especially the left) were depicted. In order to\nexclude the possible presence of bulla, CT was performed. The CT scan demonstrated the presence of air outlining the spine, the esophagus, the descending aorta, the trachea, the brachiocephalic\nvessels and also present within the perivascular and peribronchial sheaths. Subcutaneous emphysema was also present. The patient was treated with bronchodilator and antimicrobial therapy and he\npresented clinical improvement. A new chest radiograph was performed five days later, which demonstrated a recession of the radiological signs.",
    "discussion": "Pneumomediastinum (or mediastinal emphysema) represents the presence of air in the mediastinum outside the tracheobronchal tree and the esophagus. Pneumomediastinum is a result of alveolar rupture\nassociated with elevated alveolar pressure or alveolar disease (respiratory pneumomediastinum), a traumatic laceration of the trachea or a central bronchus, perforation of the pharynx or esophagus,\nhead and neck surgery or injury and abdominal or retroperitoneal injury or surgery. Elevated alveolar pressure is caused by airway obstruction as in asthma, or, by a foreign body, mechanical\nventilation, blunt thoracic trauma, strenuous activity, weight lifting, inhalation of cocaine, vomiting and change in altitude. Infection, ARDS, interstitial lung disease, sarcoidosis and silicosis\nhave also been described as being associated with pneumomediastinum due to alveolar disease. In spontaneous pneumomediastinum, the patients are usually young and healthy with a history of an attack\nof asthma or a bout of severe coughing or other causes of a sudden rise in intrathoracic pressure. All these can lead to alveolar rupture and air leaks via the interstitial lung tissues. The result\nis that air accumulates in the mediastinum. The patient may complain of a chest pain aggravated by deep breathing and dyspnea. Leucocytosis and fever are frequently encountered. Hammon\u2019s sign,\na crunching sound synchronous with the heartbeat, can also be heard. The majority of patients recover over a ten-day period. The radiographic signs of pneumomediastinum are based on the depiction of\nnormal anatomical structures that are outlined by air in the mediastinum, and can be demonstrated on both the frontal and lateral views. An important plain film sign of pneumomediastinum is that of\nair dissecting under and medial to the thymus (\u201cthymus sail sign\u201d). The \u201ccontinuous diaphragm sign\u201d is produced by air trapped between the heart and the diaphragm. Air\nsurrounding the pulmonary artery or its main branches can result in the \u201cring around the artery sign\u201d. The presence of substernal gas anterior to the heart\n(\u201cpneumoprecardium\u201d) may be the only radiographical finding. When air is present adjacent to major aortic or pulmonary branches, both sides of the vessel can be depicted: mediastinal air\nmay outline the medial side and the aerated lung the lateral side (\u201ctubular artery sign\u201d). Air can also reside next to a major bronchus, clearly depicting the bronchial wall\n(\u201cdouble bronchial wall\u201d). On occasion, it may be difficult to distinguish pneumomediastinum from pneumothorax or pneumopericardium on a plain chest X-ray. The distinction depends on the\nanatomic extent of the air. Pneumothorax presents an apical lucency (in the upright chest X-ray) and a medial basal lucency or the deep-sulcus sign ih the supine chest X-ray. Pneumothorax never\noutlines mediastinal structures and the air changes in distribution with a change in the patient's position, in the case of pneumothorax. Pneumopericardium is a condition that is less common than\npneumomediastinum, except in the setting of a recent heart surgery. Pneumopericardium may outline the ascending aorta and the main pulmonary artery but does not extend to the upper mediastinum and\ndoes not depict the aortic arch, the trachea or the bronchi.",
    "differential_diagnosis": "Spontaneous, pneumomediastinum, in, a, patient, with, an, asthma, attack.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002490/000001.jpg?itok=0rGo72dQ",
            "caption": "A P-A chest radiograph showing the mediastinal air lifting the mediastinal pleura off the descending aorta (indicated by a gray arrow). A linear band of air parallels the other border of the descending aorta (indicated by a gray arrowhead). Linear streaks of air surround the left main bronchus \u201cdouble bronchial wall sign\u201d (indicated by a white arrowhead). All the extent of the left hemidiaphragm is visible. The \u201ccontinuous diaphragm sign\u201d (indicated by two black arrows) is seen."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002490/000002.jpg?itok=jLKm7NNU",
            "caption": "A P-A chest radiograph showing gas outlining the inner surface of the mediastinal pleura, which depicts the aortic knob, the left border of the heart (indicated by black arrows) and the superior vena cava (indicated by a black arrowhead). Note the presence of air surrounding the brachiocephalic vessels \u201ctubular vessel sign\u201d (indicated by white arrowheads)."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002490/000003.jpg?itok=17JYdXHp",
            "caption": "A lateral chest radiograph showing air outlining the brachiocephalic vessels (indicated by a black arrowhead). Lucent streaks extend into the prespinal soft tissues (indicated by a white arrow). A lucent ring is demonstrated around the left pulmonary artery \u201cring around the artery sign\u201d (indicated by a white arrowhead)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002490/000004.jpg?itok=i9I38Xpa",
            "caption": "An axial CT image depicting air surrounding the descending aorta (indicated by a black arrowhead), the azygous vein (indicated by a white arrow), the esophagus (indicated by a black arrow) and the anterior part of the spine (indicated by two black arrows)."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002490/000005.jpg?itok=TDVPbENq",
            "caption": "A CT image showing that air also outlines the medial border of the middle lobe bronchus (indicated by a  black arrow)."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002490/000006.jpg?itok=OSSy1J1X",
            "caption": "A CT image showing a collection of air in the anterior mediastinum surrounding the aortic knob arch (indicated by a black arrow), the superior vena cava (indicated by two black arrows) and the thymus (indicated by two black arrowheads). Subcutaneous emphysema is demonstrated in the left axillary space (indicated by a black arrowhead)."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "Conventional radiography",
      "Conventional radiography",
      "CT",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/2490",
    "time": "03.03.2005"
  },
  "2536": {
    "case_id": 2536,
    "title": "Tracheal Bronchus",
    "section": "Chest imaging",
    "age": "88",
    "gender": "male",
    "diagnosis": "Tracheal Bronchus",
    "history": "Fever of unknown origin. Previous history of tuberculosis in early adulthood.",
    "image_finding": "The patient presented for investigation of fever of unknown origin. He had a history of tuberculosis in early adulthood.\nCT scan of the chest was performed which revealed the incidental presence of a right tracheal bronchus arising just above the main carina and trifurcating into the segmental bronchi of the right upper lobe.",
    "discussion": "Tracheal bronchus is a developmental abnormality of the airways. Its prevalence ranges from 0,1%-2% on the right side and 0,3%-1% on the left side in bronchoscopic examinations. A higher incidence has been noted however in children with Down\u2019s syndrome. Congenital anomalies that can be associated with a tracheal bronchus include tracheal stenosis, tracheoesophageal fistula, laryngeal web, rib and vertebra anomalies, congenital heart disease and VATER syndrome (vertebral defects, anal atresia, tracheoesophageal fistula, esophageal atresia, renal defects and radial dysplasia). There are two types of tracheal bronchus, the displaced type and the supernumerary type. In the first type either the apical (apicoposterior on the left side) segmental bronchus only or all segmental bronchi of the upper lobe arise from the tracheal bronchus. In the second type there is a normal upper lobe bronchus arising from the main carina in addition to the tracheal bronchus. The first type is more frequent. \nCT scans of the chest demonstrate an abnormal bronchus arising from the right lateral wall of the trachea usually up to 2cm above the carina. Identification of this anomaly is easier using high-resolution spiral CT protocols and coronal imaging, which can additionally  help differentiate a displaced from a supernumerary bronchus. In case of a supernumerary bronchus it can be either ending blindly (tracheal diverticula) or supplying a segment of the lung (tracheal lobe).  \nIn most cases this abnormality is clinically insignificant and represents an incidental finding. However under certain circumstances (e.g. intubated patients) it can be potentially dangerous. Common complications, as a result of insufficient drainage of the involved bronchi, include recurrent infections, chronic atelectasis, chronic bronchitis and bronchiectasis. Despite being generally a clinically insignificant abnormality, it should be considered especially in intubated patients with persistent atelectasis, as this can represent a complication due to obstruction of the tracheal bronchus\u2019 orifice. Early detection is important.",
    "differential_diagnosis": "Tracheal, Bronchus",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002536/000001.jpg?itok=gC41s9Jk",
            "caption": "Axial CT image above the carina level clearly demonstrates the tracheal origin of the displaced bronchus."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002536/000002.jpg?itok=-EFBqslV",
            "caption": "Close up axial CT image of the tracheal bronchus at a slightly lower level reveals its trifurcation into the apical, posterior and anterior segmental bronchi (arrows)."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/2536",
    "time": "26.01.2004"
  },
  "2626": {
    "case_id": 2626,
    "title": "Tracheal Hamartom",
    "section": "Chest imaging",
    "age": "60",
    "gender": "male",
    "diagnosis": "Tracheal hamartoma",
    "history": "The patient was admitted to our hospital, suffering from severe dyspnea, wheezing, high fever, productive cough and pain in the right hemithorax.",
    "image_finding": "The patient was admitted to our hospital, suffering from severe dyspnea, wheezing, high fever, productive cough and pain in the right hemithorax. He was a heavy smoker and he was complaining of shortness of breath, mainly on exertion and after meals, which had lasted for 2 years and was relieved on inhaling bronchodilators and corticosteroids.\nHe had been admitted three times, during the previous year, to different hospitals, because of recurrent attacks of fever and dyspnea, which were successively diagnosed and treated as bronchitis, pneumonia and asthmatic bronchitis.\nDespite the administration of nebulised bronchodilators, and corticosteroids, broad-spectrum antibiotics and oxygen, his clinical condition did not improve.\n  Chest radiographs showed extensive consolidation in the left lower lobe and the lingula, smaller similar lesions in the right lower lobe, and a  well-defined round mass in the tracheal lumen measuring c. 2 cm. (Fig. 1 a, b). \nCT scan confirmed the presence of the well-circumscribed mass, with low attenuation, arising with broad base from the right posterior mucosa, and containing some bands of denser tissue. The mass size, 2.2 cm, was the same on deep inspiration and expiration CT, but on the former it obstructed 88% of the lumen while on the latter 95%.  Neither tracheal wall thickening nor extratracheal extension was noticed. (Fig. 2a, b, 3)\nDuring bronchoscopy a smooth, yellowish, round mass, with ball-valve mobility, attached to the membranous portion, was seen to obstruct more than 2/3 of the tracheal lumen. Its intense vascularisation, prevented any biopsy attempt. \nSurgical removal was decided and performed, followed by prompt resolution of his signs and symptoms. Histological examination showed a mixture of cartilaginous and mesenchymal elements, fat and epithelial cells.",
    "discussion": "Tracheal tumors being rare, slow-growing, and rarely symptomatic when small, are seldom considered in the differential diagnosis of upper airway obstruction. \n The most common initial manifestation is a nonproductive cough, becoming productive when an infection occurs. Dyspnea on exertion and later at rest, and wheeze or stridor, aggravated at night, appear when the mass is large enough to cause obstruction of at least 75% of the lumen. Vague chest pain and hemoptysis may appear rarely. These patients can be initially treated for intractable asthma or frequent exacerbations of chronic bronchitis and respiratory infections.   \nAlthough previous reports suggest that chest x-rays do not usually reveal a tracheal lesion, ours were clearly diagnostic, indicating that lesions of such dimensions are detectable. Complications and repeated hospitalizations could have been prevented if the mass had not being overlooked, as it was proven on the review of all previous admissions chest radiographs. CT proved accurate in defining the attachment, extent, and consistency of the tumor, providing enough features of the mass identity. Even more it precluded any spreading to adjacent organs, and helped with three-dimensional reconstruction in planning surgical procedure.\nTracheal hamartoma seems to be extremely rare, although it is considered to be the second most common of all benign airway tumors .The differentiation of tracheal hamartoma from more invasive or malignant lesions is rather difficult. Even in the absence of any imaging signs of invasion, one can not preclude the malignant potential of such a tumor. On the other hand, some authors suggest that hamartomas cannot be differentiated bronchoscopically from carcinomas. Even if biopsy is performed and histology yields no evidence of malignancy, one can preserve doubts for the accuracy of the result. With final diagnosis remaining remote, surgical resection arises as the mandatory decision, no matter the degree of airway obstruction.\nThe misleading presentation of this rare condition reminded us that wheezing is not always asthma, and that the value of chest radiographs should not be underestimated.",
    "differential_diagnosis": "Tracheal, hamartoma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002626/000001.jpg?itok=jNg1Sruu",
            "caption": "A small, round mass (arrow) is shown in the lower trachea"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002626/000002.jpg?itok=7eLJuePI",
            "caption": "The lateral view"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002626/000003.jpg?itok=0MoioK1T",
            "caption": "CT demonstrates the mass producing tracheal obstruction on inspiration (a) (w: 1754, c: -600)"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002626/000004.jpg?itok=jfIKRUj8",
            "caption": "CT demonstrates the mass producing more severe tracheal obstruction on expiration (b) (w: 1754, c: -600). Small denser stains are discerned in the mass."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002626/000005.jpg?itok=lKgJ_9rx",
            "caption": "Soft tissue window (w: 350, c: 50) on which the mass is faintly discerned (arrow)."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/2626",
    "time": "08.09.2003"
  },
  "2665": {
    "case_id": 2665,
    "title": "Blunt left diaphragmatic rupture: radiography and CT findings",
    "section": "Chest imaging",
    "age": "25",
    "gender": "male",
    "diagnosis": "Blunt left diaphragmatic tear,10 cm long with herniation of the stomach.",
    "history": "A 25-year-old motorcyclist run over by a car was admitted to our hospital.",
    "image_finding": "A chest X-ray and a subsequent thorax-abdomen CT scan were performed. Chest radiograph showed elevation and obscuration of the left hemidiaphragm with mediastinal shift. A nasogastric tube was seen\nin the thoracic cavity (arrowheads, Fig.1). CT showed a defect in the continuity of the anterolateral left hemidiaphragm (white arrows, Fig.2b) in with intrathoracic herniation fo the stomach, seen\nmore clearly on reformatted images.",
    "discussion": "The majority of traumatic diaphragmatic hernias usually occur in young adults after a blunt trauma2. Injuries to the left hemidiaphragm are more frequent, and usually involve the\nposterolateral aspect of the hemidiaphragm3. Prompt recognition of a diaphragmatic rupture still poses a significant clinical and radiological challenge.Chest radiography remains the\ninitial screening tool4. The specific diagnostic findings of diaphragamatic tears on chest radiographs include intrathoracic herniation of hollow viscus and visualization of a nasogastric\ntube above the hemidiaphragm, although concurrent pulmonary abnormalities related to the trauma can mask these signs1. A helical CT scan has a sensitivity of 71% and a specificity of 100%\nin the detection of a diaphragmatic injuries1. Findings suggestive of hemidiaphragmatic tears include: direct discontinuity of the hemidiaphragm (the most sensitive sign); intrathoracic\nherniation of abdominal contents; the collar sign, a waistlike constriction of the herniating hollow viscus at the site of the tear; and the dependent viscera sign1, meaning that herniated\nviscera fall to a dependent position against the posterior ribs, since they are no longer supported posteriorly by the injured diaphragm. This latter sign represents an early indicator of\ndiaphragmatic tear before visceral herniation can be confidently diagnosed2. The recent trend towards nonoperative management of stable patients with blunt hepatic and splenic injuries may\nresult in diagnostic delays of concomitant diaphragmatic injuries2. Since cross-sectional imaging is routinely used to screen for internal injuries after blunt trauma, the knowledge of the\nabove described signs is essential for an early detection of diaphragmatic tears that otherwise may have been detected at surgery for concomitant lesions.",
    "differential_diagnosis": "Blunt, left, diaphragmatic, tear,10, cm, long, with, herniation, of, the, stomach.",
    "figures": [],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/2665",
    "time": "03.08.2007"
  },
  "2676": {
    "case_id": 2676,
    "title": "Left superior vena cava as an incidental finding in a 70-year-old man referred for lymphoma staging.",
    "section": "Chest imaging",
    "age": "70",
    "gender": "male",
    "diagnosis": "Asymptomatic left superior vena cava.",
    "history": "This case concerns a 70-year-old man referred to our department for staging of a lymphoma. No anatomic defects were found on doing a cardiological examination.",
    "image_finding": "A 70-year-old male patient, who had never been referred for a radiological examination, and who had been clinically diagnosed as having a lymphoma, established by doing a biochemical blood\nexamination, was referred to our department for tumor staging. A chest CT was performed and the left superior vena cava was revealed. Cardiological examination was performed afterwards, together with\ncardiac ultrasonography (images not available) which revealed the drainage of the vessel.",
    "discussion": "A persistent left SVC is thought to be the most common anomalous systemic condition to cardiac venous drainage. Its incidence is 0.3%, but it rises to 4.3% in patients with other congenital heart\ndiseases. It is most frequently found together with a right-sided SVC. An aberrant vein often connects the two cavae across the anterior mediastinum. It may be associated with drainage into the left\natrium, with an atrial septal defect, or with other lesions. As an isolated anomaly, it usually drains into the coronary sinus and causes no shunting of blood. The anomaly is due to persistence of\nthe embryonic left anterior cardinal vein. Failure of formation of the left innominate vein in the fetus also coexists. A partial anomalous pulmonary venous return via the left vertical pulmonary\nvein, which empties into the left innominate vein, is to be distinguished from the persistent left superior vena cava, with which it may be confused. On plain radiographs, the left SVC may appear as\na structure with a superadded density on the left side of the aorta. It appears to run vertically along the left superior mediastinum without obscuring the aortic knob. CT and MRI investigations can\ndemonstrate the vessel which courses laterally to the aortic arch and anteriorly to the left hilum. In the majority of patients, the vessel enters the coronary sinus of the right atrium which gets\nenlarged. The left superior intercostal vein swings around the aorta and enters the left SVC. Echocardiographic findings of the left SVC include dilation of the coronary sinus without a right atrial\nenlargement. The dilated coronary sinus can protrude into the left atrium. The diagnosis is definitively confirmed on performing contrast echocardiography. By injecting a contrast medium into a left\narm vein, the contrast will first appear in the coronary sinus, and it will later appear in the right atrium. Injection of an echo contrast into a right arm vein will opacify the right atrium without\nopacifying the coronary sinus.",
    "differential_diagnosis": "Asymptomatic, left, superior, vena, cava.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002676/000001.jpg?itok=lWVYaEb8",
            "caption": "The vessel (arrow) is seen descending on the left side of the aortic arch and the  pulmonary trunk."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002676/000002.jpg?itok=IcWxbv3r",
            "caption": "The left brachiocephalic vein is shown (arrow) immediately prior to the left superior vena cava formation."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002676/000003.jpg?itok=s6VJQ8gb",
            "caption": "The initial segment of the vessel is shown (arrow)."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002676/000004.jpg?itok=hw9n8NNu",
            "caption": "The initial segment of the vessel is shown (arrow) running on the left of the left common carotid artery. The mediastinal lymph nodes can also be seen."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002676/000005.jpg?itok=iSOSuhIl",
            "caption": "The left superior vena cava (arrow) is seen running on the left side of the aortic arch. The mediastinal lymph nodes can also be seen."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002676/000006.jpg?itok=t4AaTlHF",
            "caption": "The vessel (arrow) is seen immediately anterior to the left upper lobe pulmonary vein (lupv)."
          }
        ]
      },
      {
        "number": "Figure 7",
        "subfigures": [
          {
            "number": "Figure 7",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002676/000007.jpg?itok=bq3C-suh",
            "caption": "The vessel (arrow) is seen draining in the coronary sinus (confirmed by a cardiological US examination)."
          }
        ]
      },
      {
        "number": "Figure 8",
        "subfigures": [
          {
            "number": "Figure 8",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002676/000008.jpg?itok=QvUaQOgl",
            "caption": "The vessel (arrow) is seen draining in the coronary sinus (confirmed by a cardiological US examination)."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT",
      "CT",
      "CT",
      "CT",
      "CT",
      "CT",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/2676",
    "time": "03.03.2005"
  },
  "2819": {
    "case_id": 2819,
    "title": "Pleural fibroma (solitary fibrous tumour of the pleura)",
    "section": "Chest imaging",
    "age": "76",
    "gender": "female",
    "diagnosis": "Right sided pleural fibroma",
    "history": "Patient with cough and abnormal chest radiograph.",
    "image_finding": "The patient presented with a 2 year history of cough with dirty white sputum. There was no history of shortness of breath, chest pain, haemoptysis or weight loss. A chest x-ray (fig. 1) showed non-specific right basal shadowing. A CT scan (figs 2-5) of the thorax showed a huge lobulated mass filling the right lower lobe. This was biopsied under ultrasound guidance. The histology was reported as showing overall appearances of a solitary fibrous tumour of the pleura (pleural fibroma) with no evidence of malignant cells.",
    "discussion": "Pleural fibromas are rare tumours, accounting for less than 5% of all pleural neoplasms. They are derived from submesothelial mesenchymal cells but are not related to asbestos exposure. Approximately, half the patients with pleural fibromas are asymptomatic but cough, chest pain and dyspnoea may be presenting symptoms, particularly if the tumour is large. Hypertrophic osteoarthropathy (up to 35%) and hypoglycaemia (5%) are other well documented features. These tumours are usually slow growing and surgical excision is usually curative. Local recurrence is reported in about 16% of cases but malignant transformation is rare.\nPleural fibromas usually show soft tissue attenuation on unenhanced CT scans although higher attenuation values may occur due to the high physical density of the collagen content and prominent vascularity. This latter feature can bring about marked enhancement post intravenous contrast although in our case, the tumour enhanced less than the liver. \nMR images of the lesion would be expected to show intermediate to low signal change on T1-weighted images and low signal intensity on proton density and T2-weighted images. Enhancement post IV contrast would also be expected on MR. Calcification is seen in approximately 7% of these tumours. Rib erosion is rare.",
    "differential_diagnosis": "Right, sided, pleural, fibroma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002819/000001.jpg?itok=1fnJneJY",
            "caption": "Plain chest x-ray showing abnormal shadowing at the right lung base."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002819/000002.jpg?itok=SQq1YgIP",
            "caption": "Enhanced axial CT thorax on mediastinal windows showing huge lobulated enhancing soft tissue mass filling right lower lobe."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002819/000003.jpg?itok=P9mL4NDc",
            "caption": "Enhanced axial CT thorax on mediastinal windows showing huge lobulated enhancing soft tissue mass filling right lower lobe."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002819/000004.jpg?itok=pTy4y4I0",
            "caption": "Enhanced axial CT thorax on lung windows showing huge lobulated enhancing soft tissue mass filling right lower lobe."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002819/000005.jpg?itok=ocsqjuO5",
            "caption": "Enhanced axial CT thorax on lung windows showing huge lobulated enhancing soft tissue mass filling right lower lobe."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/2819",
    "time": "27.02.2004"
  },
  "2838": {
    "case_id": 2838,
    "title": "CT findings of malignant pulmonary metastasis in von Recklinghausen&#039;s disease",
    "section": "Chest imaging",
    "age": "62",
    "gender": "male",
    "diagnosis": "Relapse after exeresis (malignant schwannoma).",
    "history": "A 62-year-old male presented with von Recklinghausen's disease, who had been operated twice on a left axillary lesion and for pulmonary metastases.",
    "image_finding": "A 62-year-old male patient presented with von Recklinghausen's disease. This patient was followed up for an important dysfunction of his pulmonary parameters that correlated with his disease. The\npatient had been operated twice on a left axillary lesion and for pulmonary metastases.The follow-up CT exams showed that there was a relapse of the left axillary lesion (Fig. 1) and the presence of\na lesion in the right pulmonary hilum (3.5 x 3.6 cm in size) that compressed the main right bronchus and the right pulmonary vein (Fig. 2). Another lesion at the upper right costal pleura involving\nthe fissure was clearly visible (Figs. 3, 4). A subcutaneous lesion was detected in the posterior thoracic wall, under the scapula on the right side (Fig. 5). CT scans demonstrated the presence of\nsolid fusiform masses with often seen central areas of a low attenuation for the presence of lipid foci of schwann cells, cystic degenerations. The masses were usually well defined with attenuation\nvalues of 30\u201340 Hounsfield Unit (HU) (6,7). According to the National Institutes of Health (NIH), two types of neurofibromatosis are known to be defined: neurofibromatosis type 1 (NF1) also\nreferred to as von Recklinghausen's disease and neurofibromatosis type 2 (NF2) or bilateral eighth nerve schwannomas syndrome (1\u20133). NF1 is an autosomal dominant disorder with an almost 100%\npenetrance but a variable expression and with an incidence of one case per 3000\u20134000 people. The alternate gene locus is on the long arm of Chromosome 17, and it encodes for a protein named\nneurofibromin which acts as a tumour-suppressor oncogene (1).",
    "discussion": "Neurofibromatosis includes a group of heterogeneous conditions. In most individuals, the cutaneous findings are prominent and include caf\u00e9-au-lait spots (CAL), neurofibromas, and axillary or\ninguinal freckling (70% of the cases). Lisch nodules are iris melanotic hamartomas which are found in almost all adult patients on doing a slit-lamp examination (1). The diagnoses of NF1 are made if\ntwo or more of the following signs are found: the presence of six or more CAL larger than 5 mm dimensions in prepubertal children and larger than a size of 1.5 cm in postpubertal individuals; two or\nmore neurofibromas of any type or one plexiform neurofibroma; multiple freckles in the axillary or inguinal region; a distinctive osseous lesion, such as sphenoid dysplasia or thinning of the long\nbone cortex, with or without pseudoarthrosis; optic glioma; two or more iris hamartomas (Lisch nodules) seen on performing a slitlamp or biomicroscopy examination; a first-degree relative with NF1.\nNeurofibromas arise within or are attached to nerve trunks anywhere in the skin, in the body, and in the intracranial and intraspinal spaces. Histologically, neurofibromas comprise fibroblasts,\nSchwann cells that are predominant, and neurites. Multisystemic alterations are common, such as seizures and intellectual compromise, optic and acoustic involvement, intracranial and spinal tumours,\nan increased incidence of malignancies, congenital osseous defects, endocrine disorders, gastro-intestinal tract involvement, and vascular anomalies. The tumours are usually found to be benign but in\nabout 3% of the patients, nodular and plexiform neurofibromas transform to malignant peripheral nerve-sheath tumours (1,2,6,7). An X-ray scan was taken, which depicted the evident skull\nabnormalities, multiple frontobasal and osteoarticular defects and other bone deformities. A sonography when taken demonstrated that neurofibromas are mostly hyperechoic with coarse internal echoes\nand lobulated margins. Nonplexiform neurofibromas in NF1 appear as hypoechoic fusiform masses with relatively regular and well-defined margins. CT scans demonstrate these solid fusiform masses in the\ndistribution of nerves, with central areas of a low attenuation for the presence of lipid foci of schwann cells, cystic degenerations.The masses usually have values of 30\u201340 HU. Plexiform\nneurofibromas are depicted as widespread sheets of nodular tissue with attenuation values identical to the fusiform form. Paraspinal neurofibromas may be seen at every level, with various sizes. On\nmagnetic resonance imaging, we can observe intracranial neural sheath tumours as being isointense to brain tissue on T1-images and hyperintense to brain tissue on T2-images. After the administration\nof a contrast agent it is found that tumours enhance intensely. Both schwannomas and neurofibromas are hypointense or mildly hypointense compared to the spinal cord as seen on T1-images and\nheterogeneously hyperintense as seen on T2-images (6,7). The NF1 is a complex multisystemic disorder, and some alterations can coexist together. These tumours can represent a several pathological\nconditions such as abdominal aortic aneurysms, brain astrocytomas, artero-venous malformations idiopathic pulmonary fibrosis, neuroblastomas, parathyroid-adenomas, thyroid nodules, lymphomas,\nlymphangiomatosis, metastasis of an unknown primary tumour or lung tumour, etc. Paravertebral neurofibromas can extend into the spinal canal and mimic ganglioneuromas or cystic-formations (caused by\nmyxoid degeneration). A contrast agent is sometimes useful, but neurofibromatosis has the same features of a neoplasm. In all cases, it is fundamental to obtain the clinical aspects and the\npathological history of the patient and the clinical correlations and symptoms of the diseases mentioned above. When there are still doubts and the imaging features do not give a sure and clear\ndiagnosis, the biopsy of these lesions can demonstrate the nature of the lesion and propose a definitive diagnosis (6,7). In the case that we describe, there is relapse of the lesion after surgical\nexeresis (which proved it to be a malignant schwannoma) and also that there is an unusual association with pulmonary metastases (4,5).",
    "differential_diagnosis": "Relapse, after, exeresis, (malignant, schwannoma).",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002838/000002.jpg?itok=QOCLNcWn",
            "caption": "A CT image with contrast agent in the lung window showing the lesion in the right pulmonary hilum (3.5 x 3.6 cm) that compresses the main right bronchus and the right pulmonary vein isodense with respect to the nearer soft tissues. The fibrosis of the right lung with atelectasia areas and ground glass areas with some bubbles can be observed. The fibrosis is seen to be less evident in the left lung but the bubbles and the ground glass aspects are believed to be present anyway."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002838/000003.jpg?itok=9tsfq0ey",
            "caption": "A CT image with contrast agent in the lung window showing the lesion at the upper right costal pleura to be isodense with respect to the nearer soft tissues. Many big bubbles are believed to be present, especially to the right near the mediastinum and the costal pleura."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002838/000004.jpg?itok=3FS_GeLD",
            "caption": "A CT image with contrast agent in the lung window showing the lesion at the upper right costal pleura involving the fissure.The pulmonary formation is seen to have the same density as that of the soft tissue. Tthe pulmonary fibrosis that destroys the normal interstitial ramifications is seen."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002838/000005.jpg?itok=h4ix_keP",
            "caption": "A CT image with contrast agent in the mediastinum window showing the lesion in the posterior thoracic wall, under the scapula on the right. Another neurofibroma is seen in the left thoracic wall, a little ovoid formation with precise edges. These formations are seen to have the same soft tissue density. In the right lung, atelectasia alterations with fibromatous  components and several mediastinum linphonodes are seen."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002838/000006.jpg?itok=t8zJJKb1",
            "caption": "A CT image with contrast agent in the mediastinum window showing a relapse of the left axillary lesion and the lesions at the upper right costal pleura. These formations are believed to be quite isodense with respect to the nearer soft tissues but a weak light contrast enhancement can be recognised in their context. The  axillary lesion is seen to be well delimitated but with no precise edge. Instead the costal lesions do not seem to be very well delimitated and they involve the costal structures."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT",
      "CT",
      "CT",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/2838",
    "time": "28.12.2005"
  },
  "2847": {
    "case_id": 2847,
    "title": "Azygos vein dilatation in a patient with scimitar syndrome",
    "section": "Chest imaging",
    "age": "21",
    "gender": "female",
    "diagnosis": "Azygos vein dilatation in scimitar syndrome.",
    "history": "A case of azygos vein dilatation in a 21-year-old female with scimitar syndrome is presented. Scimitar syndrome and azygos vein dilatation (13 mm) were detected on doing a chest X-ray, CT angiography\nand MR angiography. To our knowledge, this is the first such case reported in the literature for azygos vein dilatation in a patient with scimitar syndrome.",
    "image_finding": "A 21-year-old woman was admitted to our clinic. During her childhood she had a history of pneumonia only once, and she did not have any other health problems. On doing a physical examination, her\nbreath sounds were found to be diminished over the right side of the chest. There was no rale, rhonchi or any pathologic breath sounds. A chest radiograph was taken, which revealed a loss of volume\nof the right lung, with narrowed intercostal spaces and a diminished right hilar shadow. The trachea and the heart were noted to be displaced to the right. A curved shadow, near the right heart\nborder, descending to the right diaphragm was also observed. It was noted that the right hemidiaphragm was 7 cm more elevated than the left hemidiaphragm. The left lung fields seemed to be normal\n(Fig. 1). A spiral computed tomographic angiography scan was performed, which confirmed the presence of a small right lung and hypoplastic right pulmonary artery, tracheal deviation to the right, a\nslight shift to the mediastinum to the right side and an azygos vein of a 13 mm diameter, which is almost equal to that of the neighbouring thoracic aorta diameter of 17 mm. Furthermore, the\npulmonary vein appeared characteristically as a broad band at the right lung base, paralleling the right heart border and extending to the subdiaphragmatic area and drained IVC (Fig. 2). On MR\nangiography, the IVC could be seen at the infradiaphragmatic part of the pulmonary vein, which drains into the right lower lobe. Also on MR angiography, the azygos vein was seen as being dilated and\nwas seen to be combined with the superior vena cava at the level of the arcus aorta (Fig. 3).",
    "discussion": "The scimitar syndrome is a rare complex disorder that has been known as pulmonary venolobar syndrome, hypogenetic lung syndrome, and right pulmonary artery syndrome. The incidence is estimated to be\none to three per 100,000 births. Females are involved more often than males (M:F=1:1.4). It can be silent clinically for a long time. The syndrome can be without any symptom or can be also severe\n(1). The main components of the syndrome are hypoplasia of the right lung, anomalous tracheobronchial tree, displacement of the heart to the right, hypoplasia of the right pulmonary artery, anomalous\nsystemic arterial supply to all or parts of the lung, cardiac anomalies and eventration of the right hemidiaphragm (1\u20133). The small pulmonary vein usually drains into the infradiaphragmatic\ninferior vena cava. Also, drainage into the right atrium, hepatic veins, the azygos or portal vein and the left atrium has been reported (2). As in our case, there is usually one vessel that drains\ntotal or part of the right lung and terminates at a subdiaphragmatic position. Most commonly, secundum type atrial septal defects and also tetralogy of Fallot, ventricular septal defects, aortic\ncoarctation, patent ductus arteriosus, hypoplasia of the left side of the heart can be seen together with this syndrome (1,2). Normally, the maximum diameter of the azygos vein is 7 mm, but in our\ncase, it was about 13 mm as seen on CT angiography and MR angiography (4). Pregnancy, congestive heart failure, portal hypertension, anomalous continuation, and obstruction, absent or idiopathic\naneurysms of the superior or inferior vena cava are causes of azygos vein dilatation. Azygos vein dilatation is due to the progress of collateral circulation dependent on a functional insufficiency\nof the VC (1\u20135). Presumably, in our case, abnormal anastomosis of the pulmonary vein to the inferior vena cava causes an increased blood volume in IVC and this condition may result with the\nazygos vein dilatation. In the differential diagnosis, McLeod\u2019s syndrome should be taken into consideration. Small pulmonary arteries on the affected side can be seen with both disorders.\nAbnormalities of the right hemidiaphragm include eventration, Bochdalek hernia, and accessory leaf of the hemidiaphragm and must be differentiated from diaphragmatic paralysis. For a definitive\ndiagnosis, although angiography is needed, noninvasive methods such as CT angiography or MR angiography demonstrate related vascular structures and may lead to diagnosis. As in our case, most\npatients with scimitar syndrome can be managed conservatively.",
    "differential_diagnosis": "Azygos, vein, dilatation, in, scimitar, syndrome.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002847/000001.jpg?itok=1TwaMPWC",
            "caption": "A posteroanterior chest radiograph showing a loss of the volume of the right lung, narrowed intercostal spaces, and a diminished right hilar shadow, to the right shift at the mediastinum. A curved shadow seened to be showing anomalous pulmonary venous return near the right heart border (indicated by an arrow). The right hemidiaphragm more elevated than the left hemidiaphragm."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002847/000004.jpg?itok=yMsl4vhr",
            "caption": "A spiral computed tomographic angiography scan showing a dilated azygos vein (indicated by a large arrow) and an anomalous pulmonary venous return (indicated by a white arrow) returning to the inferior vena cava."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002847/000007.jpg?itok=IIdxPGVr",
            "caption": "MRA showing a dilated azygos vein and anomalous pulmonary venous return to the inferior vena cava. Inferior point of view to demonstrate the component of the main structures: arcus aorta (AA), azygos vein (AV), hemiazygos vein (HAV), left pulmonary arteria (LPA), left pulmonary vein (LPV), inferior vena cava (IVC), right pulmonary vein (RPV)."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT",
      "MR-Angiography"
    ],
    "link": "https://www.eurorad.org/case/2847",
    "time": "13.01.2006"
  },
  "2850": {
    "case_id": 2850,
    "title": "Bronchoperitoneal fistula complicating perforated duodenal ulce",
    "section": "Chest imaging",
    "age": "40",
    "gender": "male",
    "diagnosis": "Bronchoperitoneal fistula",
    "history": "Percutaneous drainage of a subphrenic abscess.",
    "image_finding": "This man was admitted with a right subphrenic abscess, having had an uneventful surgical repair of a perforated duodenal ulcer a few weeks previously.\nThis was drained under CT guidance and the patient discharged a few days later.\nHe was readmitted to hospital with right upper quadrant and right shoulder tip pain. Reaccumulation of the right subphrenic abscess and right lower lobe consolidation was confirmed at CT and insertion of a pigtail catheter was performed simultaneously. A tubogram performed to show cavity size unexpectedly revealed a right bronchoperitoneal fistula and the patient expectorated contrast during the examination. A water-soluble contrast meal found no evidence of a duodenal leak or fistula.\nBronchoscopy showed right middle lobe secretions and no other abnormality. A right postero-lateral thoracotomy was performed and a 5-cm abscess crossing the right hemi-diaphragm into the right subphrenic space was found and drained and adhesions and a fistula between the right lower lobe and right diaphragm were divided. He made and uneventful recovery and was discharged home.",
    "discussion": "Case reports of bronchoperitoneal fistula secondary to perforated duodenal ulcer are uncommon. In this case a subphrenic abscess secondary to perforated duodenal ulcer with erosion of the diaphragm and fistulous communication with the bronchial tree is likely to have occurred. Surgical debridement of the subphrenic abscess and division of the fistula was necessary in this case; however, a case report of conservative management of transdiaphragmatic fistula with percutaneous drainage of subphrenic abscess with successful outcome has been cited (1). Another case report has discussed bronchoperitoneal fistula secondary to chronic Klebsiella pneumoniae subphrenic abscess (2).\nBronchial fistulae can occur with structures within and outside the thorax, the commonest form being bronchopleural fistula usually after lobectomy or pneumonectomy for pulmonary malignancy. Stump failure due to dehiscence of sutures and infection is the commonest origin of a fistula. The principal causes of bronchial fistula are infection and carcinoma, with trauma and inflammatory processes being less common causes.\nFormation of bronchial fistulas with abdominal viscera is rare and colobronchial fistula develops mostly due to abdominal sepsis and subphrenic abscess, with colonic carcinoma and Crohn\u2019s disease being less common causes.",
    "differential_diagnosis": "Bronchoperitoneal, fistula",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002850/000001.jpg?itok=3cZcznzz",
            "caption": "Right subphrenic abscess."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002850/000002.jpg?itok=CwaIvmAL",
            "caption": "Fluid attenuation subphrenic collection."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002850/000003.jpg?itok=D08YhLRW",
            "caption": "Right lower lobe consolidation above the subphrenic collection."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002850/000004.jpg?itok=5FoygWb-",
            "caption": "Contrast fills a small residual subphrenic cavity and crosses the diaphragm via a fistula into the right lower lobe bronchial tree."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "Ultrasound",
      "CT",
      "Digital radiography"
    ],
    "link": "https://www.eurorad.org/case/2850",
    "time": "07.03.2004"
  },
  "2908": {
    "case_id": 2908,
    "title": "Scimitar syndrome: Radiographic and CT findings",
    "section": "Chest imaging",
    "age": "65",
    "gender": "male",
    "diagnosis": "Scimitar syndrome.",
    "history": "A patient was presented for a routine check-up and no clinical problem was found to exist.",
    "image_finding": "The patient was referred to our department for a routine check-up without any clinical problem. The patient\u2019s history was also clear. A Posterior-Anterior (PA) chest radiograph was taken and a\ncurvilinear tubular, soft tissue density parallel to the right heart border was revealed (Fig. 1). Scimitar syndrome was considered the most likely diagnosis. Computed Tomography (CT) was performed\nfor a further evaluation of the lesion. Plain CT and contrast enhanced CT (Fig. 2) confirmed the vascular nature of the lesion and formed the basis for the diagnosis. Sagittal reconstruction of CT\nimages with a contrast agent (Fig. 3) clearly demonstrated the course of this anomalous vein, which descends vertically into the lung and curved frontally to enter the inferior vena cava (IVC) below\nthe diaphragm (Fig. 4). No other associated anomalies were revealed.",
    "discussion": "The scimitar syndrome [also known as the hypogenetic lung syndrome, epibronchial right pulmonary artery syndrome (Richter K. et al, 1967) or mirror image lung syndrome (Dalith F. and Neufeld H.,\n1960)] is a rare, complex, congenital disorder almost exclusively affecting the right lung. (1) It was first described by Cooper and Chassinat in 1836. (2) The term congenital venolobar syndrome was\nfirst intro duced by Felson B. in 1972. (3) The incidence is estimated to be 1\u20133 per 100,000 births; however, the true incidence is unknown as the syndrome can remain asymptomatic. (2) The term\n\u201cscimitar syndrome\u201d [first introduced by Halasz et al. in 1956 due to its similarity with the Turkish sword (Fig 5)] implies the presence of an anomalous pulmonary vein with drainage\nbelow the diaphragm (IVC, hepatic veins, portal vein or azygos vein). In rare cases, it directly enters into the right atrium or coronary sinus. (1, 4, 5) The most common components of the congenital\npulmonary venolobar syndrome are hypogenetic lungs and anomalous pulmonary venous return (1, 5) Other less constant components are anomalous arterial supply of the right lower lung, smaller or absent\nright pulmonary artery, horseshoe lung, sequestration, tracheobronchial abnormalities (tracheal stenosis or diverticulum, bronchiectasis), accessory diaphragm, hepatic herniation and rarely absent\nIVC. (1, 4) Approximately 25% of patients present with congenital heart disease, most commonly septal defects. (2, 4) When isolated, scimitar syndrome is compatible with normal life, as a left to\nright shunt is not of clinical magnitude. (1, 4) It is usually detected incidentally and needs no therapeutic intervention. In cases of associated abnormalities and severe clinical problems,\noperative repair is considered mandatory. The preoperative assessment includes some form of angiography (DSA, CTA or MRA) for a detailed evaluation of pulmonary arteries and veins. Finally, surgical\nreconstruction of any congenital anomaly and re-implantation of the abnormal vein directly to the left atrium may be performed.",
    "differential_diagnosis": "Scimitar, syndrome.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002908/000007.jpg?itok=knodQxZL",
            "caption": "A PA chest radiograph demonstrating  a curvilinear soft tissue density (arrow)  parallel to the right heart border."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002908/000008.jpg?itok=WM3sh6MM",
            "caption": "A computed tomography images before and after contrast agent administration demonstrating the vascular nature of the lesion (arrows)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002908/000009.jpg?itok=G0B6I4Y4",
            "caption": "Sagittal reconstruction of CT images with a contrast agent revealing the course of the anomalous vein (arrows)."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002908/000010.jpg?itok=ONZOG3Ry",
            "caption": "The anomalous pulmonary vein (arrow) crossing the right diaphragm and entering the IVC."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/2908",
    "time": "13.01.2006"
  },
  "2919": {
    "case_id": 2919,
    "title": "Aspergilloma causing Pneumopericardium and Death",
    "section": "Chest imaging",
    "age": "21",
    "gender": "female",
    "diagnosis": "Invasive Aspergillosis and Aspergilloma causing Pneumopericardium.",
    "history": "History of inoperable carcinoma of the cervix, on chemotherapy, became neutropenic. Admitted to ITU with respiratory distress secondary to invasive aspergillosis, developed cavitating lung lesion which eroded through the mediastinum into the pericardium causing cardiac arrest and death.",
    "image_finding": "A 21 year old female presented to the Intensive Care Unit with severe breathlessness. She was found to be neutropenic as a result of the chemotherapy she had been receiving for a recent diagnosis of inoperable carcinoma of the cervix. She was not known to have any pre-existing lung condition. Initial chest radiograph showed bronchopneumonia. She was ventilated and treated empirically for bacterial and fungal chest infection. Her condition improved during the first week, and antifungal and antibacterial drugs were discontinued. \nOver the next week her condition deteriorated with chest radiograph findings compatible with widespread bronchopneumonia.  As sputum culture was repetitively normal a bronchoscopy was carried out. Bronchoscopic washings grew aspergillus fumigatus and she was recommenced on antifungal drugs. Her condition failed to improve and a CT scan was carried out which demonstrated a large cavitating lesion within the right lung in close proximity to the mediastinum.  The following day she went into EMD cardiac arrest in which initial CPR was successful.  A chest radiograph taken immediately afterwards revealed pneumopericardium and bilateral pneumothoracies. Intercostal drains were inserted as a last resort but she died shortly afterwards.\nThe clinical suspicion was that the cavitating lesion had eroded through the mediastinum into the pericardial space. \nThe clinical picture, imaging findings and post-mortem were in keeping with the initial diagnosis of invasive Aspergillosis causing an area of lung parenchymal infarction in which an Aspergilloma developed. This later eroded through the mediastinum into the pericardium.",
    "discussion": "Aspergillosis is regarded as a spectrum of disease usually due to Aspergillus fumigatus in the lungs with three major components:\n1)\tMycetoma(Aspergilloma) \u2013 usually in a pre-existing cavity and commonest form of  pulmonary involvement due to Aspergillus\n2)\tInvasive Pulmonary Aspergillosis(IPA) \u2013 mainly in neutropenic patients \n3)\tAllergic Bronchopulmonary Aspergillosis \u2013 due to hypersensitivity to the fungus.\n\nIPA was first described in 1953. The vast majority of IPA occurs in immunocompromised hosts and neutropenia in particular is the most important predisposing factor. The fungus erodes the lung parenchyma and other associated structures.\nThe chest radiograph findings are often variable and show non-specific changes. Lesions that are suggestive of IPA include ill-defined rounded areas of consolidation, often with pronounced air-bronchograms. Wedge shaped consolidations have been described, due to infarction secondary to vascular invasion. Areas of cavitation (often with the Air \u2013 Crescent sign) and rarely a miliary pattern can also occur. \nThe use of HRCT in IPA patients has been shown to be associated with a more favourable outcome, probably due to earlier diagnosis. Chest CT is more sensitive than plain film and findings range from multiple nodules to the \u2018Air- Crescent\u2019 sign and the \u2018Halo\u2019 sign. These two important signs on CT are characteristic of IPA.\nThe Air-Crescent sign occurs when air fills the space between and area of necrotic tissue and the surrounding lung parenchyma. The crescent becomes apparent when there is an opaque layer of haemorrhagic tissue peripheral to the air. This sign relies on neutrophil function and only occurs during marrow recovery, so is a late sign. It is estimated to be evident in 50% of cases.\nDuring the neutropenic period the Halo sign may be seen on CT as an area of ground glass around a pulmonary nodule, which is representative of pulmonary haemorrhage. \nAspergilloma is a fungal ball that has developed in an area of damaged lung, usually due to Tuberculosis or other chronic lung conditions. It has been described in cavities caused by other fungal infections. An Aspergilloma may be asymptomatic for years or it may cause haemoptysis due to invasion of local blood vessels, rarely it invades lung parenchyma.\nRadiologically, Aspergilloma is a Mid \u2013 Upper lobe cavity sometimes seen with a crescent of air. An interesting sign that may occur is the variation in the position of the central mass with a change in position of the patient. Aspergilloma may be present but not evident on the plain radiograph. CT is more sensitive at picking up Aspergilloma. Surgical treatment of Aspergilloma carries a relatively high mortality.\nPneumopericardium can be differentiated from pneumomediastinum on the plain radiograph. In the latter, the air tracks around the aortic knuckle, this is not seen in pneumopericardium.",
    "differential_diagnosis": "Invasive, Aspergillosis, and, Aspergilloma, causing, Pneumopericardium.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002919/000001.jpg?itok=q5y78YeC",
            "caption": "Thorax CT scan demonstrating a right sided upper lobe cavitation. Also widespread consolidation and bilateral pleural effusions can be seen."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002919/000002.jpg?itok=PPRVJc6A",
            "caption": "HRCT image demonstrating the Right sided cavity in close proximity to the mediastinum.  Also present are widespread consolidation and bilateral pleural effusions."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002919/000003.jpg?itok=5TRSzUKC",
            "caption": "Plain Chest Radiograph taken after cardiac arrest. Bilateral pneumothoracies can be seen and also Pneumopericardium. This can be differentiated from pneumomediastinum by the lack of air around the aortic knuckle."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002919/000004.jpg?itok=6dItAHRi",
            "caption": "The mycetoma is clearly demonstrated in the medial aspect of the right lung close to the mediastinum."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002919/000005.jpg?itok=dvpAXEEI",
            "caption": "This section demonstrates the inner aspect of the pericardium with the heart removed. The black arrow points out the 3mm hole where the aspergilloma eroded into the pericardium."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/2919",
    "time": "04.05.2004"
  },
  "2944": {
    "case_id": 2944,
    "title": "Bronchopulmonary dysplasi",
    "section": "Chest imaging",
    "age": "7",
    "gender": "male",
    "diagnosis": "Bronchopulmonary dysplasia.",
    "history": "A young boy presented with a failure to thrive. He had been born pre-term and required supplementary oxygen therapy for the first few months of life. At the age of six months, he developed Rous\nSarcoma Virus (RSV) bronchiolitis.",
    "image_finding": "The patient was born at 25 weeks gestation, and weighed 970 g. During the first week, he developed increasing respiratory problems and required ventilation for 10 days. Following extubation, he had a\nprolonged period of oxygen dependence. At six months, while still in the neonatal unit, he developed RSV bronchiolitis. He left the neonatal unit at the age of nine months and was recommended to\nundergo home oxygen therapy, which was required until he was three and half years. At the age of seven, he was referred for further assessment due to a failure to thrive. He weighed 15 kg, had a\nheart rate of 90 and a respiratory rate of 20. Respiratory and cardiovascular examinations done were otherwise found to be unremarkable. A CXR, echocardiogram, overnight saturation monitoring and\nblood tests were found to be normal. Due to his respiratory problems, at around the time of birth, a CT scan of the chest was performed. The CT scan found to be showed low attenuation areas\nthroughout both lungs which were associated with decreased vessel markings. Only the middle lobe and lingula had a normal attenuation. The findings were consistent with a diagnosis of\nbronchopulmonary dysplasia. The differential diagnosis made suggested obliterative bronchiolitis, but there were no real bronchial abnormalities to support this.",
    "discussion": "Bronchopulmonary dysplasia (BPD) was first described in 1967 in prematurely born infants with severe respiratory distress (RDS) and who were treated with intermittent positive pressure ventilation\nand oxygen supplementation. With advances in treatment, the clinical and radiological presentation has changed, and the condition is now commonly referred to as chronic lung disease of infancy (CLD).\nThe condition affects 3000\u20137000 neonates in the United States each year of which only 4000 survive infancy. Most of these neonates live on to reach adult life. The incidence of BPD has\ndecreased with the advent of modern therapy, although with an increasing number of survivors, the total number of cases has remained the same. The current criteria used for diagnosis are (1) Positive\npressure ventilation during the first two weeks of life for a minimum of three days. (2) Clinical signs of respiratory compromise persisting for more than 28 days of age. (3) Requirements for\nsupplemental oxygen for more than 28 days of age to maintain a PaO2 above 50 mmHg. (4) Chest X-ray examinations with findings consistent with BPD. The four major risk factors for the development of\nBPD are: (1) Premature birth, (2) Respiratory failure \u2013 of any cause, (3) Oxygen supplementation, (4) Mechanical ventilation. Although known to be very common in patients with BPD, RDS is not\nan absolute precursor to the disease. With the advances in neonatal care, the disorder now most frequently occurs in infants weighing <1 kg. The precise aetiology of BPD is unknown, although it is\nalmost certainly multifactorial. The elevated oxygen concentrations lead to the production of oxygen free radicals and the release of chemotactic factors that attract polymorphonuclear leucocytes.\nThis results in an inflammatory reaction and the release of proteolytic enzymes. Pre-term babies have lower levels of anti-oxidant enzymes, increasing the susceptibility to lung oxygen toxicity.\nVentilation causing repeated stretching of the immature lung has also been strongly implicated, as has the arrest of normal lung development in very pre-term babies. Histological examinations\nrevealed squamous metaplasia of the large and small airways, peri-bronchial and peri-bronchiolar fibrosis, obliterating fibroproliferative bronchiolitis and prominent hypertrophy of smooth muscle. A\ndestruction of elastin fibres, which provide the structural support for the alveolar septal development, is seen. The radiological findings have changed over the last 30 years due to an improvement\nin the treatment. The plain film findings of progressive reticular and cyst-like shadowing with hyperexpansion are now rarely seen. Both radiographic and pulmonary functions tend to improve with age.\nThe CT findings include areas of reduced lung attenuation and perfusion with a decrease in the size and number of vessels. Bronchial wall thickening, decreased diameter in the ratio of bronchus to\npulmonary artery, linear opacities and bullae are also described. The areas of reduced attenuation may be due to small airway obstruction, decreased bronchial diameter and arrested acinar\ndevelopment. The treatment for BPD includes steroids, surfactant therapy, modified ventilatory techniques, fluid restriction, appropriate nutrition, diuretics, bronchodilators and RSV prophylaxis.\nTwo recent long term studies indicate that the survivors of BPD were twice as likely to be hospitalised in the first 2 years of life as compared with pre-term infants without BPD. Pulmonary function\nwas also worse but a study in 1990 of young adults with prior BPD showed the pulmonary dysfunction to be asymptomatic. However, since the introduction of new neonatal techniques no long term\nassessment has been possible.",
    "differential_diagnosis": "Bronchopulmonary, dysplasia.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002944/000001.jpg?itok=baTMW9EN",
            "caption": "Figs. 1a-c demonstrates a mosaic lung pattern with areas of reduced attenuation associated with decreased vascularity."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002944/000002.jpg?itok=ol3pLWOx",
            "caption": "See the legend for 1a."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000002944/000003.jpg?itok=PCINZ5e3",
            "caption": "See the legend for 1a."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/2944",
    "time": "11.04.2005"
  },
  "2981": {
    "case_id": 2981,
    "title": "Solitary fibrous tumour of the ple",
    "section": "Chest imaging",
    "age": "54",
    "gender": "male",
    "diagnosis": "Solitary fibrous tumour of the pleura.",
    "history": "A 54-year-old male patient with a history of ischaemic heart disease presented with chest discomfort.",
    "image_finding": "A 54-year-old male patient, with a history of ischaemic heart disease, presented with chest discomfort. A chest X-ray was performed which showed a large rounded opacity in the left mid-zone with a\nsharp lower border and indistinct upper border characteristic of an en face pleural mass. A contrast enhanced CT scan was done, which showed the presence of a fairly large well defined lobulated mass\nof soft tissue density in the right hemithorax, posteriorly, measuring 7.5 x 6 cm, and abutting the posterior chest wall. The margins made an acute angle with the chest wall, but the tapering edges\nof the pleura were well demonstrated. The mass showed a homogeneous enhancement interspersed with streaks of dense contrast. There was no evidence of chest wall invasion, pleural effusion or\nmediastinal lymphadenopathy. At surgery, the tumour was found to be arising from the confluence of the oblique and horizontal fissures. The absence of chest wall invasion and lymphadenopathy was\nconfirmed. The appearances revealed the presence of a benign tumour. Histopathology showed morphological features of a solitary fibrous tumour of the pleura, which was supported by the strong\nexpression of CD34 antigen.",
    "discussion": "Solitary fibrous tumour of the pleura is also known as pleural fibroma or benign mesothelioma. Most investigators now believe that the tumour originates from the submesothelial connective tissue of\nthe either the parietal or the visceral pleural surface. They usually arise over the convexity of the lung. An uncommon tumour it is slightly more common in females than in males. There is no age\npredilection although the mean age at presentation is around 50 years. There is no known aetiology and there is no association with asbestos exposure or smoking. Although the neoplasm is\nhistologically and biologically benign, malignant forms exist and in some cases distinction between the two is difficult, if not impossible. Most patients are asymptomatic. Occasionally they may have\ncough, chest pain or dyspnoea. Hypertrophic osteo-arthropathy occurs in up to 20% of cases. A rare feature is symptomatic hypoglycaemia associated with the expression of insulin-like growth factor I\nor II by the tumour. This is more common in malignant than in benign tumours. A majority of these tumours arise in relation to the visceral pleura. They are well circumscribed and attached to the\npleura by a short pedicle. Occasionally, tumours in the medial pleura extend into the mediastinum and those in the fissures extend into the pulmonary parenchyma, especially when they are large.\nHistology shows haphazardly arranged, interlacing fascicles of spindle cells, with collagen interspersed between the cells. Large tumours may show focal myxoid degeneration and fibrous tissue\nhyalinisation. Immunohistochemistry is characteristically positive for CD34 and vimentin and negative for cytokeratin. This is useful when histology is in doubt, to differentiate from malignant\nmesothelioma, which is positive for cytokeratin and negative for CD34. On imaging, the tumour is sharply defined, lobulated and of homogeneous density. The size may range from 1 to 40 cm. It is\nlocated in relation to the interlobar fissure/ adjacent to the diaphragm / mediastinum or the chest wall. Small lesions have a broad base towards the pleura and frequently form obtuse angles with the\nchest wall. Howvever when the tumour is large (more than 4 cm) they often form acute angles and it is difficult to determine the site of origin. Pedunculated tumours may show a change in position\nwith respiration, needling or change of posture. Calcification within the mass and pleural effusion are rare. Even on a CT scan, it is seen that most tumours that are more than 5 cm form acute angles\nwith the chest wall. A smooth tapering pleural margin and the displacement of adjacent lung parenchyma are helpful signs in determining the extrapulmonary origin. The benign tumour appears low in T1-\nand T2-weighted MRI scans, due to the presence of fibrous tissue. In presence of foci of necrosis or haemorrhage, there may be areas bright signal on the T2-weighted images. The fibrous tissue\nenhances on gadolinium administration. The prognosis involves the performance of a surgery, which is curative. The majority of the tumours are benign, with a small percentage of them being malignant,\nrecurring locally. Pleural effusion, chest wall invasion and origin from the parietal pleura are suspicious signs for malignant transformation.",
    "differential_diagnosis": "Solitary, fibrous, tumour, of, the, pleura.",
    "figures": [],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/2981",
    "time": "19.12.2005"
  },
  "3028": {
    "case_id": 3028,
    "title": "Paravertebral extramedullary plasmacytom",
    "section": "Chest imaging",
    "age": "56",
    "gender": "female",
    "diagnosis": "Paravertebral soft tissue solitary plasmacytoma.",
    "history": "A 56-year-old female patient with dorsal pain irradiated to the right thoracic area. On doing a clinical examination, it was diagnosed as being due to the presence of a soft tissue mass on the right\nscapular area.",
    "image_finding": "A 56-year-old female patient, with no clinical history of interest, came to our hospital with dorsal pain that irradiated to the right costal area. She also complained of asthenia and a palpable mass\non the right scapular area. The physical examination revealed a soft tissue mass on the right subscapular region. A PA thoracic X-ray scan was performed, ando showed an extrapulmonary masson the\nright hemithorax, with an approximate size of 10\u201320 cm. The thoracic CT with intravenous contrast revealed a significant mass with no marked enhancement, localized on the right hemithorax that\ngot through the thoracic wall and penetrated the vertebral foramen. No bone destruction was noted. Subsequently, an MRI of the dorsal spine was performed, showing a voluminous pre and paravertebral\nneoformation, affecting fundamentally paravertebral soft tissues, with no fat suppression and no medullary component being clearly observed. Immunohistochemistry studies that were done detected a\nmonoclonal Ig G chain (Lambda subtype), and a Lambda light chain. After performing a surgical biopsy, the definitive diagnosis was an immature extramedullary plasmacytoma.",
    "discussion": "The extramedullary plasmacytoma is known to be a rare tumor and it is characterized by plasmatic cell proliferation. It is included in the entity known as Monoclonal Gammopathies, with the multiple\nmyeloma and the solitary plasmacytoma of the bone.\nThey represent 5%\u201310% of all plasmatic cell illnesses, and the extramedullary plasmacytoma is different from the other two entities, because it is settled in the soft tissues and it does not\naffect the bone.\nThe extramedullary plasmacytoma is known to be a very infrequently encountered condition, and it is localized most commonly in the upper respiratory tract, where it represents only 0\u201316% of all\nthe malignant neoplasies of this localization. Also, in all the literature that we had referred to, we have not found any case reports that deal with extramedullary plasmacytomas in the paravertebral\nsoft tissues, and this is the reason for our interest in this case.\nWhen immunohistochemistry techniques are performed, it is characterized by an elevation of the Ig G, lambda subtype, and it indicates the malignancy of the tumor.\nThe imaging techniques allow the localization of the tumor, its characterization as a solid mass, and confirms that there is no bone affection. The definite diagnosis of these lesions is\nanatomopathological.",
    "differential_diagnosis": "Paravertebral, soft, tissue, solitary, plasmacytoma.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003028/000001.jpg?itok=oGBkiiFG",
            "caption": "A PA thoracic X-ray image that shows a high-density mass located on the right hemithorax with an approximate size of 10--12 cm."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003028/000002.jpg?itok=smCdeZI0",
            "caption": "A lateral X-ray image showing the extrapulmonary origin of the mass."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003028/000003.jpg?itok=-K7vcgEd",
            "caption": "Thoracic CT image: soft tissue mass with no significant enhancement located on the right hemithorax, penetrating the thoracic wall. No bone destruction is seen."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003028/000004.jpg?itok=GWJhJU7H",
            "caption": "Thoracic CT image: The mass goes through the vertebral foramen."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003028/000005.jpg?itok=HghM4coa",
            "caption": "An axial T2 image showing a hiperintense voluminous pre and paravertebral neoformation that goes through the vertebral foramen."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003028/000006.jpg?itok=BSWqe6y_",
            "caption": "A sagittal T2 image: The hiperintense mass goes through several vertebral foramens."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003028/000007.jpg?itok=dE8e7luu",
            "caption": "An axial T2 image: The mass fundamentally affects the paravertebral soft tissues. There is no medullary component clearly seen."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT",
      "MR"
    ],
    "link": "https://www.eurorad.org/case/3028",
    "time": "19.02.2008"
  },
  "3129": {
    "case_id": 3129,
    "title": "Meandering pulmonary vein syndrome",
    "section": "Chest imaging",
    "age": "32",
    "gender": "male",
    "diagnosis": "Meandering vein syndrome.",
    "history": "A 32-year-old male, who was a HIV seropositive patient, presented with a right pulmonar hilum tumefaction. Imaging investigations were performed to precisely evaluate.",
    "image_finding": "This patient had a history of esophageal and anal congenital malformations. He was diagnosed with HIV seropositivity after a blood donation. He was a healthy man with no clinical complaints. A\ncardiopulmonary examination was found to be normal. His chest X-ray on admission showed an enlarged right hilum. A lymphadenopathy was suspected, and an enhanced CT-scan was performed. It\ndemonstrated an abnormal pulmonary vascularity with a right superior vein (RSPV) coursing posterior to the bronchus intermedius, then joining the ipsilateral inferior vein, forming a common trunk.\nThis one normally entered the left atrium. There was no abnormal lymph node present. A complementary MR scan with three dimensional contrast-enhanced magnetic resonance angiography was performed in\norder to eliminate the possibility of any associated cardiovascular malformation. The MR scan confirmed an isolated anomalous course of the right superior pulmonary vein.",
    "discussion": "Anomalous venous pulmonary return (AVPR) is defined by the presence of one or more than one pulmonary veins not connected with the left atrium. Different variations have been described. Total AVPR is\nalways associated with an atrioseptal defect and requires immediate surgery at birth. Various clinical manifestations can reveal partial AVPR; they depend on the degree of abnormal return and the\npresence or absence of an atrioseptal defect. In this case, there was no abnormal venous return. The pulmonary blood from the right upper lobe drains normally into the left atrium via a large trunk.\nThis abnormal venous course is named \"meandering pulmonary vein\". It has been described in association with right pulmonary hypoplasia and the appearance of a scimitar radiological sign. The\n\"meandering vein\" can be considered a variant of the scimitar syndrome, even though in this case, there was no abnormal venous return at all. It can be included as part of a multiple malformation\nsyndrome such as in this patient. Of course, no treatment was necessary in this patient. A gadolinium enhanced-MRA procedure provided a clear depiction of the abnormality, and a fine explanation of\nthe abnormal X-ray.",
    "differential_diagnosis": "Meandering, vein, syndrome.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003129/000001.jpg?itok=UFB7fJ7e",
            "caption": "A posteroanterior chest X-ray showing an enlarged right hilum."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003129/000002.jpg?itok=WCsvxgj5",
            "caption": "A spiral CT image showing the arch of the right superior pulmonary vein visible posterior to the bronchus intermedius."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003129/000003.jpg?itok=dEmLXwEk",
            "caption": "A spiral CT section (5 mm) depicting the right superior pulmonary vein joining the right inferior homolateral vein forming a common trunk."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003129/000004.jpg?itok=MYnj8l86",
            "caption": "An image obtained with MRA showing the atypical course of the right  pulmonary veins and their confluence."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT",
      "MR-Angiography"
    ],
    "link": "https://www.eurorad.org/case/3129",
    "time": "28.12.2005"
  },
  "3148": {
    "case_id": 3148,
    "title": "Hilum overlay sign and the hilum convergence sign",
    "section": "Chest imaging",
    "age": "55",
    "gender": "female",
    "diagnosis": "Thoracic goiter.",
    "history": "A patient presented to the emergency room with symptoms of dysphagia and dyspnea.",
    "image_finding": "A 55-year-old female presented to the emergency room with symptoms of dysphagia and dyspnea. The PA chest X-ray demonstrated the presence of a large anterior mediastinal mass. The superior extent of\nthe mass extended above the thoracic inlet and was associated with a discrete rightward deviation of the trachea. The mass extended inferiorly to the level of the base of the heart. Axial CT images\nof the lower neck showed a heterogeneous mass that was contiguous with the left lobe of the thyroid gland. Axial CT images at the level of the aortic arch demonstrated the large substernal component\nof the mass which displaced the ascending aorta and superior vena cava posteriorly.",
    "discussion": "It is known that thyroid abnormalities account for the majority of thoracic inlet in adults. They may extend inferiorly into the anterior, middle, and posterior compartments of the mediastinum. When\nlocated in the anterior mediastinum, thyroid masses are almost always located posteriorly to the great vessels, usually in a paratracheal location. The majority of mediastinal masses of thyroid\norigin represent a thyroid goiter, and they almost always extend inferiorly from the thyroid gland. A truly ectopic thyroid goiter known to be rare. Other thyroid abnormalities, such as thyroid\nadenomas, and malignant thyroid neoplasms, infrequently extend into the mediastinum. Because a thyroid goiter accounts for the majority of mediastinal masses of thyroid origin, the demographics of\nthyroid mediastinal masses are similar to those of a thyroid goiter with a tendency to occur predominantly in middle-aged female patients. The following are the CT imaging features of a mediastinal\nthyroid goiter: a) continuity of the mass with the cervical thyroid gland; b) foci of high attenuation on noncontrast examination, reflecting a high iodine content of the thyroid tissue; c) foci of\nheterogeneous attenuation ( low attenuation cystic areas and high attenuation foci of calcification); d) intense and prolonged enhancement following administration of an intravenous contrast; e) as\non plain radiographs, deviation or compression of the trachea is frequently identified on CT. Felson described the hilum overlay sign and the hilum convergence sign in order to distinguish between an\nenlarged heart and enlarged pulmonary artery from a mediastinal mass. Felson stated that the proximal segment of the visible left pulmonary artery lies lateral to the cardiac shadow or just within\nits outer edge in over 98% of individuals and lies slightly more than 1cm within the silhouette in the remainder. A similar situation occurs on the right side. Even with pericardial effusion or\ncardiac enlargement, this relationship holds, with only an occasional exception. The configuration of an anterior mediastinal mass may closely resemble that of an enlarged heart or a pericardial sac,\nbut the mass can hardly lie directly medial to the pulmonary artery, since the heart and the pericardium pre-empt this location. Such a mass will overlap the main pulmonary arteries which then become\nclearly noticeable within the margins of the mass. On the other hand, if the pulmonary artery derives from the lateral edge of such an anterior mediastinal shadow, an enlarged heart or pericardial\nsac is indicated. A corollary of the hilum overlay sign is sometimes useful in distinguishing between a large pulmonary artery and a juxtahilar mediastinal tumour. If the pulmonary artery branches\nconverge toward the mass rather than toward the heart, then it is an enlarged pulmonary artery that is being dealt with. The reverse indicates a mediastinal mass and pertains the hilum convergence\nsign.",
    "differential_diagnosis": "Thoracic, goiter.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003148/000001.jpg?itok=vVMhmgfG",
            "caption": "A PA chest X-ray demonstrating a large anterior mediastinal mass. The superior extent of the mass extends above the thoracic inlet and is associated with a discrete rightward deviation of the trachea. The mass extends inferiorly to the level of the base of the heart"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003148/000002.jpg?itok=4pZG4kWr",
            "caption": "The hilum overlay sign: the mediastinal mass overlaps the main pulmonary artery which isl seen well within the margins of the mass."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003148/000003.jpg?itok=gD4o15a8",
            "caption": "Axial CT images of the lower neck showing a heterogeneous mass that is contiguous with the left lobe of the thyroid gland."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003148/000004.jpg?itok=9skUm2Vu",
            "caption": "CT images at the level of the aortic arch demonstrating the large substernal component of the mass which displaces the ascending aorta and superior vena cava posteriorly."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003148/000005.jpg?itok=FmZqHfST",
            "caption": "CT images at the level of the aortic arch demonstrating the large substernal component of the mass which displaces the ascending aorta and superior vena cava posteriorly."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/3148",
    "time": "03.06.2006"
  },
  "3205": {
    "case_id": 3205,
    "title": "Spontaneous hemothorax: an unusual presentation of pulmonary metastasis from benign giant cell tumor of bone",
    "section": "Chest imaging",
    "age": "20",
    "gender": "male",
    "diagnosis": "Pulmonary metastases from benign giant cell tumor of bone",
    "history": "We report a case with pulmonary masses in which sudden onset of hemothorax developed with acute respiratory failure. He twice underwent surgical resections for primary and local recurrent lesions. Chest radiography revealed massive right pleural effusion and a mass in the left lung base. Contrast-enhanced computed tomography was helpful in identifying a well-demarcated mass in the right lower lobe. Both masses displayed heterogeneous enhancement and wide contact with the pleura.",
    "image_finding": "A 20-year-old man with chest and back pain, dyspnea, and palpitations was brought to the emergency department of our hospital in 2002. \nHe had present with pathological fracture of the 4th cervical vertebra 5 years earlier, and benign giant cell tumor of bone had been diagnosed based on biopsy results. Surgical resection and bone grafting for the primary and local recurrent lesions had been performed twice, in 1997 and 1998. The interval between onset and local recurrence was 5 months.\nOn admission, heart rate was 94 beats/min and blood pressure was 110/52 mmHg. Physical examination revealed pallor of the palpebral conjunctiva, mild tachycardia, tachypnea, and diminished respiratory sounds in the right lung. Arterial oxygen saturation in room air was decreased to 91%. Laboratory results yielded normal results except for mild hypoxemia. Anteroposterior spine chest radiography identified compression of the right lung with massive pleural effusion and a mass in the left lung base (Fig. 1). Thoracic drainage and continuous aspiration for the right-sided pleural effusion were started immediately. Since the aspirate was bloody, hemothorax was diagnosed. Contrast-enhanced computed tomography (CT) visualized a large amount of right pleural effusion, and an ovoid heterogeneously enhanced mass in each lung (Fig. 2). The left pulmonary mass was located dorsally in the lower lobe, and was well demarcated and in wide contact with the pleura, whereas the right pulmonary mass was buried in the collapsed lung, and was poorly demarcated from the surrounding tissue (Fig. 2). No calcification or cystic changes were observed in either mass. Angiography was performed to locate the source of hemorrhage, but no clear evidence of extravasation was seen. Unenhanced CT performed on hospital day 5 indicated some improvement of right hemothorax, with the mass located in the lower lobe in wide contact with the pleura (Fig. 3). Subsequent systemic examination identified no local recurrence or metastases to other sites. \nThoracotomy for resection of the pulmonary metastases was performed 1 month after admission. The right thoracic cavity contained a massive old hematoma, with a mass of clotted blood present around the tumor, partially adherent to the pleura. Tumors in both lungs were turgid and tense, and bled easily. \nPathologically, the resected tumors comprised proliferating ovoid- to spindle-shaped cells, intermingled with osteoclast-like, multinucleated giant cells showing no apparent atypism. Pulmonary metastases from giant cell tumor of bone was therefore diagnosed. The histopathological features of both tumors closely resembled those of the primary lesion.\nAs of the last review, the patient remained in a disease-free state.",
    "discussion": "Although giant cell tumor of bone is histologically classified as benign, metastasis to distant sites in the absence of sarcomatous transformation is known. Distant metastases occur frequently in the lung, but no cases of hemothorax due to pulmonary metastasis have previously been reported.\nNeoplastic diseases causing hemopneumothorax include primary benign lung tumors (chiefly vascular tumors), primary malignant lung tumors, and metastatic lung tumors. Metastatic lung tumors are commonly malignant, such as angiosarcoma, hepatocellular carcinoma, choriocarcinoma, and malignant hemangioendothelioma. However, benign tumors such as chondroblastoma have also reportedly displayed pulmonary metastases [1]. Bronchopleural fistula and lung parenchymal infarction distal to tumor emboli [2] in the case of malignant metastatic lung tumors, and secondary aneurysmal bone cysts [1] in the case of benign metastatic lung tumor such as chondroblastoma, have been involved in the development of hemopneumothorax. \nTubbs et al. reported that, on chest radiography and CT, metastatic lesions from giant cell tumor of bone were round to oval, commonly appearing in the periphery and base of the lung as nodular opacities of homogeneous density [3]. In this case, tumors in both lungs showed similar CT features. In addition, marked contrast-enhancement of the tumors was observed, in addition to wide contact with the pleura. Most hemopneumothorax-causing metastatic tumors are hypervascular, and Hihara et al. [4] described contrast-enhanced CT findings similar to ours. The possibility of hemopneumothorax is thus worth remembering when the following combination of CT findings are noted with metastatic tumors: 1) wide contact between tumor and pleura; and 2) high contrast-enhancement of the tumor.\nLocal recurrence is frequently seen immediately before or concurrent to detection of pulmonary metastases from giant cell tumor of bone [3,5]. Siebenrock et al. reported that the number of operations to control the primary lesion could represent a factor in the development of pulmonary metastases [5]. The relatively aggressive nature of giant cell tumor of bone may have been involved in the development of hemothorax in this patient. \nPulmonary metastases from giant cell tumor of bone are commonly treated using surgical resection. Although recurrence after resection of pulmonary metastases is not uncommon [3,5], metastatic tumors grow relatively slowly, and frequently more than one surgical resection is performed [5]. A follow-up study for a mean of 11.9 years after diagnosis of pulmonary metastases from giant cell tumor of bone revealed that 79% of patients who underwent surgical resection only were free from disease by the end of follow-up, with a mortality rate from tumor of 17.4% [5]. Other studies have reported similar results [3], and pulmonary metastases from giant cell tumor of bone display a better prognosis than most metastatic lung tumors.\nThis patient represents a case in which giant cell tumor of bone metastasizing to the lung caused hemothorax with acute respiratory failure. Although it may be rare, pulmonary metastases from giant cell tumor of bone should be included in the differential diagnosis of hemothorax.",
    "differential_diagnosis": "Pulmonary, metastases, from, benign, giant, cell, tumor, of, bone",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003205/000001.jpg?itok=2t0GwPf0",
            "caption": "Anteroposterior spine chest radiography indicated compression of the right lung with massive pleural effusion and a mass (arrow) in the left lung base."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003205/000002.jpg?itok=IqO5npUL",
            "caption": "Contrast-enhanced CT of the chest (mediastinal window setting) shows right hemothorax and a heterogeneously enhanced solid nodular lesion (arrow) in the collapsed parenchyma of the right lung."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003205/000003.jpg?itok=OiMWTBaY",
            "caption": "Contrast-enhanced CT of the chest (mediastinal window setting) shows a well-defined, heterogeneously enhanced solid nodular lesion in wide contact with the posterior pleura in the left lower lobe."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003205/000004.jpg?itok=tXZhXQGR",
            "caption": "Unenhanced CT of the chest (mediastinal window setting) after thoracic drainage and continuous aspiration, obtained on hospital day 5. Hemothorax was slightly improved (c.f. Fig. 2a), and a mass lesion (arrow) was visualized in the right lower lobe in wide contact with the pleura."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/3205",
    "time": "27.02.2006"
  },
  "3241": {
    "case_id": 3241,
    "title": "Cystic pneumocystis jirovecii pneumoni",
    "section": "Chest imaging",
    "age": "34",
    "gender": "male",
    "diagnosis": "Cystic form of pneumocystis jirovecii pneumonia.",
    "history": "A 34-year-old patient presented with a history of cough which he had had for one month.",
    "image_finding": "A 34-year-old heavy smoker was referred to our hospital with a history of cough which he had had for one month. He had no other complaints. The patient had been followed up for 14 years for a\npost-transfusional HIV seropositivity. He had an AIDS status since Candida albicans oesophagitis was diagnosed in 1996. Recently, antiretroviral treatment had been suspended after four lines. A\npulmonary physical examination was found to be abnormal at the base of the right lung. Auscultation disclosed rhonchi over the right lower lobe. X-ray (Fig. 1) and computed tomography of the lungs\n(Fig. 2), including thin section acquisition (Fig. 3), was performed. A diagnosis of the cystic form of Pneumocystis jirovecii Pneumonia (PCP) was made based on results of the Polymerase Chain\nReaction of the bronchoalveolar lavage, the radiological features and the elevation in the serum lactate dehydrogenase level. The treatment consisted of oral administration of\ntrimethoprim-sulphamethoxazole (Bactrim).",
    "discussion": "Pneumocystis jirovecii pneumonia (PCP) is said to be caused by pneumocystis jirovecii (formerly pneumocystis carinii) an ubiquitous protozoan which is classified as a fungus. PCP is the most common\npulmonary infection in patients with AIDS and the most frequently used index to diagnose AIDS in the industrialized world. Even the first episode can be severe with a high mortality rate (up to 25%).\nPCP occurs mainly in immunocompromised patients (undergoing bone marrow or organ transplantation, receiving corticosteroids or chemotherapy \u2026) and especially in patients with the Acquired\nImmunoDeficiency Syndrome (AIDS). The maximal risk exists when the CD4+ count is less than or equal to 200 cells per cubic millimetre. The clinical symptoms of PCP are non-specific and variable in\ntheir presentation: non-productive cough, dyspnea, shortness of breath, and fever. The clinical course at the onset of infection is also variable. It can be insidious or brutal with a great\nalteration of the clinical status. PCP has a large spectrum of radiological and CT features. Classical X ray signs include diffuse or perihilar, bilateral, symmetric, reticular or granular\ninfiltrates that can be exclusively interstitial or associated with air-space consolidation. The classical CT pattern is an extensive ground-glass attenuation, homogeneous or patchy in its\npresentation, sometimes associated with a thickening of the septal lines. However, atypical features are more and more frequently encountered and must be known. These findings include cavitating\nnodules or masses, cysts, spontaneous pneumothorax, focal alveolar or lobar consolidation, miliary nodular pattern, and interstitial fibrosis (in the chronic form of PCP). Mediastinal and hilar lymph\nnode enlargement, and pleural effusions can also be seen, but differential diagnosis in cases such as mycobacterial and bacterial infections, lymphoma and Kaposi\u2019s sarcoma should be excluded.\nPCP may present as an upper lobe distribution, simulating tuberculosis especially in patients with AIDS treated with prophylactic inhaled pentamidine. The cystic form of PCP is encountered in\n10%\u201330% based on different studies. The cysts are often multiple, varying in size, location and extent of inflammation. They are frequently thin walled, sometimes surrounded by alveoli filled\nwith an inflammatory exudate. Their etiology is unclear. Several theories have been proposed : check-valve bronchiolar obstruction, cavitary infarction due to necrotizing vasculitis etc. Some of\nthese cysts can be located in the subpleural area, and the patients with the cystic form of PCP have a higher prevalence of pneumothorax, sometimes with a grim prognosis. The differential diagnosis\nof the cystic form of PCP includes bullous emphysema, cystic lesions of intravenous drug abusers, post-infectious pneumatoceles (Staphylococcus), post-traumatic pneumatoceles, coccidiodomycosis,\nnecrotizing metastasis and less frequently lymphangioleiomyomatosis or histiocytosis X. The treatment consists of oral administration of trimethoprim-sulphamethoxazole (Bactrim) or inhaled\npentamidine. The response is rapidly favourable when treated in 50% of the cases. The regression of the radiological abnormalities is seen in about one month. However, cysts can persist either\ntransiently or even permanently. In the case of persistent symptoms, a neoplastic or an associated infectious process as well as interstitial fibrosis should be ruled out.",
    "differential_diagnosis": "Cystic, form, of, pneumocystis, jirovecii, pneumonia.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003241/000001.jpg?itok=elBlv17h",
            "caption": "A chest X-ray scan performed 1 month before admission."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003241/000002.jpg?itok=Una47UbN",
            "caption": "A chest X-ray scan performed on admission.No change is visible."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003241/000003.jpg?itok=9nrcBfX4",
            "caption": "A CT image showing multiple cyst-like lesions disseminated  in both lungs. No mediastinal lymphadenopathy or parenchymal consolidation is seen."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003241/000004.jpg?itok=-Wov6bUG",
            "caption": "A CT image showing one cystic lesion localized in the sub-pleural area."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003241/000005.jpg?itok=s2iOcgzh",
            "caption": "A thin section CT image confirming the presence of multiple thin-walled cystic lesions. No evidence of bronchiectasies or ground-glass opacities. No interstitial abnormalities."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003241/000006.jpg?itok=kscPsRon",
            "caption": "A CT image showing one cystic lesion localized in the sub-pleural area."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/3241",
    "time": "24.02.2008"
  },
  "3256": {
    "case_id": 3256,
    "title": "Hepatopulmonary Syndrome",
    "section": "Chest imaging",
    "age": "54",
    "gender": "male",
    "diagnosis": "Hepatopulmonary Syndrome",
    "history": "Patient with liver cirrhosis and intermittent dyspnea",
    "image_finding": "A patient with liver cirrhosis was admitted because of intermittent dyspnea. There is known smoking-related emphysematous diffuse lung disease. Arterial blood-gas analysis showed a decreased pO2\n(59mmHg) and pCO2 (26mmHg) on room air. A conventional chest roentgenogram (Figure 1) demonstrates reticulonodular opacities predominantely in the lower lobes. A thin-section CT demonstrates dilated\nvessels (Figure 2a) with an increased number of terminal branches extending to the pleura (Figure 2b).",
    "discussion": "Hepatopulmonary syndrome is a process associated with end-stage liver disease. The diagnosis is established with three criteria: chronic liver disease, increased alveolar-arterial gradient and\nevidence of intrapulmonary vascular dilatation [1, 3]. Especially the peripheral vasculature is significantly larger whereas the central pulmonary arteries are spared [2]. In cirrhotic patients the\nclearence of many circulating mediators is reduced which is believed to be the etiopathogenesis for hepatopulmonary syndrome. However the principal vasoactive substance that causes hepatopulmonary\nsyndrome has not been identified. Hypoxemia is seen in one-third of decompensated cirrhotic patients and is believed to result from an inability of oxygen to diffuse to the center of the massively\ndilated peripheral vessels. CT is useful in the differential diagnosis as it rules out other causes of hypoxemia such as pulmonary fibrosis. Typical CT features are dilated peripheral vasculature and\nbibasilar reticulonodular opacities [3].",
    "differential_diagnosis": "Hepatopulmonary, Syndrome",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003256/000001.jpg?itok=icRbBkiw",
            "caption": "dilated vessels and reticulonodular opacities"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003256/000004.jpg?itok=DmuxeySQ",
            "caption": "Figure 1b\ndetailed view of HPS"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003256/000002.jpg?itok=ff3oaLp8",
            "caption": "dilated vessels and reticulonodular opacities"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003256/000003.jpg?itok=Jb0nuKag",
            "caption": "dilated terminal arterial branches extending to the pleura"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/3256",
    "time": "06.02.2008"
  },
  "3313": {
    "case_id": 3313,
    "title": "Fibrosing mediastinitis",
    "section": "Chest imaging",
    "age": "75",
    "gender": "female",
    "diagnosis": "Fibrosing mediastinitis.",
    "history": "An asymptomatic 75-year-old woman underwent a preoperative chest radiograph.",
    "image_finding": "The radiograph showed the presence of a great mass in the right paracardiac, located in the anterior mediastinum. A contrast-enhanced CT scan (mediastinal windows) which was taken, manifested an\nanterior mediastinal mass measuring 12 x 7 cm, soft-tissue attenuation with invasion to the adjacent structures. Calcifications were not observed. The fine needle biopsy of this lesion was performed,\nby obtaining a smear with extensive areas of fibrosis. The definitive diagnosis was made with biopsy. It was found that this tumor had infiltrated anterior thoracic wall.",
    "discussion": "Fibrosing mediastinitis is a rare benign disorder characterized by the proliferation of dense fibrous tissue that infiltrates the normal mediastinal fat planes and encases or invades the adjacent\nstructures. It affects patients who are typically young (30\u201340 years old) without a predilection for either sex. There may be two types of fibrosing mediastinitis, focal and diffuse. The focal\ntype is probably caused by an abnormal immunological response to a previous H.capsulatum infection, although other implied infections exist(tuberculosis, aspergillosis, mucormycosis, blastomycosis\nand cryptococcosis). The diffuse type is usually associated with autoimmune disease, radiation therapy, trauma, Hodgkin disease and drug therapy with methysergide maleate. The clinical manifestations\nare related to the obstruction of vital mediastinal structures. The differential diagnosis of fibrosing mediastinitis includes other lesions of the mediastinum, such as lymphoma, thymoma, metastatic\ncarcinoma, lung cancer, and germinal cell neoplasms. The radiological features of fibrosing mediastinitis usually manifest on chest radiographs as a nonspecific widening of the mediastinum, with the\ndistortion and obliteration of normally recognizable mediastinal interfaces or lines. In CT scans, the condition typically manifests as the presence of a mediastinal mass, with soft-tissue\nattenuation that can invade the adjacent structures. The focal pattern, seen in 82% of the cases, manifests as a mass of soft-tissue attenuation that is frequently calcified and is usually located in\nthe right paratracheal or subcarinal regions or in the hila. The diffuse pattern, seen in 18% of the cases, manifests as a diffusely infiltrating, noncalcified mass that affects multiple mediastinal\ncompartments. On MR imaging, it typically manifests on T1-weighted MR images as a heterogeneous, infiltrative mass of intermediate signal intensity. Its appearance on T2-weighted MR images is more\nvariable, as regions of both increased and markedly decreased signal intensity are frequently seen in the same lesion. The fine needle biopsy of these lesions is frequently found to be insufficient\nfor the diagnosis by the extensive areas of fibrosis. The definitive diagnosis requires a biopsy.",
    "differential_diagnosis": "Fibrosing, mediastinitis.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003313/000001.jpg?itok=8xwX4iOi",
            "caption": "A posteroanterior chest radiograph showing a mass in the right paracardiac, located in the anterior mediastinum."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003313/000002.jpg?itok=q4OpA6V7",
            "caption": "A lateral chest radiograph showing a great mass located in the anterior mediastinum."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003313/000003.jpg?itok=VfAoAHsI",
            "caption": "A CT scan (mediastinal windows) showing a soft-tissue attenuation in the anterior mediastinum."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003313/000004.jpg?itok=kGTDcbFi",
            "caption": "A CT scan (mediastinal windows) showing a soft-tissue attenuation in the anterior mediastinum."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003313/000005.jpg?itok=XZpIzBl0",
            "caption": "The photograph showing a well-circumscribed tumor with the areas of fibrosis."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/3313",
    "time": "03.06.2006"
  },
  "3359": {
    "case_id": 3359,
    "title": "Mac Leod syndrome and bronchogenic cyst",
    "section": "Chest imaging",
    "age": "8",
    "gender": "female",
    "diagnosis": "Mac Leod syndrome and bronchogenic cyst.",
    "history": "An 8-year-old female patient presented to the Pediatric Department with a history of consecutive bronchial pneumonia from the age of 1 year. She had cough and a defective thorax development. The spirometry showed a restrictive syndrome.",
    "image_finding": "A conventional chest radiograph was taken, which demonstrated a hyperlucent left lung with bronchiectasis on the inferior left lobe, and a mass in the anterior mediastinum (Fig. 1a, b). A contrast enhanced CT scan showed hypoplastic left pulmonary artery, cystic bronchiectasis and reduced density of the left lung parenchyma (Fig. 2a, c, d). Besides, the CT scan showed the presence of a paratracheal cystic mass compressing the mediastinal structures (Fig. 2b). The Magnetic Resonance Imaging confirmed the presence of a paratracheal cystic mass compressing the left main bronchus, the left pulmonary artery, and the left atrium (Fig. 3a, b). The ventilation-perfusion scintigraphy showed a marked hypoperfusion of the left lung (Fig. 4a, b). Pulmonary angiography showed a hypoplastic left pulmonary artery compared to the right side.",
    "discussion": "Mac-Leod syndrome (syn.: Swywer-James-syndrome) is a manifestation of postinfectious obliterative bronchiolitis. The involved lung or portion of the lung does not grow normally and is slightly smaller than the opposite lung (2). Radiographically, pulmonary hyperlucency caused by overdistended alveoli combined with diminished arterial flow characterizes its imaging appearance. The lung is expected to grow by progressive alveolarization in a child between the age of 2 and 8 years. Thereafter, lung growth is related to hyperexpansion of the existing alveoli. Mac-Leod syndrome is characterized by diminished vascularity, arrest of progressive growth and alveolarization of the lung and resultant hypoplasia . Multifocal areas of air trapping may be seen. Patients with Mac-Leod syndrome have a small lung, compensatory overexpansion of the contralateral lung, peripheral bronchi and bronchioles \"pruned\" secondary to obliterative bronchiolitis, a mosaic pattern of hyperlucency on CT, and small vessels and vascular occlusions in the abnormal areas (3). Adults with Mac Leod syndrome may be asymptomatic or may have cough, recurrent respiratory infection and haemoptysis. Bronchogenic cysts are lesions of congenital origin derived from the primitive foregut and are the most common primary cysts of the mediastinum. They are often unilocular, and contain clear fluid or, less commonly, hemorrhagic secretions or air. They are lined by columnar ciliated epithelium, and their walls often contain cartilage and bronchial mucous glands. It is unusual for them to have a patent connection with the airway, but when present, such a communication may promote infection of the cyst by allowing bacterial entry. Some bronchogenic cysts are asymptomatic. The most frequent symptoms are cough, fever, pain, and dyspnea. Tracheobronchial compression and pulmonary infections can occur in children because of the relatively soft tracheobronchial tree (1). Complications of bronchogenic cysts are frequent . Most of the complications result from compression of adjacent structures. Infection is a common complication, especially in cysts with bronchial communications. The cyst can rupture into the trachea, the pericardial cavity, or the pleural cavity. Pneumothorax is not a rare complication and is usually accompanied by pleuritis. Severe haemoptysis is rarely reported. This is a rare case of Mac-Leod syndrome associated with bronchogenic cyst. It is not clear if the Mac leod syndrome is secondary to compression on the left main bronchus and pulmonary artery.",
    "differential_diagnosis": "Mac, Leod, syndrome, and, bronchogenic, cyst.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003359/000001.jpg?itok=k9Gv77sU",
            "caption": "Conventional p.a. chest radiograph showing a hyperlucent left lung with bronchiectasis on the inferior left lobe."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003359/000002.jpg?itok=GhPmwQYE",
            "caption": "Conventional lateral chest radiograph showing the presence of a mass in the anterior mediastinum."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003359/000003.jpg?itok=c4AOQZAt",
            "caption": "A CT image demonstrating a hypoplastic left pulmonary artery."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003359/000004.jpg?itok=S79tZp-8",
            "caption": "A CT scan showing the presence of a paratracheal cystic mass compressing the mediastinal structures."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003359/000005.jpg?itok=GVWbZMo_",
            "caption": "A CT image demonstrating reduced density of the left lung parenchyma."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003359/000006.jpg?itok=mT_4C2Cc",
            "caption": "A CT image demonstrating cystic bronchiectasis on the inferior left lobe."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003359/000007.jpg?itok=d-ElRVjE",
            "caption": "A coronal T2-weighted MR image demonstrating the presence of a high signal mass in the left paratracheal region."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003359/000008.jpg?itok=x74eNOKR",
            "caption": "A coronal T2-weighted MR image demonstrating the presence of a paratracheal cystic mass compressing the left bronchial tube, the left pulmonary artery and the left atrium."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003359/000009.jpg?itok=mDweeF0u",
            "caption": "The ventilation-perfusion scintigraph showing a reduced ventilation on the left lung (ventilation scintigraph)."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003359/000010.jpg?itok=X5sFIGRs",
            "caption": "The ventilation-perfusion scintigraph demonstrating a marked reduction of perfusion on the left lung (perfusion scintigraph)."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT",
      "MR",
      "Nuclear medicine conventional"
    ],
    "link": "https://www.eurorad.org/case/3359",
    "time": "24.02.2008"
  },
  "3375": {
    "case_id": 3375,
    "title": "A hard day&#039;s night -- Pneumorrhachis and pneumomediastinum following violent vomiting",
    "section": "Chest imaging",
    "age": "22",
    "gender": "male",
    "diagnosis": "Pneumorrhachis.",
    "history": "We present an interesting and unusual finding in the spine, which arose as an incidental finding on a CT imaging procedure, primarily carried out to rule out oesophageal pathology in a young male. We\ndiscuss the radiological findings of pneumorrhachis and their significance.",
    "image_finding": "A 22-year-old man presented to Glasgow Royal Infirmary having flown from Ireland to attend a football match. He presented complaining of facial swelling, dysphagia and pleuritic central chest pain of\na recent onset of 12 h. There was a history of considerable alcohol intake in the 48 h prior to admission, subsequently associated with vigorous and prolonged vomiting. Past medical history included\nCrohn\u2019s disease, which remained asymptomatic on a prescription of Mesalazine 1 g daily. On examination, he was flushed, and was found to be pyrexial (38.2 \u00baC), tachycardic(102 bpm) and\nnormotensive. There was bilateral erythematous facial and neck swelling and tenderness, and crepitus. A chest and abdominal examination was unrevealing. A chest radiograph taken at the time of\nadmission showed the occurrence of pneumomediastinum and extensive surgical emphysema in the neck and upper thorax, with a subtle pneumopericardium. There was no evidence of pneumoperitoneum seen on\nthe abdominal radiograph. The patient was commenced on intravenous antibiotics and referred for computed tomography of the chest and abdomen (see images). The CT scans of the neck and chest with oral\nand IV contrast administration demonstrated extensive pneumomediastinum with tiny bilateral pneumothoraces. There was no evidence of leakage of the oral contrast from the oesophagus, and no evidence\nof fluid collection or an abscess within the mediastinum. Air was also shown within the spinal canal posteriorly from C6 to T10, with air seen in the right-sided neural exit foramina of the lower\ncervical spine. There was no evidence of fluid or an abscess within the spinal canal. There was an evidence of mucosal thickening of the distal oesophagus. An endoscopy performed two days later\ndemonstrated a mucosal laceration of the squamous oesophagus at the oesophagogastric junction, but no evidence of a complete perforation. A diagnosis of a sealed oesophageal perforation, complicated\nby pneumomediastinum and pneumorrhachis, was made. Conservative treatment was continued, with the commencement of nasojejunal feeding. The patient made an uneventful recovery. A repeat CT scan showed\nconsiderable resolution of pneumomediastinum, subcutaneous emphysema and pneumorrhachis, with no evidence of mediastinitis or sepsis. The oesophageal mucosal thickening had resolved. The patient was\ndischarged after nine days.",
    "discussion": "Pneumorrhachis, or epidural emphysema, refers to the presence of air within the spinal epidural space. As in this case, it may be accompanied by the presence of air within the neural exit foramina.\nIt is a well-described sequela of trauma (1) and of instrumentation (2). It is more rarely seen, as in this case, in association with a spontaneous pneumomediastinum. Isolated case reports describe\npneumomediastinum and pneumorrhachis in association with asthma (3), martial arts exercises (4), amphetamine intoxication (5), spontaneous pneumothorax (6) and energetic marijuana smoking (7). In all\nthese cases, the primary aetiology may have been alveolar rupture with the secondary passage of air into the mediastinum. In two further case reports, as in our case, pneumomediastinum and\npneumorrhachis have been demonstrated following forceful vomiting. Again as in our case, an oesophageal pathology and possible self-limiting tears of the oesophagus were implicated, but there was no\nevidence of oesophageal rupture to indicate that a frank Boerhaave\u2019s syndrome was present (8, 9). The mechanism of air entry into the epidural space has not been conclusively demonstrated;\nhowever it has been suggested (8) that the cervical neural exit foramina lie in free communication with the fascial planes of the retropharyngeal space. As the neural exit foramina in turn\ncommunicate freely with the epidural space (10), a potential pathway for air under pressure may be established. Our observation of air distending the cervical neural exit foramina would tend to\nsupport this view. All cases so far reported, including this one, indicate a benign course. Pneumorrhachis in these circumstances would therefore appear to be a benign phenomenon. It does however\npresent a startling appearance, which radiologists must be able to interpret.",
    "differential_diagnosis": "Pneumorrhachis.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003375/000001.jpg?itok=vEZ9xMMR",
            "caption": "An image showing extensive pneumomediastinum and subcutaneous emphysema. Air is clearly seen within the spinal canal."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003375/000002.jpg?itok=AwvfpqKQ",
            "caption": "An image showing pneumorrhachis at a lower level. Pneumomediastinum\\'s again being shown. A subtle left pneumothorax with air in the oblique fissure(also seen on other images, not included is also being shown)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003375/000003.jpg?itok=WHKm57GH",
            "caption": "An image showing the presence of air lying in the right neural exit foramen, depicting the probable site of entry for causing pneumorrhachis, on a background of widespread subcutaneous emphysema."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003375/000004.jpg?itok=EG6LVtPc",
            "caption": "A further image showing the extent of air within the spinal canal. This could easily be overlooked if viewed on soft tissue settings alone."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT",
      "CT",
      "CT",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/3375",
    "time": "23.02.2006"
  },
  "3378": {
    "case_id": 3378,
    "title": "Mediastinal teratoma: advantages of MR imaging versus CT-scan.",
    "section": "Chest imaging",
    "age": "65",
    "gender": "female",
    "diagnosis": "Mature teratoma of the mediastinum.",
    "history": "A 65-year-old female patient presented to our hospital with a cough lasting for two months, and reported a recent appearance of severe chest pain and dyspnoea. Her history showed a prior diagnosis\nand treatment for breast cancer.",
    "image_finding": "This patient, with a prior history of breast cancer, was admitted to our hospital with recurrent episodes of cough, over the last two months, accompanied in the last week by dyspnoea and posterior\nchest pain. A chest radiogram in standard projections was performed, the results of which showed a large opacity in the upper part of thorax, probably in the anterosuperior mediastinum. For a better\nstudy, we subsequently carried out a thorax CT scan that confirmed the initial radiographic findings, and showed the presence of an an elliptical formation (50mm MD) in the thymic recess, with\ncalcified walls and a fat-like density, with a presumably benign pattern. A MR exam (flash t1-weighted and haste t-2 weighted sequences) of the chest was required for presurgical evaluation and\nbetter tissue characterization. It defined the mass as a neoformation with peculiar benign features (not enhanced after contrast, not cystic, moderately dishomogeneous), with diffusely calcified\nwalls and a strong signal in the t2-weighted sequences, highly suggestive of a predominant composition of fat tissue, not of a malignant formation.",
    "discussion": "The word \"teratoma\" is derived from the Greek word \"teras\", meaning monsters. Mature teratomas are neoplasms that may be generated from any germinal layers. Consequently, depending on the cells of\norigin, these tumours have the potential to express as any of the three mature forms of the germ cell lines, namely the ectoderm, mesoderm and the neuroderm. Their presentation occurs most commonly\nin the gonads, altough extragonadal localizations are not rare and may develop along the body midline, like in the neurocranium, mediastinum, retroperitoneal space, and the sacrococcygeal region.\nBetween extragonadic localizations, mediastinal teratomas are uncommon, occur in all age groups and with no sex predilection, making up about 5%-10% of all mediastinal neoformations, and are thought\nto be responsible for approximately 1 in 3400 hospital admissions. About 53% of patients have no symptoms at the time of diagnosis, especially in adult subjects, in whom the tumour is found\nincidentally after blood exams (which show a high CA 19-9 level with no other explanation possible) or on routine chest radiographs. In symptomatic cases, the presentation is usually in the\nanterosuperior mediastinum, with predominant respiratory symptoms of chest pain, dyspnoea, and cough. Rarely, the presentation may show a major cardio-vascular engagement, involving the heart and the\ngreat vessels.Up to 36% of all mediastinal teratomas may present with dramatic, life-threatening symptoms (pneumothorax, pleural or pericardial effusions, superior vena cava syndrome) in case of\nrupture (into the lungs and bronchial tree, in the pleural space, pericardial space, or great vessels). Regarding the rupture process of mature teratomas, the most acceptable hypothesis attributes\nthe causal role to the presence of digestive enzymes secreted by the pancreatic tissue, salivary gland tissue, or intestinal mucosa within the tumour: a high amylase activity in the pleural effusion\nor in the tumour contents is often reported. The other hypotheses offered of chemical inflammation, ischaemia, pressure necrosis and infection, prove to be unreliable. However, in case of a rupture,\nan early diagnosis and treatment improve the survival rate. The only reasonable treatment of mediastinal teratomas is surgical, and should be performed whenever rupture, mass-effect complications\n(such as atelectasis of lung tissue, adhesion to or compression of adjacent structures), or a malignant transformation, are present or probable; the results and outcome after surgical resection are\nexcellent. The differential diagnosis includes other mediastinal formations such as a thymoma, lymphoma, lipoma, echinococcus cysts, or a fibrous outcome of mediastinitis. CT is the modality of\nchoice for the diagnostic evaluation of these tumours that typically manifest as a heterogeneous anterior mediastinal mass, encapsulated and well-demarcated, containing soft-tissue, fluid-filled\ncystic areas, fat, or calcium attenuation, or any combination of the four. This pleomorphic appearance is an important clue to distinguish these lesions from other neoplasms which have a mainly solid\ncomposition. Calcification is seen in between 20% and 80% of the cases, which could be focal, rim-like, or rarely represented as teeth or bone. Fat is visible on the CT scan in half of these cases, a\nfinding that is highly suggestive of this diagnosis. The fat-fluid level within the mass is particularly diagnostic. MR imaging, owing to its multiplanar capability and high contrast resolution,\noften provides superior information about the nature (cystic lesions can appear solid on CT, miming other types of lesions), location, and extent (craniocaudal and intraspinal extension) of disease,\nnot forgetting its high degree of sensitiveness in depicting infiltration of the adjacent structures by a fat plane obliteration.The MRI findings of most cases reveale the presence of oval shaped\nlesions, with a varied intensity pattern (depending on the composition of the tumour). The wall often has solid protuberant fatty parts with a high signal intensity in T1-weighted images and a\nmoderate signal in T2-weighted images. They eventually present areas of cystic degeneration which are hyperintense on T1-weighted images and hypointense on T2-weighted images. Lesions with spiculated\nborders, thick capsules, heterogeneous contents, fat plane obliteration around the tumour, or direct invasion into the adjacent structures with or without effusion, are to be retained, at the risk of\nrupture or malignant degeneration.",
    "differential_diagnosis": "Mature, teratoma, of, the, mediastinum.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003378/000001.jpg?itok=D175F5wf",
            "caption": "A CT image showing the presence of a mediastinal mass with a hyperdense wall and a fat-like composition."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003378/000002.jpg?itok=m43njqEi",
            "caption": "T2-weighted MR sequence showing the teratoma as being a moderately hypointense mass with a calcified wall and a heterogeneous fat-like composition."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003378/000003.jpg?itok=MIDImefJ",
            "caption": "A TRUF sequence image evidencing the heterogeneous and pseudocystic content of the mass."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003378/000004.jpg?itok=D4MOwDV7",
            "caption": "A T1-weighted image more clearly showing the prevalent fatty composition of the teratoma."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/3378",
    "time": "24.02.2008"
  },
  "3397": {
    "case_id": 3397,
    "title": "Methotrexate-affected lungs in the case of rheumatoid arthritis",
    "section": "Chest imaging",
    "age": "70",
    "gender": "male",
    "diagnosis": "Methotrexate induced pneumonitis in rheumatoid lungs.",
    "history": "A 70-year-old male patient demonstrated a normal white blood count (normal values for both neutrophils and eosinophils), and his chest X-ray photographs showed a bibasal interstitial reticulonodular\nshadowing.",
    "image_finding": "The investigations done on a 70-year-old male patient demonstrated a normal white blood count (normal values for both neutrophils and eosinophils), and his chest X-ray photographs showed a bibasal\ninterstitial reticulonodular shadowing. The results of HRCT confirmed the occurrence of diffuse bilateral fibrotic changes with architectural distortion, traction bronchiectasis, and honeycombing.\nThere were also some areas of discrete ground glass opacification.",
    "discussion": "The 70-year-old male patient was managed conservatively with oxygen therapy and withdrawal of methotrexate. Over the next 2\u20133 weeks, the patient showed a dramatic clinical improvement, with\nnormalisation of his breathing, exercising capacity, and oxygen saturations. The difficulty in this case was to establish the cause of the patient's deterioration. The differential diagnosis included\na pulmonary manifestation of his rheumatoid condition, which is a complication that occurred during his drug therapy. Pulmonary manifestations of rheumatoid lungs include: (1) Diffuse interstitial\npulmonary fibrosis mostly of UIP type and present in 10% of patients, is clinically, radiographically, and histologically similar to ideopathic pulmonary fibrosis. HRCT classically shows a bibasal\nsubpleural honeycombing, with traction bronchiectasis. The results of pulmonary function tests show restricted lung volumes and gas transfer typical of pulmonary fibrosis. (2) more common are airway\nabnormalities, in up to 70% especially in patients who have no ILD such as chronic bronchitis, bronchiactasis and obliterative bronchiolitis (3) Pleural disease(in up to 40%) with pleurisy or pleural\neffusion. The pleural fluid is characteristically an exudate (protein >30 gl), with a raised LDH, a low complement and a high titre of rheumatoid factor. (4) Pulmonary nodules and Caplan\u2019s\nsyndrome. Pulmonary nodules may be discovered incidentally, and they may cavitate, become infected, cause haemoptysis, or rupture into the pleural space producing a pneumothorax. Caplan\u2019s\nsyndrome occurs where coal worker's pneumoconiosis or other pneumoconiosis becomes complicated by rheumatoid nodules. (5) Obliterative bronchiolitis typified by progressive narrowing and gas trapping\nof small airways. (6) Organising pneumonia with patchy consolidation. (6) Pulmonary vasculitis and haemorrhage. Methotrexate characteristically induces an acute reversible cellular interstitial\npneumonitis. It may induce lung disease irrespective of the indication for which it is prescribed. The associated immunosuppression also increases the risk of infections, which include conditions\nsuch as pneumocystis carinii pneumonia. PCP was excluded in that patient on basis of clinical and diagnostic back ground wiht following clinical improvement in responce to measuers taken at time.\nDrug induced lung disease induced by methotrexate is seen in 5-10% of cases.Morphological findings include ground glass appearance in most cases as seen in this case, less often features of OP or\nDAD. The fact of drug induced lung diseas was based on exclusion of overlying infection, morphlogical HRCT findings during acute symptoms and clinical improvement of patient after cessation of the\nmedication. NO follow up imaging was performed for that patient.",
    "differential_diagnosis": "Methotrexate, induced, pneumonitis, in, rheumatoid, lungs.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003397/000001.jpg?itok=POnIb8F0",
            "caption": "Changes of interstitial reticulo-nodular shadowing, mainly the bases are seen."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003397/000002.jpg?itok=fQMyMIZK",
            "caption": "An HRCT scan showing extesive fibrotic changes throughout both the lungs."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003397/000003.jpg?itok=h_o4lIuc",
            "caption": "Established fibrosis mainly on the left lung, traction bronchiectasis and a complete loss of architecture are seen."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003397/000004.jpg?itok=BoRAhRf3",
            "caption": "Bronchiectic changes, honeycomb appearance ground glass are seen."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003397/000005.jpg?itok=qVeQ0Xxr",
            "caption": "Areas of a discrete ground glass opacification mainly in the left upper and mid-zones are seen."
          },
          {
            "number": "Figure 2e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003397/000006.jpg?itok=brIRrDss",
            "caption": "An architectural distortion reflecting lung fibrosis."
          },
          {
            "number": "Figure 2f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003397/000007.jpg?itok=7wcRimXT",
            "caption": ""
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/3397",
    "time": "26.01.2006"
  },
  "3436": {
    "case_id": 3436,
    "title": "Imaging in the detection of an intercostal nerve schwannom",
    "section": "Chest imaging",
    "age": "48",
    "gender": "male",
    "diagnosis": "Ordinary Schwannoma of the intercostal nerve.",
    "history": "A 48-year-old male presented with pain in the thoraco-lumbar spine, which had irradiated to the 8th left intercostal space. He underwent an X-ray, ultrasonography and gadolinium-enhanced magnetic\nresonance imaging studies for further analysis.",
    "image_finding": "We report the case of a 48-year-old man with pain in the thoraco-lumbar spine, irradiated to the 8th left intercostal space. He did not report the occurrence of any trauma. The chest X-ray and the\nspecific study of the ribs, showed a round and regularly-shaped mass of about 1.5 cm in size, projecting into the 8th intercostal space. Ultrasonography and gadolinium-enhanced magnetic resonance\nimaging (MRI) confirmed the presence of such a mass. The patient underwent a percutaneous excision under an ultrasound guide. A microscopic examination revealed a typical Schwannoma featuring cystic\nareas and with the predominant occurrence of Antoni B areas.",
    "discussion": "A schwannoma, also known as neuroma or neurilemmoma, is a benign tumour that arises form nerve sheath cells (Schwann cells). The occurrence of a schwannoma is relatively common at all ages (with a\ngreater incidence between the ages of 20 and 50 years), and it accounts for around 5% of all benign neoplasms of soft tissues. In most cases, it presents as an encapsulated, solitary and slow-growing\nmass. In rare cases, it can be found associated with Von Recklinghausen\u2019s neurofibromatosis (NF-1). Microscopically, schwannoma may present areas comprising of compact fascicles of spindle\ncells (Antoni A) or loosely textured (Antoni B) zones. The most common sites of occurrence are the head, neck, flexor areas of the upper and lower extremities, the posterior mediastinum and\nperitoneal areas. In about 8.5% of cases it is localized to the trunk. The presentation is often as an asymptomatic localized mass. In the case we presented, the main symptom was pain, localized to\nthe thoraco-lumbar spine, irradiating to the 8th left intercostal space, which had worsened during the last year. Pain was found to increase with movements of the trunk and of the upper left arm, and\nit worsened with pressure of the chest. The chest X-ray, projectively on the 8th intercostal space, showed the presence of a round and regularly-shaped mass with fluid content. Ultrasonography showed\nthe presence of a hypo-echoic mass measuring 2 cm round in shape, with no sign of vascularization localized along the nerve. It also showed that this mass was clearly separated from the parietal\npleura. The need for a differential diagnosis between a cyst and a neoplasm originating from nerve roots, justified the decision to perform an MRI study. The study was done on a 1.5 T MR scanner,\nwith T1, T2, fat-suppressed T2-weighted sequences (STIR), and post-gadolinium T1-weighted sequences, on the coronal and axial planes. It showed a mass with a low signal on T1-sequences and a high\nsignal on T2- and STIR sequences. The mass showed no enhancement in the central area and a peripheral rim of enhancement on T1-weighted images post-gadolinium. Both at CT and at MRI, schwannomas show\nan intense and early vascularization (typical of Antoni A areas). The detection of a capsule on the MRI, visualized as a low intensity rim, can be detected in 70% of the schwannomas. Schwannoma\nfeaturing cystic areas and with predominantly Antoni B areas may have different vascularization patterns: enhancement may be delayed, with only peripheral rim enhancement or no enhancement of\nnecrotic areas. Differential diagnosis has to be made with (a) neurofibromas, which are usually located centrally in the nerve and rarely present with cystic or necrotic areas; (b) ancient\nschwannomas which are bigger in size and present calcifications and areas of hyalinization; (c) malignant schwannomas, which are rapidly growing mass (>5 cm), irregularly shaped and presenting\nwith oedema and central necrotic areas; (d) synovial sarcomas; (e) granulomas and (f) haemangiopericitomas.",
    "differential_diagnosis": "Ordinary, Schwannoma, of, the, intercostal, nerve.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003436/000001.jpg?itok=tHUzs7jx",
            "caption": "A chest X-ray showing the round and regularly-shaped mass of about 1.5 cm in size, projectively on the 8th intercostal space."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003436/000002.jpg?itok=ErRe39L2",
            "caption": "An ultrasonograph showing the round, hypo-echoic mass."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003436/000003.jpg?itok=JVCp-E3Q",
            "caption": "An MR image showing a low signal on a T1-weighted sequence on the axial plane."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003436/000004.jpg?itok=aCR0rXRQ",
            "caption": "An MR image, coronal plane, showing a high signal on the T2-weighted sequence."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003436/000005.jpg?itok=2r9Ku1OD",
            "caption": "An MR image, T1-weighted sequence, acquired in the arterial phase."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003436/000006.jpg?itok=_SZpOF6i",
            "caption": "An MR image, post IV contrast administration, showing the peripheral rim of enhancement on the T1-weighted sequence during the late phase."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "Ultrasound",
      "MR",
      "MR",
      "MR",
      "MR"
    ],
    "link": "https://www.eurorad.org/case/3436",
    "time": "10.04.2005"
  },
  "3546": {
    "case_id": 3546,
    "title": "Intrapulmonary  bronchogenic   cyst  with   respiratory  distress:  X-ray and CT findings",
    "section": "Chest imaging",
    "age": "2",
    "gender": "male",
    "diagnosis": "Intrapulmonary bronchogenic cyst",
    "history": "A 2 month-old boy was admitted in emergency to our hospital with acute dyspnea and wheezing.",
    "image_finding": "Case report A 2 month-old boy was admitted in emergency to our hospital with acute dyspnea and wheezing. Auscultation revealed no breath sounds on the left hemithorax which was hyperresonant on\npercussion; the cardiac area was right- shifted. A chest x-ray showed a rounded opacity with regular borders and a hypertransparent area within it. Air trapping was present in the left upper\npulmonary lobe with a contralateral mediastinal shift (Fig.1). A non-contrast CT of the chest showed a rounded well-defined mass, 1.5 cm in diameter, with a smooth wall-thickening and air-fluid\nlevel; other small rounded air-filled areas were also present. Furthermore, a transmediastinal hernia of the left upper lobe and a contralateral mediastinal shift were present (Fig.2A-B). A pulmonary\ncyst was diagnosed in the left upper lobe which communicated with the bronchial tree. A segmentectomy was therefore performed and the patient became symptoms free.",
    "discussion": "Discussion Embryologically, bronchogenic cysts result from an anomalous budding of the ventral portion of the primitive foregut, where the trachea and the bronchial tree arise, between the 26th and\n40th day of intrauterine life (1). Rates of mediastinal and pulmonary brochogenic cysts are variable, ranging from 20 to 86% for mediastinal cysts, and from 14 to 60% for intraparenchymal cysts\n(2,3). Histologically, they are usually unilocular, thin-walled, and lined by the ciliated respiratory epithelium and contain bronchial glands, nerves and cartilages. Usually they contain serous or\nmucoid fluid; if communication with the airway develops the cyst may contian air (1). The symptoms are cough, dyspnea, dysphagia, wheezing and chest pain, mainly related to the development of\ninfection within the cyst and to the compression of the airways and/or the mediastinal vessels. The differential diagnosis of the parenchymal forms includes lung abscess, hydatidosis, fungal disease,\ntubercolosis, infected bullas, vascular malformations and neoplasm (3). On CT scans bronchogenic cysts are sharply marginated masses demonstrating water or soft tissue density. Differences in attenuation result from the amount of proteinaceous fluid within the\ncysts. Cysts do not enhance after administration of IV contrast.  Most bronchogenic\ncysts are relatively characteristic in appearance on CT but in atypical cases with hemorrhage or infection, findings may be confused with those of necrotic adenopathy, cystic lung disease, or lung\nabscess.Mediastinal cysts are visualized as a mediastinal mass on conventional radiographs. Intrapulmonary cysts usually\npresent as a solitary pulmonary nodule unless the cyst contains air. Because hydatids cyst are common in our region, hydatidosis is an important differential diagnosis . The case presented\nhere, was characterized by an acute onset, with respiratory distress and a general bad condition of the baby, due to airways obstruction. Early diagnosis of bronchogenic cysts in pediatric age is of\nvital importance since cysts do not regress spontaneously and can become dangerous for possibile airways obstruction and infection. Surgical excision is the treatment of choice, with the following\ncomplete remission of symptoms.",
    "differential_diagnosis": "Intrapulmonary, bronchogenic, cyst",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003546/000001.JPG?itok=hY52UwFq",
            "caption": "A posteroanterior chest x-ray shows a left pulmonary round opacity surrounded by a radiopaque limb with a hypertransparent area  in it. Air trapping in the left upper lobe and a contralateral mediastinal shift  are present."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003546/000003.JPG?itok=WkcdT8Zf",
            "caption": "A non-contrast CT scan shows a rounded well-defined mass with a smooth wall  thickening with air in it. Hyperinflation with a transmediastinal hernia of the left upper lobe and a  mediastinal shift to the right side are demonstrated."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003546/000002.JPG?itok=l7d6Xc25",
            "caption": "Note the air-fluid level and the small rounded air-filled areas in the anterior part of the cyst."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/3546",
    "time": "17.02.2006"
  },
  "3561": {
    "case_id": 3561,
    "title": "Delayed Presentation of Bochdalek Herni",
    "section": "Chest imaging",
    "age": "68",
    "gender": "male",
    "diagnosis": "A case of delayed presentation of Bochdalek Hernia",
    "history": "This is a case of delayed presentation of Bochdalek Hernia in an adult. The only symptom was chronic cough. Diagnosis was made by Chest X-Ray and CT Thorax.",
    "image_finding": "A 68 year old gentleman was sent by GP for a chest X-ray as he had chronic cough for many years. Proper history was not obtainable as patient was suffering from severe dementia. As initial chest\nX-ray showed an abnormality near the left costophrenic angle, patient was sent for a repeat PA and lateral chest X-rays. Both these views showed a persistent rounded opacity near the posterior\ncostophrenic angle. As advised by radiologists, a contrast enhanced axial CT scan of thorax and abdomen was done. CT scan showed that the opacity in CXR represents confluence of upper pole of\nupwardly displaced left kidney, cranial most part of spleen and abundant perirenal fat. Most likely all of these had herniated into thorax through foramen of Bochdalek. No other abnormality detected.",
    "discussion": "Congenital Diaphragmatic Hernia (CDH) constitutes a major surgical emergency especially in newborn. The three basic types of CDH are Posterolateral hernia, Anterior Morgagni hernia and the less\ncommon Hiatus hernia. (1) In 1848, Victor Alexander Bochdalek, professor in anatomy in Prague described both right and left posterolateral CDH. To this day, this type of CDH is referred to as\nBochdalek hernia in honour of him. (2) Bochdalek foramen is formed due to incomplete fusion of pleuroperitoneal membranes to close the canal. Bochdalek hernia usually presents in neonatal period.\nHowever late presenting Bochdalek hernia has been described. CDH has prevalence of between 1.7 and 5.7 per 10,000 live births. (3) Prenatal diagnosis is usually made by ultrasonography. But in some\ncases diagnosis may not be possible in utero. If an in utero diagnosis is not made, it tends to present as a neonatal emergency with respiratory distress, vomiting and cyanosis and it can be\ndiagnosed from plain x-rays.CDH may be associated with Intrauterine growth retardation, chromosomal abnormalities and/or other malformations (10-50%). So search for other malformations by\namniocentesis with analysis of fetal karyotype is essential, whenever CDH is prenatally diagnosed. (4) Commonly associated malformations are pulmonary hypoplasia, pulmonary sequestration,\npolyspleenia, ASD, VSD, hydronephrosis, etc. (5) Neonatal presentation is managed as a surgical emergency. Another presentation of the entity is during adulthood when it can either present as an\nincidental finding or presents clinically due to acute digestive or respiratory complications. Incidence of this late presentation varies between 5 and 25% of all Bochdalek hernias. (6) When noted as\nan incidental finding, PA or lateral film of the chest will demonstrate a focal bulge approximately 4-5 cm anterior to the posterior diaphragmatic insertion overlying the cardiac silhouette. But a\nprevious normal chest x-ray doesn\u2019t rule out Bochdalek hernia as this defect can be plugged by spleen or by presence of containing sac. (7) Computed tomography will demonstrate this bulge to be\nfat attenuation most commonly, with less likely preservations including bowel or kidney herniating through the defect. When the contents of the hernia are large or consist of abdominal organs, the\ndiagnosis can be made without much difficulty. However, such is not the case when the Bochdalek hernia contains only a small amount of retroperitoneal fat protruding through a narrow diaphragmatic\ndefect. In addition, it is difficult to qualitatively distinguish the protruded retroperitoneal fat from other pathophysiological conditions such as diaphragmatic fat, intrathoracic lipoma, or\nliposarcoma. When fat is atypical, MR will be more conclusive. One study showed 68% of delayed presentation Bochdalek hernias were on right side while 18% on left side and 14% were bilateral (8)\nManagement of Bochdalek hernia in adult is controversial. In adults while surgical treatment is frequently needed for the treatment of symptomatic diaphragmatic hernia, the surgical treatment of\nasymptomatic diaphragmatic hernia may be performed days to years later according to patient status. (3) The most commonly used approaches are thoracotomy, laparatomy or combined approach although few\nsuccessful laproscopic repairs have been reported. (9)",
    "differential_diagnosis": "A, case, of, delayed, presentation, of, Bochdalek, Hernia",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003561/000001.jpg?itok=vD9hlBd7",
            "caption": "Chest X-Ray PA View- A rounded abnormality near left costophrenic angle"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003561/000006.jpg?itok=RwB4nKvt",
            "caption": "CT Thorax showing protrusion of kidney and perirenal fat protruding through hernia"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003561/000007.jpg?itok=KUsqEZpo",
            "caption": "CT Thorax - There  is an incidental finding of a calcified plaque involving the diaphragmatic pleura on contralateral side..could be related to asbestosis  exposure"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003561/000008.jpg?itok=0-MBo1rR",
            "caption": "CT Thorax with different lung window"
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003561/000011.jpg?itok=XuHtaOu0",
            "caption": "Chest X-ray Lateral view - A similar rounded leision found on lateral view as well"
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003561/000012.jpg?itok=0xqA1IUJ",
            "caption": "CT Scan Lateral View showing left kidney and peri-renal fat protruding through the defect"
          }
        ]
      },
      {
        "number": "Figure 7",
        "subfigures": [
          {
            "number": "Figure 7",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003561/000013.jpg?itok=qwzRgWPk",
            "caption": "CT Scan Lateral with different lung window"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/3561",
    "time": "02.11.2006"
  },
  "3596": {
    "case_id": 3596,
    "title": "ndobronchial Metastasis from Renal Cell Carcinoma.",
    "section": "Chest imaging",
    "age": "80",
    "gender": "male",
    "diagnosis": "Endobronchial Metastasis from Renal Cell Carcinoma.",
    "history": "We report here the case of a patient in whom an endobronchial lesion developed 2 years after right nefrectomy. The lesion was demonstrated with computed tomography of the chest performed because the\npatient suffered from recurrent episodes of hemoptysis, cough and dispnea.",
    "image_finding": "A 80-year old man who had undergone a right nephrectomy for renal cell carcinoma 2 years previously was admitted in the ospital because recurrent episodes of hemoptysis, cough and dispnea. On\nphysical examination respiratory sounds in the inferior right lung field were decreased.Routine blood test were normal. A chest computed tomography was performed. The exam revealed, a solid\nendobronchial lesion ( 2,5 cm) obstructing partially the principalis bronchus and the inferior bronchus of the right lung. Multiple areas of distelectasia were present. A lymphonodal swelling, 4 cm\nin diameter, was present in the anterior superior mediastinum. Bronchoscopy confirmed the presence of an endobronchial polipoid lesion protruding into the lumen of right the principalis bronchus and\nof the inferior bronchus of the right lung. The histologic exam of the lesion revealed endobronchial metastasis of renal cell carcinoma.",
    "discussion": "The lung is an extremely common site for metastasis from extratoracic tumors, in fact metastasis were found in 30% of the patients. Endobronchial metastasis from non pulmonary carcinoma is uncommon,\noccurring in only 2\u00e2\u20ac\u20185 % of patients with cancer, according to autopsy findings [1-3]. The tumors showing endobronchial metastasis with greater frequency are, in decreasing order:\nbreast cancer, renal cell cancer, colon cancer and melanoma. Other authors found that renal cell carcinoma is the most common lesion involving the bronchus secondarily [4]. The tumor dissemination\noccurred by haematogenous or lymphatic spread. In fact the bronchi are supplied by the systemic circulation and receive centripetal lym\u00adphatic drainage and thus, distal tumor emboli can migrate\ninto the bronchus. The most typical symptoms are coughing and hemoptysis, while dispnea is seen less frequently. The radiologicals manifestations are very various and they can mime a central\nbroncho\u00adgenic carcinoma. The most typical manifestation is a partial or complete atelec\u00adtasis [3]. The sites more frequently involve for metastasis from renal cell carcinoma are: lung,\ngangli, liver, adrenal glands, controlateral kidney and brain. Endobronchial metastasis are very rare. After surgical removal of renal cell carcinoma, follow-up imaging is especially important in the\nfirst 2 years, when recurrence is most likely[5].",
    "differential_diagnosis": "Endobronchial, Metastasis, from, Renal, Cell, Carcinoma.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003596/000001.jpg?itok=0y6suK9Z",
            "caption": "Enhanced CT scan show a solid endobronchial lesion obstructing the rigth principalis bronchus. Around 4 cm node is demonstrated on the anterior mediastinum."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003596/000002.jpg?itok=0JG3k4rA",
            "caption": "Enhanced CT scan show a solid endobronchial lesion obstructing the  right inferior bronchus"
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003596/000003.jpg?itok=PZU3FWcV",
            "caption": "Enhanced CT scan show a solid endobronchial lesion obstructing the  right inferior bronchus"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003596/000004.jpg?itok=mdMqihxY",
            "caption": "On the parenchimal window diffuse multiple areas of subatelectasis on the superior a nd inferior right lobe are well demonstrated"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003596/000005.jpg?itok=kavfICj5",
            "caption": "On the parenchimal window diffuse multiple areas of subatelectasis on the superior a nd inferior right lobe are well demonstrated"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/3596",
    "time": "25.07.2005"
  },
  "3609": {
    "case_id": 3609,
    "title": "Carcinoid of the trachea. Report of a case.",
    "section": "Chest imaging",
    "age": "20",
    "gender": "male",
    "diagnosis": "Carcinoid tumor of the trachea",
    "history": "A 20 year-old male patient was presented to our department due to hemoptysis.",
    "image_finding": "A 20 year-old male patient presented to our department due to hemoptysis for a period of one month. Patient\u2019s history, clinical examination and blood analysis was negative. Plain and contrast\nenhanced computed tomography revealed an oval, solitary, strongly enhancing lesion of 1.5 cm maximum diameter protruding from the posterior wall of the lower third of the trachea (Figure 1, 2). No\nextraluminal lesion or any additional findings from the lung parenchyma or mediastinum were revealed. The patient underwent a bronchoscopy in which a small spherical polypoid reddish lesion was shown\nassuming a polypoid configuration, attached to the posterior wall of the trachea, covered by intact mucosa (Figure 3). Pathologic examination of tissue sample showed that the lesion was a typical\ncarcinoid. The patient underwent segmental resection of the trachea with direct anastomosis. One year later the patient is free of symptoms and without local or distance recurrence of the disease.",
    "discussion": "Bronchial carcinoid tumours constitute 1-5% of all lung tumours. They derive from neuroendocrine cells that the normal lung contains within the epithelium of the airways as single cells or as\nclusters, known as neuroepithelial bodies. (1) Most patients are younger than 40 and there is neither age predilection nor any relation to smoking or other environmental factors. There are two types\nof bronchial carcinoid: typical and atypical carcinoid. (2) Typical carcinoid represents the majority of cases (85% to 90%) and follows a relative benign course without presenting secretory activity\nor metastasis to distant sites. (3) On the other hand atypical carcinoids present clinical and cellular characteristics intermediate ranging from typical carcinoid to small cell carcinoma of the\nlung. (2) They present with coughing, wheezing or relapsing pneumonia due to obstructive phenomena. Due to their high vascularity (they receive blood supply from bronchial arteries) they may cause\nhemoptysis. They may secrete enough ACTH to cause Cushing\u2019s syndrome, while carcinoid syndrome is rare and presents if only liver metastases exists. (4) Symptoms from intraluminal growth of\nthese tumours may be the initial presentation of these lesions. Radiographically carcinoid tumours are usually solitary, round or oval, well-defined lesions and rarely exceed 4cm. Calcifications with\na variety of patterns are occasionally identified and the tumour presents marked enhancement on CT and MRI examination. MRI may be more accurate in detecting these lesions since in T2-weighted\nsequences the high signal of the tumour compared with the dark background of the lung parenchyma makes the lesion more obvious than in CT. PET scanning on the other hand, due to the low metabolism of\nthese tumours, does not demonstrate high uptake of FDG and does not allow the detection of the lesion or the differential diagnosis from benign pulmonary nodules (5)",
    "differential_diagnosis": "Carcinoid, tumor, of, the, trachea",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003609/000001.jpg?itok=G4WGUZaw",
            "caption": "Small oval lesion attached to the posterior wall of the trachea."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003609/000002.jpg?itok=MTEsF7cf",
            "caption": "Polypoid intraluminal lesion with strong enhancement after contrast agent administration"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003609/000003.jpg?itok=BSIYKdFY",
            "caption": "Polypoid intraluminal lesion protruding from the posterior wall of the trachea with strong enhancement after contrast agent administration"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003609/000004.jpg?itok=Nv8_MiSD",
            "caption": "Small spherical reddish lesion attached to the posterior wall of the trachea covered by an intact mucosa"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/3609",
    "time": "17.02.2006"
  },
  "3622": {
    "case_id": 3622,
    "title": "Focal Pure Ground Glass Opacity (pGGO) in metachronous neoplasias",
    "section": "Chest imaging",
    "age": "62",
    "gender": "male",
    "diagnosis": "Bronchioloalveolar Carcinoma (BAC).",
    "history": "An asymptomatic 62 years old man underwent to a follow up total body CT for restaging after surgery for kidney and rectum cancers.",
    "image_finding": "A Patient underwent to total nephrectomy for an atypical cyst localized at the lower pole of the left kidney; histologically it was a clear cell adenocarcinoma (Fig. 1). One year later a rectum\nresection was performed for primitive adenocarcinoma. Three years later a total body ct showed a focal pure ground glass opacity (pGGO) at the left lower lobe (Fig.2a-c). A six monthly HRCT control\nwas performed to verify the lesion: it was the same in size and morphology (Fig. 3a-c). Because of peripheral lung nodules with a large ground glass opacity component (1) or pure ground glass opacity\n(pGGO) on thin-section computed tomographic scan, which do not disappear during follow-up, tend to be bronchioloalveolar carcinomas or minimally invasive adenocarcinomas of the lung, a lobectomy was\nperformed (a thoracoscopic wedge resection was not possible because of the site of the lesion) to assess the true nature of the lesion as regard to establish if it was a focal bronchioloalveolar\ncarcinoma (BAC), an atypical adenomatous hyperplasia (AAH) or post-traumatic fibrosis (four years before he had had a chest trauma). On histology multiple foci of bronchioloalveolar adenocarcinoma\nwere present (Fig.4a-i).",
    "discussion": "Clear cell carcinoma of the kidney may present as a solid, papillary or, less commonly, a cystic neoplasm (2). Also BAC shows heterogeneous patterns; it may present as: 1) Solide nodule or mass; 2)\nPure ground glass opacity (pGGO); 3) Area of focal or diffuse consolidation; 4) Diffuse ill-defined nodules (with centrilobular or random distribution); 4) Multifocal ground-glass opacity with or\nwithout interlobular septal thickening: \"crazy paving pattern\"; and less commonly, as \"Tree in bud\" pattern. The most common presentation of BAC is like a solitary nodule (3,4) with a typical\nspiculated appearence (5); the nodule may be associated with both soft tissue opacity and areas of ground glass opacity or present as a focal area of pure ground glass opacity (pGGO) (4). The GGO is\na common finding on high resolution CT characterized by areas of increased attenuation of the lung with preservation of bronchial and vascular margins. It may correlate with different pathogenic\nprocesses, such as like partial filling of air spaces, increased capillary blood volume, inflammatory or fibrotic interstitial thickening. Infiltrative GGO can representing either interstitial or\nalveolar processes. GGO is a non specifing finding; however, the correlation with any of the associated CT findings (nodular lesions, consolidation, septal thickening, fibrosis, vessels or airway\ncalibre alterations, air trapping), and clinical data is helpful in narrowing the range of diagnostic possibilities, or even in suggesting a specific diagnosis (6). In BAC GGO results from the\ntendency of the tumor to spread locally using the lung structure as a stroma (lepidic growth); it may represent the presence of intra-alveolar tumor growth, and mucin and fluid produced by the tumor;\nfocal BAC may diffuse by bronchogenic spread(4). The pGGOs of lung cancer nodules do not only increase in size or density, but may also decrease rapidly or slowly with the appearance of solid\ncomponents. Close follow-up until the appearance of a solid component may be a valid option for the management of pGGO otherwise a transbronchial lung biopsy or a lobectomy should be performed.\nTherefore a pGGO must be always considered like a potential focus of BAC or adenocarcinoma.",
    "differential_diagnosis": "Bronchioloalveolar, Carcinoma, (BAC).",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003622/000001.jpg?itok=dOgww6uk",
            "caption": "Arterial phase: a contrast enhanced septated cyst at the left kidney lower pole: atypical cist, histologically clear cell adenocarcinoma."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003622/000002.jpg?itok=jp0H232S",
            "caption": "Lower lobe of the left lung: blood vessels inside a focal pure ground glass\nopacity (pGGO)."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003622/000003.jpg?itok=-3h-cCFj",
            "caption": "Branching Vessels."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003622/000004.jpg?itok=xl4yjf95",
            "caption": ""
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003622/000005.jpg?itok=cj2b-Fep",
            "caption": "6 months later the focal area of pure ground glass opacity (pGGO) was the same\nand no other lesions were found in the lungs."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003622/000006.jpg?itok=zF4Y22s9",
            "caption": ""
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003622/000007.jpg?itok=UsITlij6",
            "caption": ""
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003622/000009.JPG?itok=weLQH0EY",
            "caption": "In the following pictures (a-i): microscopic cut sections of surgical specimens\nrelative to the focal ground glass area of the lung, showing multiple foci of\nBronchioloalveolar Carcinoma (BAC): machrophages and sheats of\nneoplastic cells."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003622/000008.JPG?itok=gOWhi2yB",
            "caption": ""
          },
          {
            "number": "Figure 4c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003622/000010.JPG?itok=Ckwl46OG",
            "caption": ""
          },
          {
            "number": "Figure 4d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003622/000011.JPG?itok=hd6y78JC",
            "caption": ""
          },
          {
            "number": "Figure 4e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003622/000012.JPG?itok=2JuqhkIB",
            "caption": ""
          },
          {
            "number": "Figure 4f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003622/000013.JPG?itok=7TxQSO96",
            "caption": ""
          },
          {
            "number": "Figure 4g",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003622/000014.JPG?itok=lNu-FBJZ",
            "caption": ""
          },
          {
            "number": "Figure 4h",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003622/000015.JPG?itok=eDPV01HJ",
            "caption": ""
          },
          {
            "number": "Figure 4i",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003622/000016.jpg?itok=zWGZDXQ6",
            "caption": ""
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/3622",
    "time": "22.02.2006"
  },
  "3686": {
    "case_id": 3686,
    "title": "Benign Metastasizing Leiomyoma (BML) presenting as  pulmonary mass lesions",
    "section": "Chest imaging",
    "age": "53",
    "gender": "female",
    "diagnosis": "Benign Metastasizing Leiomyoma (BML) of the lung.",
    "history": "A 53 year old non-smoker, Caucasian lady presented in the chest clinic with a history of progressive shortness of breath and a chronic cough for the last two years.",
    "image_finding": "Her past medical history included bronchiectasis since childhood for which she underwent a left lower lobectomy at the age of 13 and an abdominal hysterectomy for menorrhagia secondary to uterine\nfibroids at the age of 39. Her systemic examination was unremarkable apart from some coarse inspiratory crackles over right lung base. Investigations including full blood count, liver and renal\nbiochemistry were within the normal range. Aspergillus precipitans were negative. Sputum was negative for acid-fast bacilli, malignant cells and cultures were negative for any pathogenic organisms. A\nchest radiograph was performed (Figure 1) which was followed by a CT scan (Figures 2A, 2B, 2C & 2D). What is your differential diagnosis and what will you do next? A CT guided biopsy was\nperformed and the patient has now been followed up for 7 years and is well on no current therapy. What is your diagnosis?",
    "discussion": "Chest radiograph (Figure 1) shows a rounded soft tissue opacity in the right upper zone. The changes in the left lung base are longstanding and related to the previous left lower lobectomy. C.T chest\n(Figures 2A, 2B, 2C & 2D) demonstrates multiple rounded soft tissue attenuation lesions in both lungs, the largest lying posteriorly in right upper lobe, with no evidence of mediastinal\nlymphadenopathy. The biopsy from the right upper lobe lesion shows smooth muscle proliferation, without evidence of atypia, mitotic activity or necrosis; these are highly suggestive of a leiomyoma\n(Figure 3). Review of the histology from the previously removed uterine leiomyomas was performed, which showed a benign smooth muscle tumour. On immunohistochemical staining there was weak estrogen\nreceptor positivity, with appearances identical to the lung biopsy tissue. These findings confirmed the diagnosis of Benign Metastasizing Leiomyoma (BML). She has remained asymptomatic over last 7\nyears, with no change in the size of the lesion on follow up radiographs. BML is a rare condition usually seen many years after a hysterectomy for uterine leiomyomas (Ref.1).BML represents a rare\nform of a histologically benign tumour which behaves in a malignant fashion. It is believed that haematogenous spread of uterine leiomyomas may be responsible for the pulmonary or extra-pulmonary\nmetastases (Ref.2). Another view remains that these tumours are at the lower spectrum of leiomyosarcoma, as they are encapsulated and could cause metastasis (Ref.1, 3). Patients generally present\nbetween third and sixth decade with a past history of uterine leiomyomas, the youngest reported case in the literature was aged 23 (Ref.2). Presentation can be an incidental finding or with\nnon-specific symptoms in the form of a dry or a productive cough, shortness of breath, haemoptysis or recent bouts of chest infection. Physical findings are usually unremarkable. A high degree of\nclinical suspicion is required to diagnose this condition. BML is an important diagnosis to consider in middle aged females with a past history of uterine leiomyomas. This patient presented with\nBronchiectasis raising the question whether any correlation between the two conditions exists or is this a rare incidental occurrence. The typical imaging findings include well defined multiple\npulmoary mass lesions with no particular zonal predominance. Usually no pleural effusions or lymphadenopathy is seen. The diagnosis is confirmed by fine needle cytology or biopsy of the lesions\nperformed under image guidance, at bronchoscopy (Ref.3, 4) or following surgical removal. The management of this condition is wide ranging. The role of estrogens in the development of this condition\nis yet to be fully proven, but the presence of hormonal receptors makes them amenable to hormonal therapy including estrogen receptor modulators and aromatase inhibitors. Large nodules causing\ndisabling symptoms in the form of haemoptysis or recurrent chest infections can be removed surgically or during bronchoscopy, although recurrences have been reported (Ref.4).",
    "differential_diagnosis": "Benign, Metastasizing, Leiomyoma, (BML), of, the, lung.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003686/000001.jpg?itok=RWCnD6B7",
            "caption": "PA Chest Radiograph showing a rounded soft tissue opacity in the right upper zone.The changes in the left lung base are longstanding and related to the previous left lower lobectomy"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003686/000002.jpg?itok=C6cs7wGL",
            "caption": "CT Chest.Lung Windows demonstrating multiple rounded soft tissue attenuation lesions in both lungs, the largest lying posteriorly in right upper lobe,with no evidence of mediastinal lymphadenopathy."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003686/000003.jpg?itok=PVuyLFiz",
            "caption": "Fig.2B.Chest CT (Figures 2A,2B &amp; 2C) demonstrates multiple rounded soft tissue attenuation lesions in both lungs, the largest lying posteriorly in right upper lobe,with no evidence of mediastinal lymphadenopathy"
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003686/000004.jpg?itok=C79pRI6K",
            "caption": "C.T chest (Figures 2A,2B &amp; 2C) demonstrates multiple rounded soft tissue attenuation lesions in both lungs with no calcification, the largest lying posteriorly in right upper lobe,with no evidence of mediastinal lymphadenopathy"
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003686/000006.jpg?itok=J3NehQNv",
            "caption": "Fig.2D. CT Chest. Lung windows showing multiple small soft tissue nodules in the right lung."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003686/000005.jpg?itok=7lVRDDBL",
            "caption": "The biopsy from the right upper lobe lesion shows smooth muscle proliferation, without evidence of atypia, mitotic activity or necrosis; these are highly suggestive of a leiomyoma"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/3686",
    "time": "16.11.2006"
  },
  "3703": {
    "case_id": 3703,
    "title": "Inflammatory Mediastinal Mass: A Complication of Continuous 5 Fluorouracil Infusion through a Hickman Cathete",
    "section": "Chest imaging",
    "age": "57",
    "gender": "female",
    "diagnosis": "Mediastinitis secondary to central extravasation of 5-fluorouracil and central thrombophlebitis",
    "history": "We describe a case of mediastinitis and upper-body venous thrombosis caused by catheter-related thrombophlebitis and probable superior vena cava / left brachiocephalic vein perforation with\nsubsequent 5-fluorouracil extravasation in a patient undergoing a post-operative chemotherapy for metastatic pancreatic cancer.",
    "image_finding": "In June 2001 57 year old woman had a left subclavian Hickman catheter inserted for the administration of 5 fluorouracil for metastatic pancreatic adenocarcinoma. Three weeks into her treatment the\npatient experienced a pleuritic right sided chest pain radiating to the ipsilateral shoulder. She received symptomatic treatment in the form of dihydrocodeine and diclofenac. Three weeks later, and\ndespite continuous use of analgesics, the patient presented with a similar type of pain. A chest radiograph showed the tip of the central line lying in the course of the left brachio-cephalic vein\n(Fig. 1). Colour-duplex ultrasound showed no venous thrombosis and she was sent home. In her last week of the treatment the patient was hospitalised with severe chest pain, a hoarse voice and painful\nswelling of the left arm. Colour-duplex ultrasound showed left subclavain vein thrombus. Analgesics and a therapeutic dose of low molecular weight heparin were prescribed and the central vein\ncatheter was removed. The patient\u2019s symptoms gradually improved, no infectious source was found and the patient was commenced on anticoagulant therapy. A computed tomography scan of the thorax\nrevealed a superior mediastinal soft tissue mass encircling the superior vena cava and surrounding the great vessels (Fig. 2). These findings were consistent with mediastinitis presumed to be\nsecondary to extravasation of 5FU. She was discharged home on warfarin and dihydrocodeine. A second computed tomography scan, two months later, showed resolution of the mediastinal mass (Fig 3) but\nprogressive metastatic disease in the liver. She died twelve weeks later.",
    "discussion": "Two hazards of infusional chemotherapy combined to cause this patient\u2019s symptoms, extravastion of vesicant agent and catheter-related thrombophlebitis. Vesicant agent extravasation is a major\ncomplication of chemotherapy. Pain, soft tissue swelling, and superficial ulceration are common after vesicant extravasation into the skin. The degree of tissue damage relates to the amount and the\nconcentration of the drug extravasated and the local tissue response to injury1. Vesicant agents given by continuous infusion increase the risk of extravasation1 and it is\nrecommended that when vesicants are administered by continuous infusion, a central vein catheter or a portacath is used2. However, extravasation even in this setting can occur from fibrin\nsheath formation (catheter tip encasement acting as a one way valve), catheter fracture, suture nick, device defect, or venous perforation from catheter erosion2. Although confirmatory\ncontrast venography was not carried out, a superior vena cava or left brachiocephalic vein perforation seems the most likely explanation for this patient\u2019s symptoms. The pleuritic right sided\nchest pain radiating to the tip of right shoulder can be attributed to involvement of the right mediastinal pleura. Irritation of the mediastinal parietal pleura results in referred pain to the\nipsilateral root of the neck and over the ipsilateral shoulder, mediated via the phrenic nerve (C3 to C5 dermatomes)3. Hickman catheters provide safe and long-term venous access\nparticularly in patients with solid tumours who benefit from outpatient infusional therapy that enhances their quality of life and avoids costly inpatient treatment. However, the widespread use of\nHickman catheters has been accompanied by significant complications. Ray et al4 reported that approximately 30%of Hickman lines required elective removal because of sepsis, thrombosis,\nmigration or blockage. Catheter-related venous thrombosis has been observed particularly in patients with solid tumours, complicating up to 28% of catheters5,6 . Some of this is due to the\nhypercoagulable state of the patients with solid tumours as well as the local irritant effects of chemotherapy. In this case the left subclavian thrombus is a clear demonstration of catheter-related\nvenous thrombosis. More unusual is the simultaneous presentation of left arm swelling and hoarseness of voice. It has been postulated that mediastinal inflammation secondary to catheter-related\nthrombophlebitis may be a cause of recurrent laryngeal nerve palsy (RLNP)7.8 . Keidan et al.7 reported three patients with major thrombophlebitis of the superior vena cava or\nits main tributaries, who at the time were receiving infusional chemotherapy through a central vein catheter and complained of hoarseness of voice. One of those patients had solitary thrombus in the\nleft subclavian vein. Vocal cord paralysis and RLNP were confirmed by direct laryngoscopy. Chest computed tomography revealed marked inflammatory changes in the superior mediastinum in two of those\npatients. Direct laryngoscopy was not performed in our case but the acute onset of hoarseness of voice, the associated left subclavian thrombus, and the speedy recovery following central catheter\nremoval strongly points to a transient RLNP as a sequel of thrombophlebitis induced mediastinal inflammation. Furthermore, the presence of an extravasation\u2013related mediastinal mass would have\ncontributed to this particular sequel.",
    "differential_diagnosis": "Mediastinitis, secondary, to, central, extravasation, of, 5-fluorouracil, and, central, thrombophlebitis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003703/000001.jpg?itok=0MmtJTgT",
            "caption": "Figure 1\nChest radiograph: shows the tip of the central venous catheter lying in the\n line of  the left brachio-cephalic vein"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003703/000002.jpg?itok=YC6b3xS0",
            "caption": "Figure 2\nChest computed tomography scan: superior mediastinal soft tissue mass encircling the superior vena cava and surrounding the great arteries"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003703/000003.jpg?itok=DLOn6zVB",
            "caption": "Figure 3\nChest computed tomography scan (two months later): resolution of the mediastinal mass"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/3703",
    "time": "20.11.2007"
  },
  "3831": {
    "case_id": 3831,
    "title": "Pulmonary Alveolar Microlithiasis",
    "section": "Chest imaging",
    "age": "19",
    "gender": "male",
    "diagnosis": "Pulmonary alveolar microlithiasis",
    "history": "Routine chest x-ray of an asymptomatic patient disclosed an interstitial bilateral micronodular pattern. HRCT showed a diffuse micronodular pattern, randomly distributed in the lung parenchyma,\nassociated with thickening of the subpleural and mediastinal interlobular septa. Individual nodules had spontaneous high density. CT-guided lung biopsy was performed, pathologist disclosed\nintraalveolar microliths.",
    "image_finding": "A routine chest x-ray of an asymptomatic patient disclosed an interstitial bilateral micronodular pattern, obscuring the diaphragmatic and cardiac contours (Fig.1). There was no previous history of\noccupational diseases, allergies or medications. Physical examination and laboratory data were normal. Blood gases revealed PO2 values of 75 mmHg, PCO2 42 mmHg, pH 7.4 and O2 saturation of 95%. A\nrestrictive pattern was present, with a decrease of the single breath diffusing capacity for carbon monoxide. HRCT performed showed a diffuse micronodular pattern, randomly distributed in the lung\nparenchyma, associated with thickening of the subpleural and mediastinal interlobular septa, displaying the characteristic pattern of a shaggy heart. Individual nodules had spontaneous high density\nenabling their identification with soft tissue window along interlobular septa (Fig.2- Fig.3). A CT-guided lung biopsy was performed. Pathology disclosed intraalveolar microliths with a concentric\nlamellar structure, without alveolar wall involvement or interstitial fibrosis (Fig.4).The patient underwent treatment with diphosphonate during three years without any substantial modification of\nthe clinical picture.",
    "discussion": "Pulmonary alveolar microlith\u00edasis is a rare entity first described in 1918 by Harbitz, and definitive characterized by Sosman in 1957 [1]. Although of unknown origin an autosomal recessive\nheritance was suggested. From the pathological point of view it consists in the widespread deposit of hidroxyapatite crystals occupying the alveoli. Plethysmography is consistent with this data\nrevealing reduced lung volumes and diffusion capacity [1].There is no age or sex predominance. Patients are usually asymptomatic and the disease follows an indolent course, that within one or two\ndecades may end up with the development of pulmonary fibrosis, hypertension and cor pulmonale [2,3]. Laboratory data is usually non-specific without evidence of hypercalcemia or hypercalciuria [2,3].\nThe paucity of clinical manifestations usually contrasts with the striking abnormalities seen on chest radiographs [3]. The radiographic appearance is characteristic and pathognomonic, showing minute\n\u201csand-like\u201d calcifications, diffusely scattered throughout both lung fields, with higher density at lung bases with a predominantly subpleural location. Since interlobar fissures and\npleural lines are prominent the \u201cblack pleural line\u201d sign was described by Felson corresponding to a linear radiolucency of 1-2 mm [3,4,5]. Findings on HRCT consist of diffuse calcific\nnodules along the sub-pleural spaces, ground-glass opacities and interlobular septal thickening. The counterpart of the \u201cblack pleural line\u201d is formed by a fat density-layer of 1-2 mm\nlocalized between the ribs and the adjacent pulmonary parenchyma, visible from the middle to lower zones [4,5]. On MRI the scattered microliths may cause increased signal intensity on T1-weighted\nimages. Interstitial fibrosis and thickened alveolar walls seen in advanced stages of the disease show high signal intensity on the T2-weighted images [4]. So far no effective treatment to this\ndisease exists and diphosphonate is usually used in order to inhibit microcrystal growth despite a weak evidence of its clinical efficacy and the non-negligible risk of bone fractures. In patients\nwith end-stage disease therapeutic options may include combined heart/lung transplantation.",
    "differential_diagnosis": "Pulmonary, alveolar, microlithiasis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003831/000001.jpg?itok=49Gr_-YW",
            "caption": "Chest radiograph, showing diffuse calcified micronodules, obscuring the diaphragm and heart contours."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003831/000002.jpg?itok=HdIBIWMd",
            "caption": "Chest HRCT showing a bilateral, symmetrical, micronodular pattern with a random distribution accompanied by thickening of interlobular septa at the mediastinal contour resulting in the \u201cshaggy heart\u201d appearance."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003831/000003.jpg?itok=DoGpj8bF",
            "caption": "Chest HRCT showing dense calcic densities in lung parenchyma, along interlobular septa."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003831/000004.jpg?itok=QC5t5a9U",
            "caption": "Lung biopsy (Hematoxylin-eosin stain) showing intraalveolar microliths with concentric lamellar structure, without alveolar wall involvement."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/3831",
    "time": "25.07.2005"
  },
  "3834": {
    "case_id": 3834,
    "title": "Accelerated Phase Usual Interstitial Pneumoni",
    "section": "Chest imaging",
    "age": "67",
    "gender": "female",
    "diagnosis": "Accelerated Phase Usual Interstitial Pneumonia",
    "history": "Accelerated phase usual interstitial pneumonia (UIP) is a relatively rare condition in which there is an acute deterioration in lung function of patients previously suffering from stable idiopathic\npulmonary fibrosis. This is associated with a ground glass appearance superimposed on a background of fibrosis on HRCT.",
    "image_finding": "A 67 year old lady presented to the Respiratory Medicine Department of our institution with a persistent productive cough. Her chest radiograph demonstrated basal reticular shadowing consistent with\nfibrosis (figure 1). Transbronchial biopsies taken at this time produced non-specific changes. The original HRCT performed showed bilateral reticular opacity in a predominantly subpleural\ndistribution with overall features consistent with a UIP pattern (figure 2). A clinical diagnosis of idiopathic pulmonary fibrosis was made. Within a year of the original diagnosis a sudden\ndeterioration in respiratory function occurred. This was on the background of stable respiratory function since presentation. The acute presentation included profound breathlessness requiring high\ndependence support. No specific signs of infection were seen. A CT Pulmonary Angiogram (CTPA) was performed as the differential included pulmonary embolus as well as exacerbation of usual\ninterstitial pneumonia. The CTPA demonstrates a reticular pattern with predominantly bibasal peripheral fibrosis similar to that seen on previous imaging. In addition to this extensive new diffusely\ndistributed ground glass opacity is seen. Breathing artefact is present which is a reflection of the acute illness (see figure 4). No evidence of pulmonary embolus was seen. The radiological\nfeatures, combined with the clinical presentation, were typical of accelerated phase UIP. Despite high dose corticosteroid therapy the patient died.",
    "discussion": "The term Usual Interstitial Pneumonia (UIP) describes the histopathological process that occurs in the lungs in association with a clinical diagnosis of Idiopathic Pulmonary Fibrosis (IPF). The\ncondition is one of the recognised idiopathic interstitial pneumonias that have recently been reclassified by the American Thoracic Society and European Respiratory Society working group\n1. Most patients with IPF undergo a gradual deterioration but in a small proportion of cases a more dramatic clinical deterioration can be seen in association with increased chest\nradiographic shadowing. Akira et al. assessed the accelerated deterioration of patients with UIP using CT 2. Their primary finding was of increased parenchymal opacification superimposed\non the pre-existing reticular fibrotic pattern. Three patterns of distribution of the acute opacity were identified which corresponded with the prognosis and enabled prediction of response to\ntreatment. The first group had peripheral opacity, showed varying degrees of benefit from corticosteroids and carried the best prognosis. Histologically this group demonstrated acute fibroblastic\nproliferation. The second group demonstrated a diffuse pattern of opacity, described by Akira et al as resembling acute interstitial pneumonia superimposed on a background of chronic UIP. This group\nhad the worse prognosis. A third group had a prognosis between the two described above and demonstrated multifocal opacity. Multlifocal and diffuse patterns exhibit \"fulminant acute diffuse alveolar\ndamage with thickening of the alveolar walls due to oedema, inflammatory cells and active fibroblastic proliferation and hyaline membrane formation\" histologically. Indeed Parambil et al also found\ndiffuse alveolar damage as the predominent histological feature in addition to the underlying IPF in acute axacerbations of UIP3.In this case the new opacity is diffuse and concurs with\nthe reports in terms of outcome. In patients with known idiopathic interstitial lung diseases such as UIP it is important to consider the accelerated phase of the condition when determining the cause\nfor a sudden deterioration. Furthermore differentiation from infection and pulmonary embolism is important in establishing optimum therapy.",
    "differential_diagnosis": "Accelerated, Phase, Usual, Interstitial, Pneumonia",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003834/000001.jpg?itok=NisYHI4F",
            "caption": ""
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003834/000003.jpg?itok=QSZ0Zhb-",
            "caption": ""
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003834/000004.jpg?itok=oRWrv3U5",
            "caption": "This image demonstrates the reticular pattern typicial of Idopathic Pulmonary Fibrosis. The features on this image are predominantly reticular subpleural changes."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003834/000005.jpg?itok=gwQSIl7c",
            "caption": "This image demonstates the other changes of IPF with focal areas of honeycombing seen medially adjacent to the aorta and spine."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003834/000006.jpg?itok=A7NrQVf4",
            "caption": "This image is taken at a similar level to the images prior to the acute deterioration inorder to show the direct changes. The acute scan was done as a CTPA protocol which is aquired spirally but the slice thickness of 3mm is the same as the previous scan. There has been a change in the extent of reticular fibrotic change, but the primary feature is the extensive superimposed ground glass change."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003834/000007.jpg?itok=ShproHmf",
            "caption": "The widespread ground glass change is again seen. The motion artifact is a reflection of the severity of the acute respiratory distress."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/3834",
    "time": "07.03.2007"
  },
  "3842": {
    "case_id": 3842,
    "title": "Pulmonary septic emboli",
    "section": "Chest imaging",
    "age": "30",
    "gender": "male",
    "diagnosis": "Pulmonary septic emboli",
    "history": "Our patient had fever (38-39\u00b0C), unproductive cough and pleuritic pain. X-ray showed ill defined peripheral nodular infiltrates. CT showed multiple subpleural nodules, related to terminal branches of the pulmonary artery, some with a peripheral cavitation with crescent shape. Blood culture was positive for S. aureus and echocardiography showed tricuspid vegetation.",
    "image_finding": "The patient presented to the emergency room with malaise, fever (38-39\u00b0C), unproductive cough and pleuritic chest pain with seven days of evolution. Physical examination showed: body temperature (39\u00b0C), tachycardia with normal cardiac sounds, and tachypnea with symmetric murmur on pulmonary auscultation. Laboratory data showed: Anemia (Hb- 10,7mg/dl), leukocytosis (14300cells/dl) with neutrophilia (91%), elevation of PCR (32mg/dl), and normal blood gases. Admission chest X-ray showed ill defined nodular infiltrates, predominantly in the periphery of lower lobes, some presenting a silhouette sign with the left cardiac border and diaphragm. One of the opacities, in the lower left pulmonary field, had a central hypertranslucency that was related to cavitation (Fig. 1). On CT scan we could see in all pulmonary lobes multiple subpleural nodules, closely related to terminal branches of pulmonary artery. The nodules measured less than 2cm, had well defined borders and some had a peripheral cavitation with a crescent shape (Figs. 2, 3); in the lower lung lobes, there were areas of consolidation with ill defined borders and air bronchograms (Fig. 4). The patient also had a blood culture (positive for S. aureus) and an echocardiography, which showed cardiac vegetation on the tricuspid valve. After two months of intravenous antibiotics, blood cultures became negative, cardiac vegetation disappeared and chest x-ray didn\u2019t show any lesion.",
    "discussion": "This entity consists in thromboembolic material with septic origin causing the occlusion of small pulmonary arteries [1]. Septic thrombus can arise from endocarditis (most frequently associated with intravenous drugs abuse), infected catheter, abscess, septic thrombophlebitis, urinary and odontogenic infection. The etiological agent is usually S. aureus [2]. Prognosis is closely related to early diagnosis; establishing the diagnosis is not always straightforward since radiographic signs may be non-specific, blood cultures negative, and heart murmur undetectable [3]. Chest x-ray remains the screening test, although findings are nonspecific (multiple, bilateral, peripheral nodular lesions with ill defined borders, some with cavitation and pleural effusion) [4]. CT is more sensitive and specific. Documented findings include: multiple peripheral parenchymal nodules, a feeding vessel sign, cavitation, and wedge-shaped peripheral lesions abutting the pleura. Additional findings may be infiltrates, air bronchograms within nodules, and extension into the pleural space [3]. Diagnosis is made on the basis of characteristic imaging abnormalities in association with one or more of the following criteria: Positive blood cultures, tricuspid valve vegetations proven by echocardiography, a compatible clinical course, or other signs of septic embolization [5]. Treatment consists of intravenous large spectrum antibiotics, until blood cultures become negative and valve vegetation disappeare.",
    "differential_diagnosis": "Pulmonary, septic, emboli",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003842/000001.jpg?itok=qMSoVkDq",
            "caption": "Chest X-ray shows nodular infiltrates with ill-defined borders, predominantly in lower zones of both fields. \nOne opacity in the lower left pulmonary field as a central lucency"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003842/000002.jpg?itok=iA3sba3d",
            "caption": "Three well defined peripheral nodules, closely related with terminal branches of pulmonary artery; two nodules have a peripheral cavitation with crescent shape."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003842/000003.jpg?itok=XM95CZQM",
            "caption": "Multiple peripheral nodules in lower lobes, closely related with terminal branches of pulmonary artery. One nodule is cavitated."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003842/000004.jpg?itok=pWGetYlf",
            "caption": "Areas of consolidation with air bronchograms in lower lobes."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/3842",
    "time": "27.03.2008"
  },
  "3890": {
    "case_id": 3890,
    "title": "Amiodarone pulmonary toxicity",
    "section": "Chest imaging",
    "age": "60",
    "gender": "female",
    "diagnosis": "Amiodarone pulmonary toxicity",
    "history": "Our patient who was on long term amiodarone treatment presented with a 10 day history of cough and dyspnea. Chest X-ray showed multiple pulmonary infiltrates. HRCT depicted patchy areas of ground\nglass attenuation and areas of consolidation, with a peripheral and peribronchovascular distribution, associated with dilated bronchi. The amiodarone was discontinued and the patient treated with\ncorticosteroids.",
    "image_finding": "The patient presented to the emergency room a ten day history of malaise, low grade fever, unproductive cough and dyspnea. Physical examination revealed: body temperature (38,50C), tachycardia and\ndiffuse lung crackles. There was a history of auricular fibrillation for which the patient had been treated with amiodarone (400mg/day), but there was no known occupational exposures. Chest X-ray\nshowed multiple infiltrates in both pulmonary fields with ill-defined borders and linear opacities predominantly in lung bases. There was also elevation of left diaphragm and plate atelectasis (Fig\n1) parallel to the diaphragm extending to the pleural surface. HRCT demonstrated ground glass attenuation and areas of consolidation throughout both lungs with a peripheral and peribronchovascular\ndistribution; some of these areas were associated sometimes to dilated bronchi (Figs 2, 3, 4). The patient underwent bronchoscopy with biopsy, which revealed thickening of interlobular septa and\nintra-alveolar accumulation of macrophages with foamy cytoplasm. Discontinuation of the drug and treatment with corticosteroids resulted in a marked improvement of pulmonary function in the\nsubsequent days. The patient is in the second year of follow-up and continues to have normal pulmonary function and chest CT.",
    "discussion": "Amiodarone is a drug with iodine moieties, very useful and effective in the treatment of tachyarrhythmias. Unfortunately it is associated with numerous side effects: rashes, photophobia, hepatitis,\npulmonary toxicity and cardiotoxicity. Pulmonary complications show a dose relationship, with no reported toxicity with less than 400 mg daily. This reaction occurs following 1 to 10 months on the\ndrug, with a median duration of 6 months. Making the diagnosis of pulmonary toxicity is very difficult because symptoms are insidious and nonspecific (malaise, fever, shortness of breath) and are\neasily confused with infection, cardiac failure and pulmonary infarction (1). Radiographic signs include areas of consolidation or interstitial disease, which are nonspecific. Without knowledge of\ndrug exposure, several diagnoses need to be considerate([2). Usual CT findings are also nonspecific and include ground glass opacities in association with fine intralobular reticulation. Foci of\nconsolidation have also been described. More characteristic is the presence of high attenuation parenchymal-pleural lesions (82-174HU), predominantly located at the periphery of the lung and at lung\nbases, which weren\u2019t visualized in our case (3). Some histologic patterns are usually associated with amiodarone induced pulmonary lung disease, namely NSIP and COP (3,4,5) . NSIP is a mixture\nof signs of active inflammation and long-standing chronic fibrous changes, being histological divided in three sub-types accordingly to inflammatory or fibrotic predomination. Typical HRCT features\ninclude areas of ground-glass attenuation with a subpleural distribution and involving predominantly middle and lower lobes (80% of the cases) sometimes associated with a reticular pattern (50% ) or\nto bilateral, subpleural and symmetric consolidations (30%) (3,4,5). Idiopathic cryptogenic organizing pneumonia (COP) is characterised histologically by the presence of plugs of granulation tissue\nin the lumen of the distal air spaces -respiratory and terminal bronchioles, alveoli and alveolar ducts- associated with a variable degree of interstitial and air space infiltration with mononuclear\ncells and foamy macrophages. The most common HRCT appearance of COP consists of bilateral patchy areas of consolidation or a combination of consolidation and ground glass attenuation in a\npredominately subpleural and peribronchovascular distribution. Many atypical radiological presentations have been reported including multiple linear or ring shape opacities and multiple large nodules\nor masses (3,4,5). Liver, spleen and myocardium attenuation is also increased in some cases, with attenuation values ranging between 90 and 110 HU [3]. Treatment includes cessation of amiodarone and\ncorticosteroids, but in some cases the disease still progresses to respiratory failure (1, 2, 3).",
    "differential_diagnosis": "Amiodarone, pulmonary, toxicity",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003890/000001.jpg?itok=KqcD24CM",
            "caption": "Chest X-ray shows multiple infiltrates in both pulmonary fields, without predominant distribution, linear opacities predominantly in lung bases, elevation of left diaphragm associated with plate atelectasis"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003890/000002.jpg?itok=pvhE4c_S",
            "caption": "HRCT shows patchy areas of consolidation and ground glass attenuation in peripheral and peribronchovascular distribution."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003890/000003.jpg?itok=fjiz5g4E",
            "caption": "HRCT shows areas of consolidation predominantly with peribronchovascular distribution, associated with dilated bronchi."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003890/000004.jpg?itok=-560bNq2",
            "caption": "HRCT shows peribronchovascular consolidations in lower lobes."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/3890",
    "time": "09.12.2005"
  },
  "3918": {
    "case_id": 3918,
    "title": "Pseudoaneursym secondary to deceleration injury",
    "section": "Chest imaging",
    "age": "41",
    "gender": "female",
    "diagnosis": "Aortic arch pseudoaneursym and descending thoracic aorta dissection.",
    "history": "A 41 year old female suffered a serious deceleration injury which resulted in the development of a pseudoaneursym distal to the left subclavian artery and a descending thoracic aorta dissection.\nThese injuries were repaired by thoracic aortic stenting.",
    "image_finding": "This 41 year old female was involved in a serious road traffic accident which resulted in a deceleration injury. She was wearing a seat belt. On presentation the patient was hypotensive and\ntachycardic. The presenting chest radiograph demonstrated mediastinal widening suggestive of mediastinal hemorrhage and an urgent CT chest was performed using a standard dissection protocol.\nFollowing appropriate windowing a thoracic arch pseudoaneursym was demonstrated distal to the left subclavian artery (figure 1). Dissection of the descending thoracic aorta 4cms distal to the\npseudoaneurysm (figure 2) was also detected. Significant peri-aortic mediastinal haematoma (figure 3) is often the first clue to significant mediastinal injury. Figure 4 shows the axial lung windows\nwhich demonstrate bilateral pulmonary contusions predominantly on the left but no pneumothorax or pneumomediastinum. The significant impact is further indicated by the presence of both a sternal\nfracture and a fracture of T12. The patient recovered fully following placement of a thoracic aortic stent.",
    "discussion": "Following aortic trauma thoracic dissections were found in 10% of cases of aortic tears. The most common site of aortic dissection is at the aortic isthmus (88-95%) as the brachiocephalic arteries\nand ligamentum arteriosum fix the aorta in this region. The antero-medial aspect of the aortic isthmus is most commonly affected. The imaging hallmark is the identification of the intimal flap which\nseparates the aorta into a true and false lumen. The diagnostic accuracy of multirow CT angiography for the detection of thoracic dissections approaches 100%. Fractures of the sternum are encountered\nin 4% of blunt chest trauma as part of steering wheel or seat-belt syndromes. In approximately 20% of cases the aortic injury may be limited to a partial circumferential tear in the intima and/or\nmedia of the aortic wall resulting in pseudoaneursym formation. The typical CT findings are a saccular outpouching demarcated from the aortic lumen by a collar. The integrity of the adventita is\nassumed in cases of pseudoaneursym formation. A chronic pseudoaneursym will develop in 2-5% of patients whose injury is not diagnosed. If treatment such as endovascular graft placement is not\nundertaken the aneurysm may eventually rupture. Thoracic dissections coexist with a pseudoaneursym in between 2-5% of cases.",
    "differential_diagnosis": "Aortic, arch, pseudoaneursym, and, descending, thoracic, aorta, dissection.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003918/000001.jpg?itok=g0TLiOaL",
            "caption": "Sagittal reconstruction demonstrating a pseudoaneursym and sternal fracture."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003918/000002.jpg?itok=A5HLP2OZ",
            "caption": "4 cms distal to the psudoaneursym is a partial descending thoracic aortic dissection."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003918/000003.jpg?itok=OFaIFNkM",
            "caption": "Axial image clearly showing siginifcant mediastinal haemorrhage around the ascending and descending aorta."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003918/000004.jpg?itok=nbogTus7",
            "caption": "Lung windows demonstrate left lung basal contusions but no pneumothorax"
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003918/000005.jpg?itok=qtLR4Bws",
            "caption": "Sagittal image demomstrating a sternal fracture as well as a fracture of hte T12 vertebra"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/3918",
    "time": "09.12.2005"
  },
  "3927": {
    "case_id": 3927,
    "title": "xtramedullary hematopoiesis",
    "section": "Chest imaging",
    "age": "27",
    "gender": "female",
    "diagnosis": "beta-thalassemia intermedia",
    "history": "A 27-year-old female patient presented with coughing and a persistent back pain. She denied fever, dyspnoea, wheeze, night sweats and haemoptysis.",
    "image_finding": "A 27-year-old female patient presented with coughing and a persistent back pain. She denied fever, dyspnoea, wheeze, night sweats and haemoptysis. Haematological examination showed a haemoglobin\nlevel of 1.2 mmol\u00b7L\u20131, haematocrit value of 0.16, mean corpuscular volume of 90.0 fL, mean corpuscular haemoglobin concentration of 412 g\u00b7L\u20131, red\nblood cell count of 2.7x1012 cells\u00b7L\u20131, reticulocyte count of 0.11, white blood cell count of 23x109 cells\u00b7L\u20131, and platelet\ncount of 1072x109 platelets\u00b7L\u20131. Posteroanterior chest radiograph showed well-marginated bilateral, paraspinal masses, and diffuse expansion of ribs with increased\ntrabecular pattern. The computed tomography of the chest revealed widening of the ribs and well-circumscribed bilateral paravertebral soft tissue mass adjoining the thoracic vertebra, without bone\nerosion. The peripheral blood smear showed marked anisopoikilocytosis, microcytosis, hypochromia, normoblasts and target cells. The haemoglobin electrophoresis findings revealed the diagnosis of\nbeta-thalassemia intermedia. Her anaemia was controlled by transfusion of packed red blood cells. Since complications due to extramedullary haematopoiesis (EMH), such as spinal cord compression,\nhaemothorax or pleural effusion were not determined, no additional radiotherapy or hydroxyure therapy was applied, due to their myelotoxic, cytostatic or hepatotoxic side-effects. Because her serum\nferritin was very high, the patient was given chelation therapy. She was recommended for periodic controls.",
    "discussion": "The terms myeloid metaplasia and extramedullary hematopoiesis (EMH) are used to describe a pathologic process of ectopic haematopoietic activity that may occur in any organ system but that primarily\naffects the liver and spleen. It occurs with a variety of chronic anemias and myeloproliferative disorders, such as sickle cell anemia, polycythemia vera, chronic myelogenous leukemia, and\nthalassemia. The liver, spleen, and lymph nodes are frequently involved as extraosseous locations because these are hematopoietic organs during embryonic life. It is rarely seen in Gaucher's disease,\nPaget's disease, alcohol-related macrocytosis, and congenital dyserythyropoietic anaemia. EMH usually occurs as a compensatory phenomenon with chronic anemia. This erythroid response is most often\nmicroscopic but can result in organomegaly or the development of tumour-like masses usually involving the liver, spleen and lymph nodes. Less frequently involved sites include the kidney, adrenal\nglands, breasts, spinal cord, intrathoracic cavity, pleura, pericardium and intracranial cavity. When the bone marrow dysfunction is obvious and intrathoracic EMH is suspected, the presence of the\ncharacteristic findings on a chest roentgenogram and chest CT scan should suffice to make the diagnosis. These characteristic findings are: widening of the ribs, unilateral or bilateral\nwell-circumscribed lobulated paravertebral mass lesions usually located caudal to the sixth thoracic vertebrae, subpleural paracostal masses without bony erosion, absence of calcification, and the\npresence of adipose tissue within the mass. Bone abnormalities are evident on plain radiographs. Expansion of the bone marrow is seen as osteoporosis with coarsened trabeculation. With severe\ninvolvement, there is expansion of the bony cortex. Spinal cord involvement may be suggested by the presence of paraosseous masses seen on chest radiographs. Along with the bone abnormalities, CT\ndemonstrates extramedullary hematopoiesis as a soft-tissue mass that is often adjacent to involved bone. Extramedullary hematopoiesis can be distinguished from the epidural fat because the former has\nattenuation similar to that of muscle and shows enhancement with intravenous administration of contrast material. MR imaging is the most effective method of demonstrating extramedullary hematopoiesis\nin the epidural space and is indicated on an urgent basis when symptoms of spinal cord compression are present. On T1-weighted images, extramedullary hematopoiesis is seen as an extramedullary mass\nwith signal intensity slightly higher than that of the adjacent red marrow of the vertebrae. Similar findings are seen on T2-weighted images, with the signal intensity of extramedullary hematopoiesis\nbeing only slightly higher than that of bone marrow. Use of contrast material is unnecessary. T2-weighted sequences may be useful, however, to demonstrate the high signal intensity of an injured\nspinal cord. This high signal intensity is due to oedema, myelomalacia, or gliosis of the spinal cord due to chronic compression. Intrathoracic EMH is most often asymptomatic and treatment is usually\nunnecessary, except in the presence of complications. Massive haemothorax, symptomatic pleural effusion, and spinal cord compression are complications of intrathoracic EMH. Since the haematopoietic\ntissue is highly radiosensitive, low-dose radiation has been suggested as an effective method for controlling symptomatic pleural effusion or masses.",
    "differential_diagnosis": "beta-thalassemia, intermedia",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003927/000001.jpg?itok=sewrP1i1",
            "caption": "Posteroanterior chest radiograph showed well-marginated bilateral, paraspinal masses compatible with extramedullary hemopoietic tissue, and diffuse expansion of ribs"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003927/000002.jpg?itok=XKuzY3l6",
            "caption": "computed tomography showing well circumscribed bilateral paravertebral soft tissue mass located at the thoracic vertebra, and widening of posterior ribs"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003927/000003.jpg?itok=arY-8QSQ",
            "caption": "computed tomography of the chest showing widening of anterior ribs"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003927/000004.jpg?itok=it1J2Ep-",
            "caption": "computed tomography showing well circumscribed paravertebral soft tissue mass located at the thoracic vertebra, and widening of posterior ribs"
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003927/000005.jpg?itok=tN4nWjhr",
            "caption": "computed tomography showing well circumscribed paravertebral soft tissue mass located adjoining the thoracic vertebra"
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003927/000006.jpg?itok=9FGJnXij",
            "caption": "computed tomography with pulmonary window settings confirming the extra-pulmonary soft tissue mass located at the thoracic vertebra"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/3927",
    "time": "14.12.2007"
  },
  "3944": {
    "case_id": 3944,
    "title": "TRAUMATIC PNEUMATOCEL",
    "section": "Chest imaging",
    "age": "14",
    "gender": "male",
    "diagnosis": "TRAUMATIC PNEUMATOCELE TYPE I",
    "history": "14 year old male, with blunt thorax trauma after falling down from a tree.",
    "image_finding": "Thorax blunt trauma",
    "discussion": "A laceration is defined as an abnormal intraparenchymal collection of air resulting from traumatic disruption of the lung architecture. Types of laceration: Type 1 is an air-filled cavity with or\nwithout an air-fluid level, resulting from sudden compression of a pliable chest wall wherein the air-containing lung ruptures. Type 2 is an air-containing cavity in a paravertebral\nlocation,resulting from severe compression of the more pliable lower chest wall and sudden shifting of the lower lobe across the vertebral body causing a shearing type of injury. Type 3 is a small\nperipheral cavity or peripheral linear radiolucency that is always close to the chest wall where a rib has been fractured, resulting from a fractured rib that has punctured the lung. Type 4 is a\nresult of previously formed, firm pleuropulmonary adhesions causing the lung to tear when the overlying chest wall is violently moved inward or fractures, diagnosed only at surgery or autopsy. The\nintraparenchymal collections of air described are also termed pneumatoceles. When traumatic cavities fill with blood, a hematoma forms. Radiographically, traumatic pneumatoceles and hematomas are not\nusually seen until a few hours or even several days after trauma, initially obscured by surrounding contusion. The size, shape, thickness of the wall, and number of pneumatoceles varies widely from\npatient to patient. Unlike simple contusion, which resolves fairly quickly and completely, a laceration generally takes weeks to months to resolve and may result in residual scarring. Occasionally,\npneumatoceles can become secondarily infected, resembling formation of a hematoma.",
    "differential_diagnosis": "TRAUMATIC, PNEUMATOCELE, TYPE, I",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000003944/000001.jpg?itok=a8Aj53rq",
            "caption": "two pneumatoceles near the pleura surface with fluid."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/3944",
    "time": "09.06.2008"
  },
  "4005": {
    "case_id": 4005,
    "title": "Breast/chest wall metastasis deriving from a carcinoma of the lung",
    "section": "Chest imaging",
    "age": "80",
    "gender": "male",
    "diagnosis": "Metastasis to the breast/chest wall from a lung carcinoma.",
    "history": "The majority of breast tumours are primary carcinomas and the breast being the site of metastasis is only rarely seen. In this case the breast mass in a male was the result of an unusual metastatic\npattern.",
    "image_finding": "A man, who had been a heavy smoker for 65 years, attended the breast surgery department with a 5 x 5 x 3 cm palpable tumour of the right breast. It was located 5 cm. lateral of the right mammarian\npapilla. The tumour was adherent to the fascia but not to the thorax wall. Because of age restrictions neither mammography nor ultrasonography (< 75 years) was performed. Instead a palpatory,\nhistological biopsy was collected. The mass contained adenocarcinoma as well as small cell carcinoma. No glandular configurations were seen, why breast carcinoma in origin could be excluded. Lung or\nthyroid cancer was suggested. Ultrasonography of the thyroid gland revealed no tumour. Conventional X-ray of the thorax (single picture, frontal projection), revealed a tumour at the level of the\nlower part of the right lung. Still, without the lateral projection it was impossible to determine, if the tumour was located in the lung or in the breast. No other tumours were suspected from the\npicture. Next a CT-examination of the upper abdomen was performed, on which the breast mass was clearly seen. Furthermore the images revealed a 2.8 x 2.7 x 2.3 cm lobulated tumour of the anterior,\nlower part of the right lung, as well as a focal thickening of the pleura in the space between costa 7/8 on the right side. Based on the advanced disease and the general condition of the patient, he\nwas scheduled to receive palliative radiation therapy solely. He died two months later.",
    "discussion": "Malignant tumours of the male breast only accounts for 1-2 % of the primary breast carcinomas. Furthermore, the breast is an unusual site for metastasis. According to the WHO classification of\ntumours, only 0.5-6% of breast malignancies are metastases from other organs. Lymphomas, malignant melanomas, gastrointestinal tumours (GIST) and bronchial carcinomas account for most of the\nmetastases to the breast, but metastases are occasionally seen from carcinomas of the cervix, ovary, endometrium, plasma cell myeloma and from the kidney. In this case the breast/chest wall mass\nderived from a mixed lung tumour containing adenocarcinoma and small cell carcinoma. Cancer of the lung most often disseminates to the bones, liver, brain, contralateral lung or to the suprarenal\nglands. Unusual sites of metastasis involve iris, placenta, vagina and breast. Most primary chest wall tumours are benign \u2013 the majority being lipomas. Metastases as well as primary\nmalignancies of the chest wall are rare. The typical CT-appearance of a metastatic deposit in the soft tissue of the chest wall is a round or lobulated, often homogeneous, lesion, intensely enhancing\nafter administration of iv. contrast. In contrast to primary chest wall tumours which can be large, diffusely infiltrating and rapidly growing, the metastases tends to be smaller with more\nwell-defined borders. Still, in the male patient or in a female with limited glandular tissue, a metastasis to the breast from a distant tumour can be problematic to distinguish from a breast/chest\nwall metastasis, since the musculature can be infiltrated in either case. To distinguish between primary malignancies of the breast and metastatic deposits, a histological biopsy of the breast mass\nis mandatory in every case to secure the correct treatment of the patient. If the patient is male, the importance of this is emphasised, since the incidence of primary cancer of the male breast in\ngeneral is low. In case a metastatic deposit in the breast or in the chest wall is suspected, a CT scan is needed to determine the origin and eventual spread of the disease.",
    "differential_diagnosis": "Metastasis, to, the, breast/chest, wall, from, a, lung, carcinoma.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004005/000005.jpg?itok=2D0aWeZv",
            "caption": "CT examination reveals a lobulated, well circumscribed tumour of the right lung located in the anterior part of the lower lobe in the region of bronchus segmentalis basalis anterior."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004005/000006.JPG?itok=Q6_xzNol",
            "caption": "At the level of the lower lobe (right lung) a well circumscribed tumour is visible. Due to the patient\u00b4s condition, an image with a lateral projection could not be recorded, why the differentiation between breast tumour and lung tumour was difficult."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/4005",
    "time": "10.03.2007"
  },
  "4068": {
    "case_id": 4068,
    "title": "Pneumothorax in a patient with Marfan syndrome and an aspergillom",
    "section": "Chest imaging",
    "age": "57",
    "gender": "male",
    "diagnosis": "Right pneumothorax, right apical aspergilloma and bullous lung disease.",
    "history": "Ten day history of increased shortness of breath and right sided chest discomfort.",
    "image_finding": "A 57 year old man with a known history of Marfan syndrome, right apical aspergilloma and old tuberculous lung disease presented with a ten day history of increasing shortness of breath and right\nsided chest discomfort. There was no history of trauma. On examination there were reduced breath sounds throughout the right lung with bilateral scattered wheeze heard. Plain chest x-ray demonstrated\nscarring and pleural thickening at the right apex with a cavity, consistent with the known history of aspergilloma (figure 1). There was also noted to be a right sided pneumothorax. Subsequent high\nresolution CT scan of chest demonstrated an aspergilloma at the right apex with extensive bulla formation (figure 2) and a right pneumothorax (figure 3). He subsequently underwent CT guided insertion\nof a 10 French locking right pig-tail drain which was placed anteriorly in a low intercostal space and directed superiorly (figure 4). Following partial re-expansion of the right lung he developed a\npersistent air leak. He then underwent right thoracoscopy and talc pleurodesis. He subsequently made an excellent recovery.",
    "discussion": "Marfan syndrome is a dominantly inherited disorder of type I collagen with well recognized skeletal, cardiac and ophthalmological manifestations[1]. Pulmonary manifestations of the disease are less\nwell recognized, these include chronic pulmonary emphysema, interstitial lung disease with honey combing and spontaneous pneumothorax[2]. Patients with a history of Marfan syndrome frequently have\nevidence of bullae, as detailed above, and can also develop spontaneous pneumothoraces secondary to underlying lung disease[3]. Other pulmonary diseases affecting this group of patients include\nrecurrent respiratory tract infections, bronchiectasis and tuberculosis which may predispose to the development of an aspergilloma. Aspergillus is a ubiquitous fungus that causes a variety of\nclinical syndromes in the lung, ranging from aspergilloma in patients with lung cavities, to chronic necrotizing aspergillosis in those who are mildly immunocompromised or have chronic lung\ndisease[4]. Invasive pulmonary aspergillosis is a severe and commonly fatal disease that is seen in immunocompromised patients, while allergic bronchopulmonary aspergillosis is a hypersensitivity\nreaction to Aspergillus antigens that mainly affects patients with asthma. The aspergilloma (fungal ball) consists of masses of fungal mycelia, inflammatory cells, fibrin, mucus, and tissue debris,\nusually developing in a preformed lung cavity. The most common predisposing factor is the presence of a preexisting lung cavity, usually formed secondary to tuberculosis. Radiologically, aspergilloma\nis evident as an upper-lobe, mobile, intracavitary mass with an air crescent in the periphery. In asymptomatic patients, as in this case, no therapy is warranted.",
    "differential_diagnosis": "Right, pneumothorax,, right, apical, aspergilloma, and, bullous, lung, disease.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004068/000003.jpg?itok=ioU1y578",
            "caption": "Pigtail drain inserted under CT guidance"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004068/000005.jpg?itok=eQzkV02T",
            "caption": "Right sided pneumothorax (lower arrow) and aspergilloma (upper arrow)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004068/000006.jpg?itok=OmsI_pGL",
            "caption": "CT appearence of aspergilloma (arrow) and bullous lung disease."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004068/000007.jpg?itok=eJurUC01",
            "caption": "Ct appearence of right pneumothorax (arrow)."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/4068",
    "time": "11.06.2007"
  },
  "4092": {
    "case_id": 4092,
    "title": "Right Heart Failure in Idiopathic Pulmonary Fibrosis",
    "section": "Chest imaging",
    "age": "57",
    "gender": "male",
    "diagnosis": "Idiopathic Pulmonary Fibrosis",
    "history": "Patient with dyspnoea, cough and lower limb edema.",
    "image_finding": "The patient presented to our hosptial reporting a long lasting history of non-productive cough, joined in the last three months by an increasing dyspnoea and a state of general illness. Furthermore, in the last week the patient noticed edema of the lower limbs. No exposition to fibrosis-inducing agents was reported. A plain radiograph of the chest demonstrated diffuse reticular opacities in both lungs. In addition enlargement of the heart was demonstrated. A high-resolution CT scan of the thorax was performed to better characterize X-ray findings. CT imagesshowed a diffuse interstitial thickening in both lungs with multiple traction-bronchiectases. It also demonstrated diffuse sub-pleural enphysema. Multiple, small mediastinal lymph nodes were visualized. The cardiac cavities were enlarged and, especially in the right atrium and ventriculum, a typical pattern of eccentric hypertrophy (cor pulmonale) was recognizable. The diffuse fibrotic pattern and the patient history suggested a diagnosis of idiopathic pulmonary fibrosis, subsequently confirmed by a videothoracoscopy guided biopsy.",
    "discussion": "Idiopathic pulmonary fibrosis (IPF) is a progressive interstitial lung disease of unknown etiology, characterized by inflammation and fibrosis. Most cases are sporadic, but autosomal dominance has been reported. One third of patients have a history of viral, respiratory infections, wood and metal dust exposure and smoking: IPF is thought to evolve from undefined alveolar injuries produced by infectious, oxidative, or immunologic agents in susceptible individuals, resulting in recurring sequence of injury, repair, and fibrosis. No specific pathognomonic clinical findings are associated with IPF, and diagnosis is made after excluding other causes of interstitial lung disease. Clinical features are variable: dyspnea, cough, constitutional symptoms (eg, flulike illness, fatigue, weight loss, arthralgias) are the most common symptoms. Onset is insidious, and the condition follows a progressive course. At standard chest radiograph no pathognomic features are present, but abnormal findings are shown in 95% of patients: most common findings are represented by bilateral diffuse reticular infiltrates, predominately at the periphery and the bases. The most accurate imaging modality in diagnostic routine of this disease is high-resolution CT. The pattern seen on CT provides more information than plain chest radiographs: common findings are coarse, reticular, linear opacities, cystic air spaces, and fibrotic distortion of lung architecture. Areas of sub-pleural enphysema and enlarged mediastinal lymph nodes may also be detected. Differntial diagnosis includes: asbestosis, sarcoidosis, eosinophilic pneumonia, hypersensitivity pneumonitis, pneumococcal infection, pulmonary alveolar proteinosis andFarmer's Lung. Open lung biopsy and thorascopic lung biopsy are necessary for definitive diagnosis of IPF. Treatment with systemic corticosteroids, or other immunosuppressants, may benefit patients with histopathology patterns of high cellular inflammation and less fibrosis.",
    "differential_diagnosis": "Idiopathic, Pulmonary, Fibrosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004092/000001.jpg?itok=0jhDEAbP",
            "caption": "Lung window shows diffuse interstitial thickening of pulmonar apex in both lungs."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004092/000002.jpg?itok=80KkPPeV",
            "caption": "Multiple central and peripheral traction bronchiectases are clearly demonstrated in both lungs."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004092/000003.jpg?itok=lrFP3JAO",
            "caption": "The subpleural and parabronchial parenchyma exhibits emphysema with multiple bullae."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004092/000004.jpg?itok=dVN92ePJ",
            "caption": "The bifurcation of the pulmonary artery appears distended and enlarged probably due to to the increased vascular resistance in the small lung vessels."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004092/000005.jpg?itok=947waafZ",
            "caption": "Right ventricle and right atrium are enlarged and present eccentrical hypertrophy due to slow blood flow and pressure overload."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004092/000006.jpg?itok=R04aIU2S",
            "caption": "3D reconstructed image clearly shows the gross enlargement of the common trunk of the pulmonary arteries, evidencing either the enlargement of the right heart cavities due to incoming right heart failure."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/4092",
    "time": "08.04.2008"
  },
  "4113": {
    "case_id": 4113,
    "title": "Pneumomediastinum simulating an abdominal pathology",
    "section": "Chest imaging",
    "age": "92",
    "gender": "male",
    "diagnosis": "Pneumomediastinum",
    "history": "92 years old male patient, with history of cigarette smoking, presenting an oppressive right upper quadrant abdominal pain irradiating in the right shoulder, associated with deteriorated general\nhealth status.",
    "image_finding": "Chest x-ray, abdominal echography and a consultation in gastro-enterology were done. An acute cholecystitis was excluded by the echography. On the first chest x-ray's reading, only an interstitial\nsyndrome was seen, therefore a thoraco-abdominal CT was performed in order to exclude a tuberculosis, a lymphangitis carcinomatosis and an underlying abdominal pathology. The abdominal CT was normal.\nAt thoracic level, it showed emphysema associated with peripheral fibrosis. It also showed linear streaks of translucency along mediastinal and cervical structures, compatible with a\npneumomediastinum (fig. 3). In fact, it was already possible to diagnose a pneumomediatinum on initial chest x-ray (fig 1,2).",
    "discussion": "Pneumomediastinum is a rare idiopatic or secondary disorder (drugs, cough, prolonged vomiting such as in Mallory-Weiss syndrome, traumatic, post bronchoscopy, artificial respiration, asthma,\npregnancy and pneumoperitoneum), and can occur at any age, however mostly to young males smokers (1,2). The cause could be an intra-alveolar pressure increase, although there are assumptions in favor\nof surfactant and pulmonary elasticity deterioration. Air could get into mediastinum from oesophagus or bronchus, but could also come from small airways (3). Diagnosis should be suspected with\npatients presenting dyspnea (18%), thoracic pain (47%), dysphagia or subcutaneous emphysema (65%) (1,4). On chest x-ray, linear streaks of translucency accentuating vascular structures can be seen\n(2), better visualized around pulmonary arteries, left pulmonar hila, aortic arch and left cardiac border (3) (see fig. 1,2). A lateral displacement of the mediastinal pleura can also be seen. Air\ncan diffuse toward neck structures, supraclavicular and axillary areas and retroperitoneum (2,3). The use of CT has been supported by some authors based on the fact that in at least one-third of the\ncases the pneumomediastinum is not visible in a simple thoracic X-ray (5, 6, 7). Acute mediastinitis should be suspected in patients with pneumomediastinum and presenting pain with fever, usually\ncaused by tracheal, pharyngeal or oesophagus perforation. Pneumomediastinum without any complications can be treated conservatively. Pneumothorax may follow a pneumomediastinum but the inverse is not\ntrue (3). Pneumomediastinum differential diagnosis includes the pneumothorax along the mediastinal borders and the \"Match effect\" due to the abrupt change in density of the edge of the lung against\nthe heart and the mediastinum (3).",
    "differential_diagnosis": "Pneumomediastinum",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004113/000003.jpg?itok=1Ikdd_HY",
            "caption": "Lateral chest x-ray shows linear streaks of translucency around pulmonary arteries, pulmonar hila, aortic arch (red arrows)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004113/000007.jpg?itok=6SQstnxY",
            "caption": "Thoracic CT scan shows emphysema associated with peripheral fibrosis and linear streaks of translucency along mediastinal structures (red arrows)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004113/000008.jpg?itok=upEGB87Z",
            "caption": "Front view chest x-ray showing linear streaks of translucency accentuating vascular structures, around pulmonary arteries and air diffusion toward cervical structures (red arrows)."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/4113",
    "time": "21.02.2007"
  },
  "4118": {
    "case_id": 4118,
    "title": "Infected bulla of lung",
    "section": "Chest imaging",
    "age": "53",
    "gender": "male",
    "diagnosis": "Infected bulla of left lung",
    "history": "Productive cough with purulent sputum, pyrexia and dyspnoea.",
    "image_finding": "Initially treated for respiratory tract infection with antibiotics. Symptoms recurred after one month. Chest X-Ray (Figure 1) performed at this point showed a cystic lesion occupying most of left\nhemithorax . There was also a large bulla in the upper and middle zones of the right lung. These findings were confirmed on a CT scan (Figure 2a and 2b) which showed paraseptal and bullous emphysema\nreplacing the apical and anterior segments of the right upper lobe and part of the middle lobe. The entire left upper lobe was replaced by a solitary cystic lesion suggestive of a large infected\nbulla, compressing lung parenchyma underneath. The patient was referred for surgical management as he displayed symptoms of localised sepsis and significant dyspnoea. He underwent surgical drainage\nof the purulent contents of the bullous cavity with satisfactory clinical and radiological (Figure 3) outcome.",
    "discussion": "A bulla is an air filled space within the lung parenchyma resulting from destruction of alveolar tissue. Bullae have fibrous walls and are trabeculated by the remnants of alveolar septa [1]. They are\nclearly identifiable on a chest X-Ray. However, a CT scan is helpful to further identify the exact anatomical location, volume occupied, status of the adjacent lung parenchyma and presence of\ncomplicating features such as infection and pneumothorax [2]. These features are often helpful in deciding upon the appropriateness of surgical management. In general, indications for surgery are\nsevere dyspnoea, bullae occupying more than 30% of lung volume, CT scan or pulmonary angiogram demonstrating reduced blood flow to the involved lung field [3] and complications of bullous disease\n(pneumothorax, infection or massive haemoptysis). Infection in bullae is common as most communicate with the tracheobronchial tree. However, infection usually results in fibrotic contraction and the\nbullae then lose their connection with the airway and often disappear completely. Persistent symptoms and radiological evidence of localised sepsis as in the above patient is thus not at all a common\nfeature. Our patient also had poor spirometry as a result of severe bilateral bullous disease and underlying emphysema as a result of heavy smoking. These are often poor risk candidates for a general\nanaesthetic and surgery. The surgical procedure employed is usually a variation of intracavitary drainage of the cystic cavity originally introduced by Monaldi for the treatment of tuberculous\ncavitary disease [4]. This can even be performed under a local anaesthetic if necessary in compromised patients. CT scanning is of crucial importance in guiding the surgeon's approach so only a small\nincision is required in the chest wall, directly over the bullous cavity.",
    "differential_diagnosis": "Infected, bulla, of, left, lung",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004118/000001.JPG?itok=7G2L0_yb",
            "caption": "Infected bulla in left lung and large bullae in right lung"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004118/000002.JPG?itok=7cxul0OE",
            "caption": "Infected bulla left upper lobe and large bullae in anterior and apical segments of right upper lobe"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004118/000004.JPG?itok=uCLwEacf",
            "caption": "Infected bulla left upper lobe and bulla in middle lobe"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004118/000005.JPG?itok=rHircLrX",
            "caption": "Chest X ray soon after intracavitary drainage of infected bulla in left lung (Monaldi Procedure). The underlying normal lung has reinflated partially.\nOf interest, is the smooth round shadow which is actually the saline filled bladder of the Foley catheter used in the drainage of the bulla."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/4118",
    "time": "22.02.2007"
  },
  "4124": {
    "case_id": 4124,
    "title": "Traumatic aorto-oesophageal fistul",
    "section": "Chest imaging",
    "age": "68",
    "gender": "male",
    "diagnosis": "Aorto-oesophageal fistula and mediastinal abscess caused by possible fish bone impaction.",
    "history": "Circulatory collapse preceeded by signal haematemesis, a week after possible fishbone impaction.",
    "image_finding": "A 68 year old healthy male developed acute dysphagia, odynophagia and dyspnoea after eating fish. He was examined in the Accident and Emergency department and no impacted fish bone or other abnormality was detected. A week later he had an episode of mild haematemesis and on being admitted for further investigations he suffered circulatory collapse. CXR revealed a large right pleuralcollection and CT-chest revealed an aorto-oesophageal fistula and a mediastinal abscess (Figure 1). He was transferred to a tertiary centre in a state of hypovolaemic shock, for further management.Following resuscitation, he underwent oesophagoscopy which revealed free bleeding in the proximal oesophagus. Thoracotomy revealed an extensive haemothorax from rupture of a huge mediastinal abscessdistal to level of inferior pulmonary vein. There appeared to be excessive bleeding from the mediastinal abscess. The bleeding was traced to a 0.8cm linear defect in the right lateral aortic arch.This was repaired during a period of circulatory arrest after cooling the patient to 18\u00b0C on cardiopulmonary bypass. An oesophagectomy was also performed as the oesophagus had been renderedunsalvageable by dissection between the layers by blood. The putative fish bone was not found at surgery. He had a stormy postoperative period which culminated in death from sudden catastrophic bleeding from the mediastinal drain.",
    "discussion": "Aorto-oesophageal fistula (AOF) is a rare but life threatening cause of severe upper gastrointestinal haemorrhage [1] resulting from an abnormal communication between the oesophagus and the aorta.The classic syndrome of chest pain and sentinel haematemesis followed by a symptom-free interval and eventual massive upper gastrointestinal hemorrhage was first described by Chiari [2] in 1914. AOF is usually fatal [3]. Oesophageal perforation by foreign body is an uncommon aetiology, as most AOFs are complications of aortic aneurysms [4]. The cervical oesophagus, indentation by the aortic arch, tracheal bifurcation and the diaphragmatic hiatus are areas of narrowing of the oesophagus and therefore places where foreign body impaction usually occurs [6]. Sharp objects however may lodge at any level. Prompt removal of the foreign body from the esophagus has been advocated because once impaction has occurred; the likelihood of spontaneous passage of the object is small. Oedema produced by local trauma tends to lodge the object more firmly and makes later manipulation more difficult. Because of the close proximity of the aorta, sharp foreign bodies lodged in the oesophagus may perforate the aortic wall [7]. Perforation may also occur from an esophageal ulcer or paraoesophageal abscess secondary to the foreign body. The interval between the warning bleed, which signals the presence of an AOF, and massive hemorrhage may vary in duration from a few minutes to several days or weeks [8,9]. The cessation of bleeding may be related to arterial spasm of the wall of the aorta, hypotension from the initial blood loss, or temporary occlusion of the fistula by blood clot [10]. The diagnosis is rarely made ante-mortem[11]. Even when the correct diagnosis is made, therapy has been largely unsuccessful [12]. It was not until the advent of cardiovascular and bypass procedures that this condition passed from the stage of a pathologic curiosity to a treatable lesion. Diagnostic measures useful in the evaluation of a patient with a suspected AOF include CXR, contrast oesophagography, aortography, oesophagoscopy and CT Scanning. If AOF is suspected, an emergency thoracotomy should be performed in an attempt to control the haemorrhage and repair the fistula [4]. Those patients at high risk for surgical repair and without evidence of infection should be considered for embolization [13] or endovascular [14] treatment In summary, AOF should be suspected in any patient who presents with pain upon swallowing, chest pain, and vomiting of a small amount of blood with an associated recent history of documented or suspected foreign body in the oesophagus. It requires a high index of suspicion and aggressive management if the patient is to besaved.",
    "differential_diagnosis": "Aorto-oesophageal, fistula, and, mediastinal, abscess, caused, by, possible, fish, bone, impaction.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004124/000005.jpg?itok=GyI3zUnf",
            "caption": "Aorto oesophageal fistula at the level of aortic arch. There are also pockets of air with fluid in keeping with a mediastinal abscess. A right pleural effusion is also present."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004124/000002.jpg?itok=FeDefZfn",
            "caption": "Pneumomediastinum and leaked contrast within the mediastinum and possibly in the oesophageal wall. There is a moderate right sided pleural collection and a smaller collection in the left pleural space."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004124/000006.jpg?itok=qmOqwXwK",
            "caption": "Chest X ray done in the Accident and Emergency department, at initial presentation was normal."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/4124",
    "time": "26.03.2008"
  },
  "4131": {
    "case_id": 4131,
    "title": "Superior pulmonary sulcus tum",
    "section": "Chest imaging",
    "age": "52",
    "gender": "female",
    "diagnosis": "Superior pulmonary sulcus tumor",
    "history": "A 52-year-old woman with lung cancer.",
    "image_finding": "A 52-year-old woman with non-small cell lung cancer was admitted to hospital for a second opinion. She referred shoulder, chest, and arm pain radiating to her left hand. The chest X-ray demonstrated\na left superior pulmonary sulcus tumor. A CT scan was performed to evaluate local and distant extension of the neoplasm. Chest wall and mediastinal invasion, as well as pulmonary metastases were\ndemonstrated.",
    "discussion": "Pancoast\u2019s syndrome is characterized by shoulder and arm pain along the distribution of C8, T1, and T2 nerve trunks, weakness and atrophy of the hand, ptosis, myosis, and anhydrosis (1). This\nconstellation of symptoms is related to the local extension of lesions located in the superior pulmonary sulcus, most commonly non-small cell lung cancer. Indeed, even if the most common cause of\nPancoast\u2019s syndrome is non-small cell lung cancer, other entities have also been related to this syndrome, such as other cell-type tumors and diverse infectious diseases. Initial symptoms\ngenerally include pain radiating along the upper back or shoulder into the axilla. Pain might also radiate along the distribution of the ulnar nerve due to the invasion of brachial plexus and local\nbone destruction (vertebral bodies, ribs). In advanced stages of the disease, weakness and atrophy of the intrinsic muscles of the hands may occur. When invasion of the paravertebral sympathetic\nchain and inferior cervical ganglia occurs, patients present with Horner\u2019s syndrome, consisting of ptosis, myosis, and anhydrosis (1). Other signs and symptoms are chest pain, cough, and\ndyspnea (2). Diagnosis can be made with conventional chest radiography. Nevertheless, not infrequently chest X-ray is negative and a chest CT is needed for the diagnosis, being the technique of\nchoice when a superior sulcus tumor is suspected. Chest CT not only provides information about the local extension of the tumor (Fig. 1), but it also allows to identify other pulmonary metastatic\nnodules and/or to detect mediastinal lymphadenopathies (Fig. 2). MRI can assess invasion of the tumor through the pleura and the subpleural fat and evaluate brachial plexus and vascular involvement.\nIt has been reported that MRI is superior to CT in these aspects (3). This has probably changed with the advent of multidetector CT (MDCT), multiplanar reconstructions (MPR) (Fig. 3), and volume\nrendered (VR) images (Fig. 4). Indeed, MDCT has a better spatial resolution than conventional CT and MRI. Nowadays, transthoracic needle aspiration is the most commonly used for the diagnosis of\nsuperior sulcus tumors (4). Other diagnostic techniques, such as sputum cytology and fiberoptic bronchoscopy with fluoroscopic guided biopsy, are less effective for tumors located at the superior\npulmonary sulcus (5).",
    "differential_diagnosis": "Superior, pulmonary, sulcus, tumor",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004131/000001.jpg?itok=MPGDqWsa",
            "caption": "1a. Left superior pulmonary sulcus non-small cell lung cancer."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004131/000002.jpg?itok=F_9BU_PE",
            "caption": "1b. Extension of the tumor to the chest wall can be observed, with bone destruction."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004131/000003.jpg?itok=0YdF3G5r",
            "caption": "1c. The tumor also involves the left hilum."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004131/000004.jpg?itok=ATxrf5Ct",
            "caption": "Pulmonary nodules consistent with metastatic disease were detected."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004131/000005.jpg?itok=riykeHH4",
            "caption": "3a. Coronal image demonstrating the tumor at the left upper lobe extending to the hilum and involving bronchovascular structures."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004131/000006.jpg?itok=oofgW-EE",
            "caption": "3b. Chest wall invasion is clearly demonstrated in this reformatted coronal image."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004131/000007.jpg?itok=H7BNx54J",
            "caption": "4a. Coronal view. Left superior pulmonary sulcus non-small cell lung cancer with chest wall and hilar invasion."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004131/000008.jpg?itok=mImXmpG7",
            "caption": "4b. Coronal view. Left superior pulmonary sulcus non-small cell lung cancer with chest wall and hilar invasion."
          },
          {
            "number": "Figure 4c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004131/000009.jpg?itok=DQIJMxID",
            "caption": "4c. Coronal view. Left superior pulmonary sulcus non-small cell lung cancer with chest wall and hilar invasion."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/4131",
    "time": "13.01.2007"
  },
  "4210": {
    "case_id": 4210,
    "title": "ndobronchial spread of tuberculosis",
    "section": "Chest imaging",
    "age": "20",
    "gender": "male",
    "diagnosis": "Endobronchial spread of tuberculosis.",
    "history": "A 20 year-old male patient complaining of malaise, fatigue, dyspnea and cough during the last week.",
    "image_finding": "A 20 year-old male patient complaining of malaise, fatigue, dyspnea and cough during the last week, performed a chest radiogram which showed an heterogeneous consolidation, with air bronchogram and\nsilluette sign with hemi-diaphragm, in the right lower lobe. A cavitation was also seen in the apical segment of this lobe and small ill-defined nodules in the middle zone of the left lung (figure\n1). CT scan of the chest showed patchy areas of consolidation with a positive air bronchogram, almost envolving the whole right lower lobe (figure 2) and a 2,4cm cavitation, in the apical segment,\nwith thick walls and bronchial communication (figure 3). The performed high-resolution CT revealed multiple, ill-defined nodules, with few mm in diameter, in a centrilobular distribution, throughout\nthe lung parenchyma. Multifocal branching opacities, the \u201ctree-in-bud\u201d sign, were also seen (figure 4). Lymphadenopathy was not found. The diagnosis of endobronchial spread of\ntuberculosis was established and confirmed with positive smear cultures.",
    "discussion": "Tuberculosis is a topic of universal concern, because of its increasing prevalence in both immunocompetent and immunocompromised individuals in recent years. Pulmonary tuberculosis is classically\ndivided into primary and postprimary forms. The first tipically manifests radiologically as parenchymal disease, lymphadenopathy, pleural effusion, miliary disease or atelectasis. The radiologic\nfeatures of postprimary tuberculosis can be broadly classified as parenchymal disease with cavitation, airway involvement, pleural extension and other complications (1). The earliest radiologic\nfinding in postprimary tuberculosis is the development of patchy, ill-defined segmental consolidation with a predilection for the apical or posterior segment of the upper lobes or the superior\nsegment of the lower lobes. More than one segment are involved in most cases. Tuberculous cavitations most commonly occur within areas of consolidation, are often multiple and demonstrate thick,\nirregular walls. They indicate a high likelihood of activity. Endobronchial spread is the most common complication of tuberculous cavitation. High-resolution CT (HRCT) is sensitive in its detection,\nshowing small, poorly defined centrilobular nodules and branching centrilobular areas of increased opacity (\u201ctree-in-bud\u201d sign), which represent caseating necrosis within and around\nterminal and respiratory bronchioles. This \u201ctree-in-bud\u201d appearance is characteristic but not pathognomonic for active tuberculosis. It can also be seen in other pulmonary infectious\ndisorders involving the small airways (including bacterial, mycobacterial, viral, parasitic and fungal agents), idiopathic disorders (obliterative bronchiolitis, diffuse panbronchiolitis), various\ncongenital disorders (cystic fibrosis, dyskinetic cillia syndrome, yellow nail syndrome, congenital immunodeficiency states), aspiration, inhalation, immunologic disordes, connective tissue disorders\nand primary pulmonary lymphoma (2,3,4). The tree-in-bud pattern has also been described as a manifestation of intravascular pulmonary tumor embolism (4). Although the causes of this pattern are\nfrequently indistinguishable at radiologic evaluation, the presence of additional radiologic findings, along with the history and clinical presentation, can often be useful in suggesting the\nappropriate diagnosis. With endobronchial spread of tuberculosis, associated HRCT findings include bronchial wall thickening with or without bronchiectasis, consolidation, cavitation, pleural\neffusion and lymphadenopathy.",
    "differential_diagnosis": "Endobronchial, spread, of, tuberculosis.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004210/000001.jpg?itok=IDmeHn3Q",
            "caption": "Right lower lobe pneumonia with air alveologram and air bronchogram. Cavitation in the apical segment. Small ill-defined nodules in the middle zone of the left lung."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004210/000002.jpg?itok=NvRMMxuO",
            "caption": "Right lower lobe pneumonia with air alveologram and air bronchogram. Cavitation in the apical segment. Small ill-defined nodules in the middle zone of the left lung."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004210/000004.jpg?itok=3p2feIgY",
            "caption": "Right lower lobe consolidation with positive air bronchogram."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004210/000005.jpg?itok=l5zjlOmC",
            "caption": "Thick-walled cavity within consolidation in the apical segment of right lower lobe. Note the bronchial communication."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004210/000008.jpg?itok=RLdy8Y5a",
            "caption": "Ill-defined, confluent acinar nodules in a centrilobular distribution and multiple branching opacities - the tree-in-bud sign."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004210/000009.jpg?itok=rkg9J5oh",
            "caption": "Ill-defined, confluent acinar nodules in a centrilobular distribution and multiple branching opacities, the tree-in-bud sign."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/4210",
    "time": "17.02.2006"
  },
  "4295": {
    "case_id": 4295,
    "title": "A case of mediastinitis after dehiscence of sternal wound complicated by ascending aorta leakage",
    "section": "Chest imaging",
    "age": "61",
    "gender": "male",
    "diagnosis": "Mediastinitis after sternal wound's dehiscence complicated by ascending aorta leakage",
    "history": "Chest pain and dyspnea in patient with a history of recent valvular replacement with aortic root Bentall-type rebuilding.",
    "image_finding": "The patient was admitted for the recent onset of oppressive thoracic pain and increasing dyspnea. He had a history of recent (two months earlier) valvular replacement with aortic root Bentall-type rebuilding. Chest-X ray examination showed enlarged heart and mediastinum (Fig. 1). Emergency chest CT showed the presence in the ascending periaortic space of an heterogenous mass extending from the root up to the aortic arch with small air bubbles and peripheral enhancement at post-contrast scanning (Fig. 2). In addition, the mass appeared in continuity with the sternal suture, partially dehiscent, and was associated to partial displacement of the pulmonary trunk (Fig. 3). Submitted to surgical revision with mediastinal drainage andwashing, the material, mainly hemorrhagic, was sent to laboratory for bacteriologic culture. About 20 days after the surgical revision, the patient was readmitted for the newer occurrence of chest pain associated with mediastinal widening at chest-X ray. A new chest CT showed the recurrence of the above mentioned mediastinal mass with the same features and the presence of an ascending aorta leakage of contrast medium immediately above the left sinus of Valsalva (Fig. 4-5). The bacteriologic culture turned positive for Staphylococcus epidermidis.",
    "discussion": "Postoperative mediastinitis is a severe complication which occurs in approximately 2% of the patients who undergo surgical procedures requiring sternotomy or thoracotomy, and it is associated with approximately 12% operative mortality. Between the various risk factors associate with this complication, one of the most important is the presence of sternal instability with dehiscence of the surgical wound. The diagnosis of mediastinitis is based on clinical data and some associated variable CT signs, such as increase in the attenuation of the mediastinal fat, fluid collections especially if heterogenous and associated with mass-effect, air bubbles, pleural effusion, pericardic effusion, mediastinal lymphadenopathies, etc. The CT sensitivity and specificity for mediastinitis are very high (100% and 90%, respectively) if these signs are evident after 17\u00b0 postoperative day, i.e. after the time necessary for recovery of surgical-related mediastinal anomalies. This severe postoperative complication requires an early diagnosis for a prompt treatment. CT is today not only the diagnostic method of choice, but also it allows to define the extension of the disease and its relationship with mediastinal structures.",
    "differential_diagnosis": "Mediastinitis, after, sternal, wound's, dehiscence, complicated, by, ascending, aorta, leakage",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004295/000001.jpg?itok=q6f6CP8U",
            "caption": "Chest-X ray: cardiac and mediastinal enlargement and bilateral pleural effusion."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004295/000002.jpg?itok=DFcuBayE",
            "caption": "Chest CT: Inhomogeneous mass in continuity with the sternal suture, partially dehiscent, extending from the root up to the aortic arch with small air bubbles."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004295/000003.jpg?itok=YpX4oKJz",
            "caption": "Chest CT: The mass was associated with partial displacement of pulmonary trunk."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004295/000004.png?itok=j_DcdYWF",
            "caption": "Chest CT: Ascending aorta leakage immediately above the left sinus of Valsalva."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004295/000005.png?itok=7T8LQZOu",
            "caption": "Chest CT: Ascending aorta leakage immediately above the left sinus of Valsalva."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/4295",
    "time": "15.09.2008"
  },
  "4364": {
    "case_id": 4364,
    "title": "Paradoxical embolism",
    "section": "Chest imaging",
    "age": "68",
    "gender": "female",
    "diagnosis": "Paradoxical embolism through Patent foramen ovale with massive pulmonary embolism.",
    "history": "Sudden onset ill health and cardiovascular collapse on the 13th day after hip\n  surgery.",
    "image_finding": "68 years old female, 13 days after a right hemi-arthroplasty for fractured neck of femur suddenly collapsed on the ward. She was a non smoker without any previous cardiovascular disease. Her previous\nmedical history included early dementia, osteoarthritis and previous fractures. She was promptly resuscitated.\n\nHer haematological and biochemical investigations were unremarkable except for raised CRP which was found to be 400milligram/litre. ECG showed sinus tachycardia with T wave inversion in the\nanteroseptal leads. Doppler ultrasound scans of legs did not show any deep vein thrombosis (DVT). Urgent computer tomography (CT) scan was done (Figure 2,3). This showed extensive thrombo embolic\ndisease extending form the right and left pulmonary artery trunk to sub-segmental branches. Trans thoracic echocardiogram (TTE) subsequently showed a large thrombus in the right atrium undergoing\nparadoxical embolism (Figure4). This long tubular thrombus was anchored in the right atrium and was passing to left atrium and left ventricle through a previously unknown atrial septal defect. This\nfloating thrombus reached the left ventricular apex in diastole and was getting blown into the left ventricular outflow tract in systole.\n\nShe underwent emergency embolectomy and closure of atrial septal defect under cardiopulmonary bypass. Long tubular thrombus was removed from right atrium, left atrium, left ventricle and pulmonary\nartery. She made uneventful postoperative recovery and was discharged on the 7th day.",
    "discussion": "Paradoxical embolism is a relatively uncommon clinical condition where thrombi from venous circulation enter the arterial circulation producing systemic embolism. Patent foramen ovale (PFO) is one of\nthe common causes for this potentially serious phenomenon. In normal circumstances since left atrial pressure is higher than right atrial pressure thrombi do not reach arterial circulation from the\nright side. If this pressure pattern is reversed, then a right to left shunt and paradoxical embolism can result. Pulmonary embolism can raise the right atrial pressure abruptly and can lead to\nparadoxical embolism. This can happen through very small atrial septal defect (ASD) which may remain clinically silent. Trans oesophageal and Trans thoracic echocardiography are excellent tools to\ndemonstrate PFO and thrombus inside heart chambers. In this case, though CT scan showed pulmonary embolism, the thrombus that was anchored in the heart chamber could not be visualised because of the\nhigh contrast density in all available films. This case also shows the usefulness of C T scan in the diagnosis of pulmonary embolism. Spiral CT enables accurate visualization of thrombi. High quality\nimages that can be obtained from1mm or sub millimetre datasets acquired in a single breath hold from multi detector CT scans can visualise the pulmonary artery to the level of sixth order branches.\nOn C T, PE is most commonly seen as filling defect in contrast filled pulmonary artery. It is seen in more than two contiguous slice and oftene seen to fall into branches at the site of bifurcation\nof the pulmonary artery . These saddle thrombi may be seen from main pulmonary artery bifurcation to smaller branches. Most often thrombi are non occlusive. When an artery is imaged longitudinally,\ncontrast running on either side of thrombi produces the appearance of \u201crailway track\u201d. Two most common pulmonary parenchymal abnormalities seen with PE in lung setting are linear bands of\nsub segmental atelectasis and wedge shaped peripheral areas of parenchymal consolidation. When massive PE produce acute right ventricular failure, evidence of this may be visible on the CT scan in\nthe form of right ventricular dilatation and displacement of inter ventricular septum to left. C T evidence of right ventricular failure and measurement of clot burden in pulmonary artery are\nsuggested to be of prognostic importance. Other tests useful in Diagnosis of PE are of lesser diagnostic value because of the inherent weakness of all of them. Pulmonary angiography has the\ndisadvantage of being invasive and major complication rate of 3 to 4%. Ventilation perfusion scan is non diagnostic in up to 60 to 70% of cases. Demonstration of DVT by ultrasound scan will support\nthe diagnosis while its absence will not rule out the diagnosis. Though a negative ELISA D dimer assay may help to exclude diagnosis of PE it does not help to clinch diagnosis in suspected PE.",
    "differential_diagnosis": "Paradoxical, embolism, through, Patent, foramen, ovale, with, massive, pulmonary, embolism.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004364/000001.jpg?itok=YePQ_2-w",
            "caption": "Short axis view showing thrombus passing through the atrial septal defect"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004364/000002.jpg?itok=q3DyIdaC",
            "caption": "long axis view showing thrombus traversing the mitral valve reaching up to left ventricular apex."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004364/000003.jpg?itok=l35Jq_2X",
            "caption": "Thrombus in the left pulmonary artery"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004364/000004.jpg?itok=qdDY53XU",
            "caption": "Thrombus in the left pulmonary artery"
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004364/000005.jpg?itok=91G8GH0w",
            "caption": "Thrombus in the left pulmonary artery"
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004364/000010.jpg?itok=79GrELZ1",
            "caption": "Thrombus in the branches of right pulmonary artery"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004364/000006.jpg?itok=NRU-CajC",
            "caption": "Thrombus in left pulmonary artery"
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004364/000007.jpg?itok=InqhkQe6",
            "caption": "Thrombus in branches of right pulmonary artery."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004364/000008.jpg?itok=quRaezrQ",
            "caption": "Thrombus in branches of right pulmonary artery."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004364/000009.JPG?itok=DbuWyiHi",
            "caption": "Thrombus removed from heart."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/4364",
    "time": "28.12.2005"
  },
  "4379": {
    "case_id": 4379,
    "title": "Lung and musculoskeletal findings in a patient suffering from Duchenne muscular dystrophy.",
    "section": "Chest imaging",
    "age": "17",
    "gender": "male",
    "diagnosis": "Lung infection in Duchenne muscular dystrophy with severe scoliosis.",
    "history": "A young man confined to a wheelchair presented with complaints of dyspnea and non-productive cough. Chest radiograph and CT depicted severe scoliosis and right basal shadowing. Pulmonary function\ntests,blood chemistry results and ECG were impaired.The patient remained in hospital for 6 days and was discharged with significant clinical improvement.",
    "image_finding": "A young man, confined to a wheelchair since the age of 11 1/2; , presented with complaints of dyspnea and non-productive cough. Arterial blood gas exams on room air measured: pH: 7,4, PO2: 68mmHg,PCO2: 36mmHg and white cell count revealed leucocytosis (WBC: 16700 cells/mm3). Severe scoliosis was evident. Chest radiograph depicted severe scoliosis (50 o Cobb angle) and right basal shadowing(Fig.1). Chest CT revealed RLL bronchopneumonic infiltrates and 'ground-glass' pattern. Round pneumonia adjacent to the oblique interlobar fissure presenting air-bronchogram was demonstrated. A small loculated right oblique interlobar fissure effusion was also present (Fig.2). Erector spinae muscles at the convex of the scoliosis were enlarged and abnormal with fatty replacement (Fig.3). Thepatient was admitted for further exams and treatment. Pulmonary function tests showed the patient's forced vital capacity as 15 per cent of normal. Blood chemistry results were elevated for CPK:1252 IU/L (normal: 25-190 IU/L) and LDH:516 IU/L (normal: 120-230 IU/L). Electrocardiogram was abnormal with tall precordial waves and deep Q waves in left precordial leads (V5 andV6) (Fig. 4). The patient remained in hospital for 6 days and was discharged with significant clinical improvement. A serial chest CT performed 15 days after documented improvement of right lung imaging findings (Fig. 5).",
    "discussion": "Duchenne muscular dystrophy (DMD) (also referred as pseudohypertrophic muscular dystrophy) is a X-linked recessive disorder. The abnormal gene is on the short arm of the X- chromosome. The protein\nresponsible for this disease is dystrophin (427 kDa), found close to the cell membrane and involved in coupling electricial activity with muscular contraction. Dystrophin is absent in muscle biopsies\nof patients suffering from DMD. The incidence of the disease is about 1/3500 live born males. DMD has been studied by Meryon (1852), Little (1853), Gowers (1886) and Erb but the first exact\ndescription was made by Benjamin Duchenne de Boulogne in 1868. Symptoms start at the age between 2-4 years of age with delay of walking, inability of running and climbing stairs, exaggerated lumbar\nlordosis and characteristic pseudohypertrophy of the calves, quadriceps, deltoids and gluteals due to disaster of muscle and replacement by fat and connective tissue. Gradual muscle weakness begins\nfrom proximal to distal. Gowers sign is typical of DMD: the patient stays up with the aid of hands pushing on knees. Ability to walk is usually lost at the age of 12, and the patients are then\nwheelchair dependent. Cardiac involvement in DMD is very common. The most frequent ECG pattern is the presence of tall right precordial R waves and deep Q left precordial waves. Apart of muscle\nbiopsy and ECG, raised serum creatinine kinase (CPK) is also a useful diagnostic test (10 to greater than 20 times normal). Death usually occurs at the age of 20-25, typically from respiratory\ndisorders. Scoliosis starts developing at the age the patient is wheelchair dependent in 90 per cent of cases. Studies have correlated the degree of erector spinae muscle wasting to the severity of\nscoliosis, which is considered to develop due to asymmetric weakness of these muscles. The erector spinae muscle on the convex part of scoliosis is much more affected by fat tissue replacement than\nthe concave part. CT can estimate fat tissue deposition in these muscles along time and can help predict the course of scoliosis of DMD patients. Progressive deteriorating scoliosis is directly\nassociated with respiratory function. Forced vital capacity (FVC) starts decreasing from the age of 8-9 years, and reaches 10% of normal FVC by the age of 20. Thoracic scoliosis angle (calculated\naccording to the Cobb method) can evaluate the degree of respiratory deterioration. Patients with a Cobb angle greater than 40o have a higher risk for lung complications, due to small FVC. It should\nbe noted that surgical treatment of scoliosis improve life quality but does not improve FVC or life expectancy. Lung infections are frequent and recurrent in DMD patients, especially as FVC\ndecreases. However, prompt diagnosis and hospital care has reduced the percentage of deaths due to infection.",
    "differential_diagnosis": "Lung, infection, in, Duchenne, muscular, dystrophy, with, severe, scoliosis.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004379/000001.jpg?itok=VmyjblLt",
            "caption": "Severe scoliosis (Cobb angle:50\u00b0) and right basal shadowing is evident."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004379/000002.jpg?itok=OxitLbjW",
            "caption": "Mediastinal window. Infiltrates of RLL with air-bronchogram sign."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004379/000003.jpg?itok=y54WHHsg",
            "caption": "Mediastinal window. Also note a small pleural effusion (arrow)."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004379/000004.jpg?itok=zL4Y_obP",
            "caption": "Round pneumonia at the right lateral basal segment"
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004379/000005.jpg?itok=hkZfC36z",
            "caption": "In addition to the infiltrates, note the ground glass pattern."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004379/000006.jpg?itok=6-7k3Ypm",
            "caption": "Fat depostion of the erector spinae muscles on the convex part of the scoliosis on the left."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004379/000007.jpg?itok=7a18lFZi",
            "caption": "Note fat depostion of the erector spinae muscles on the convex part of the scoliosis on the left at another level."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004379/000008.jpg?itok=6QbsVh5u",
            "caption": "Note fat depostion of the erector spinae muscles on the convex part of the scoliosis on the right."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004379/000009.jpg?itok=PVvZdmgB",
            "caption": "ECG shows tall waves in all precordials, indicative of cardiomyopathy."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004379/000010.jpg?itok=sUdJ8eHU",
            "caption": "Improved imaging findings of the RLL."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/4379",
    "time": "10.08.2008"
  },
  "4469": {
    "case_id": 4469,
    "title": "Unilateral lymphangitis carcinomatosis",
    "section": "Chest imaging",
    "age": "64",
    "gender": "female",
    "diagnosis": "Bronchogenic carcinoma with unilateral lymphangitic carcinomatosis",
    "history": "The patient presented with symptoms of a lower respiratory tract infection. The lingular and left lower lobe reticular opacification failed to resolve with antibiotics. The HRCT showed unilateral lymphangitic carcinomatosis. The chest CT demonstrated a soft tissue lesion around the left lower bronchus, bilateral hilar lymphadenopathy and unilateral pleural effusion.",
    "image_finding": "The patient presented to her general practioner with symptoms suggestive of a lower respiratory tract infection. Initial chest radiograph (figure 1) demonstrates lingular and left lower lobe reticular opacification which persisted on the follow up chest radiograph despite antibiotic treatment. CT thorax and High Resolution CT was subsequently performed. The volume acquisition CT thorax (figure 2) demonstrated a soft tissue mass encasing the left lower lobe bronchus. Left basal pleural thickening and effusion (figure 3) and bilateral hilar lymphadenopathy (figure 4) was identified.The HRCT demonstrated unilateral lymphangitic carcinomatosis characterised by thickening of the interlobular septae. The histology from the transbronchial biopsy demonstrated small cell lung cancer.",
    "discussion": "Lymphangitic carcinomatosis represents 7% of pulmonary metastases. The most common primaries are bronchogenic carcinoma which is associated with unilateral disease, breast, stomach, thyroid, pancreas and cervical cancer. The chest radiograph has an accuracy of 23% although it is commonly nonspecific. Classical chest radiograph appearances include reticular opacification, coarsened bronchovascular markings, Kerley A and B lines and small volume lungs. This case demonstrated classical HRCT appearances of lymphangitic carcinomatosis. These include irregular, nodular and smoothly thickened interlobular septae. Typically there is thickening of the fissures due to involvement of the lymphatic vessels concentrated in the subpleural interstitium. There is preservation of normal pulmonaryprenchyma at the level of the secondary lobule. In addition subpleural thickening, pleural effusions (30-50%) and hilar and mediastinal lymphadenopathy (30-50%) can be seen.",
    "differential_diagnosis": "Bronchogenic, carcinoma, with, unilateral, lymphangitic, carcinomatosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004469/000002.JPG?itok=vlr7HAcE",
            "caption": "Chest radiograph with lingular and left lower lobe reticular opacification."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004469/000003.JPG?itok=kngs81ya",
            "caption": "CT thorax demonstrating a soft tissue lesion compressing the left lower lobe bronchus."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004469/000004.JPG?itok=LQffhmUS",
            "caption": "Contrast enhanced CT thorax demonstrating left basal pleural thickening and effusion."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004469/000005.JPG?itok=-PXPKhNQ",
            "caption": "Contrast enhanced CT thorax at the level of the pulmonary trunk bifurcation showing bilateral hilar lymphadenopathy"
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004469/000006.JPG?itok=TU77mkc2",
            "caption": "HRCT demonstrating interlobular thickening and beading. Incidental note is made of the right azygos lobe"
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004469/000008.JPG?itok=bUFg59YI",
            "caption": "A section from the HRCT at a more inferior level demonstrating interlobular thickening and beading."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/4469",
    "time": "03.06.2008"
  },
  "4473": {
    "case_id": 4473,
    "title": "Thoracic amoebiasis",
    "section": "Chest imaging",
    "age": "25",
    "gender": "male",
    "diagnosis": "Thoracic amoebiasis",
    "history": "25-year-old male admitted to the emergency room, with fever and pain in the right hemithorax and shoulder. The patient was a heavy smoker (1 package of cigarettes a day) and reported a one month stay in Cuba one month before the clinical symptoms began.",
    "image_finding": "Initial diagnosis was pneumonia, treated with Levofloxacin. Despite treatment, fever persisted and the patient began to have thick and smelly expectorations with weight lost. Blood test showed an increase in the ESR and Polymerase chain reaction (PCR) without leucocytosis. Cultures for aerobic and anaerobic organisms, mycobacterium and parasites (Echinococcus and Entamoeba histolytica) in blood, sputum and faeces were negative. The same was true of the serology test for Entamoeba histolytica. A chest X-ray showed two cavitating lesions in the right lower lobe Subsequent chest computed tomography (CT) without intravenous contrast identified several cavitating lesions whith a thick wall, in the right lower lobe, and smaller ones on the right upper lobe and superior segment of the left lower lobe. Two low attenuation lesions were visible in segments VI and in the interphase between segments V and VIII of the liver. On ultrasound examination the liver lesions were hypoechogenic, with accoustic enhancement. (Figure 1). Fine needle aspiration of one of the hepatic lesions and a culture for aerobic and anaerobic organisms and a Gram tincture was negative. Given that the patient had been recently in a tropical country and did not respond to the usual treatment for pneumonia, he was treated empirically with Metronidazole. Symptoms disappeared and five months later CT showed a pneumatocele without other pulmonary lesions and no changes in hepatic lesions (Figure 2). Serologic test was repeated and was positive for Entamoeba Histolytica.",
    "discussion": "Amoebiasis is a parasite infection caused by Entamoeba histolytica. It is the third most frequent cause of mortality due to parasite infections, after malaria and schistosomiasis. Its distribution is global, although it mostly affects people who belong to low social classes, in tropical and subtropical countries (1, 2); travellers to endemic areas are at risk of infection. Faecal-oral transmission occurs after consumption of food or water contaminated by faeces containing cysts, giving rise to colitis which is asymptomatic in 90% of the cases. In 1-25% of the cases, the colon wall is invaded, with dissemination via the portal vein to the liver. The liver is where most extra-intestinal disorders take place, in the form of abscesses (1-3). The chest is the second most frequent extra-intestinal organ affected. It is restricted almost exclusively to individuals with hepatic abscesses (1, 2, 4). It is usually disseminated by direct extension due to transdiaphragmatic rupture of a hepatic abscess, which occurs in 6-40% of patients with liver lesions. Hematogenous and lymphatic spread is less frequent, and dissemination secondary to aspiration is even less common (1, 3).In our case, dissemination seemed to be hematogenic due to multiple lung focuses and hepatic lesions in the lower segments. Low socioeconomic status, poor nutrition and alcoholism contribute to the development of pulmonary amoebiasis. Men between 20 and 40 years of age are more frequently affected. Patients develop fever, chest pain and haemoptysis (3). Radiological findings in pleuropulmonary amoebiasis are pleural effusion, empyema, air space consolidation, baseline atelectasis and cavitated lesions. When associated with a liver lesion, an elevated right hemidiaphragm, hepatomegalia and liver abscesses can be seen. Invasion of the inferior vena cava is unusual and may cause a pulmonary thromboembolism (1-4). The diagnosis is based mainly on serological tests, which are useful in extra-intestinal amoebiasis because microbiologic analyses may be falsely negative (3). The treatment of choice is Metronidazole, although sometimes percutaneous drainage of the empyema is necessary (2-4).",
    "differential_diagnosis": "Thoracic, amoebiasis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004473/000013.jpg?itok=raJfSBrr",
            "caption": "Figure 1: - A: Chest radiography demonstrates two cavitated lesions in the right lower lobe. - B,C,D: Chest CT without intravenous contrast shows several cavitated lesions with a thick wall in both lungs preferably in the right lower lobe. - E: Abdominal CT shows two low attenuation lesions in the right hepatic lobe. - F: Abdominal Ultrasound demonstrates a hypoechogenic liver lesion with acustic enhancement in segment VI. There was another lesion with similar caracteristics between segments V-VIII (not shown)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004473/000014.jpg?itok=sYkpubYT",
            "caption": "Figure 2: - A: Chest radiography demonstrates an atelectasis in the right lower lobe - B: Chest CT shows a pneumatocele in the right lower lobe. - C: Abdominal CT depicts the hepatic lesions with no change in respect to previous CT"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/4473",
    "time": "23.10.2008"
  },
  "4491": {
    "case_id": 4491,
    "title": "Pneumorrhachis, a benign complication of pneumomediastinum.",
    "section": "Chest imaging",
    "age": "16",
    "gender": "male",
    "diagnosis": "Pneumorrhachis",
    "history": "Patient with spontaneous pneumomediatinum and air in the epidural space on CT scan of the thorax.",
    "image_finding": "A 19 year old male patient presented with 6 day history of vomiting,with no haematemesis.There was no history of recent excessive alcohol or illicit drug intake. In the last one year patient\npresented on few occasions with similar symptoms and investigated where upper GI endoscopy showed a hiatus hernia,and a normal barium follow through study and a normal CT scan of the abdomen.On\nexamination he was afebrile,pulse rate was108/min,BP 126/75 mm of Hg,respiratory rate 12/min,oxygen saturations of 99%.CXR showed extensive surgical emphysema and pneumomediastinum.A water soluble\ncontrast swallow was performed to rule out an oesophageal perforation which did not show any leak from the oesophagus.A CT scan of the thorax was done subsequently to look for any evidence of\nmediastinal collection,which confirmed the presence of pneumomediastinum and emphysema of the subcutaneous tissues.There was also evidence of pneumorrhachis (air within the epidural space) on this\nscan as shown in figures 2 and 3.He was managed conservatively and discharged once the vomiting settled.",
    "discussion": "Presence of air in the epidural space is called Pneumorrhachis (also called Epidural pneumatosis) (1). A variety of factors can give rise to this condition.They include pneumomediastinum, traumatic\npneumothorax, lumbar epidural analgesia, skull fracture, laminectomy or discectomy, epidural abscess, unsuccessful lumbar puncture, advanced lung carcinoma, external radiation beam therapy and post\nthoracotomy (2). Air from the posterior mediastinum may dissect along the fascial planes into the epidural space as the epidural space communicates freely with the paravertebral space through the\nintervertebral foramina. Superiorly, the space is anatomically closed at the foramen magnum where the spinal dura attaches with the endosteal dura of the cranium, therefore air cannot extend\nintracranially (3). Air that enters the epidural space resolves spontaneously,most of the times.Epidural space pneumorrhachis by itself causes no symptoms.Pneumorrachis is best demonstrated by CT\nscanning but may be seen on MRI or cervical spine radiographs (4).The pneumorrhachis can be managed conservatively.",
    "differential_diagnosis": "Pneumorrhachis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004491/000004.jpg?itok=wYTchpbI",
            "caption": "CT thorax confirming the presence of the air within the chest wall muscles and showing epidural pneumatosis(Pneumorrhachis)"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004491/000005.jpg?itok=WC9kuWqJ",
            "caption": "CXR showing the pneumomediastinum"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004491/000006.jpg?itok=kRXn0PWn",
            "caption": "CT thorax(lung windows) demonstrating pneumorrhachis"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/4491",
    "time": "19.02.2008"
  },
  "4493": {
    "case_id": 4493,
    "title": "Silicosis",
    "section": "Chest imaging",
    "age": "68",
    "gender": "male",
    "diagnosis": "Silicosis",
    "history": "A 68 years old male patient presented to the emergency room with a slight dyspnoea. Chest radiography showed diffuse nodular opacities with relative sparing of the basal lung zones, and\ncalcifications in both hila.",
    "image_finding": "A 68 years old male patient presented to the emergency room with a slight dyspnoea. Chest radiography showed diffuse nodular opacities with relative sparing of the basal lung zones, and\ncalcifications in both hila. The high resolution chest CT showed bilateral conglomerate masses in the upper lungs, associated with architectural distortion and numerous well defined micronodules in\nboth lungs with posterior zonal predominance. The patient has worked in a porcelain factory for about 35 years. The history of exposure to silica and the presence of radiographic changes consistent\nwith silicosis made this diagnosis the most consistent one.",
    "discussion": "Silicosis is a fibro nodular lung disease caused by inhalation of dust containing crystalline silica (alpha-quartz or silicon dioxide), which is distributed widely, or its polymorphs (tridymite or\ncristobalite), which are distributes less widely. Silicosis has been a human scourge since antiquity. In 1705, Ramazzini cited Diembrock\u00b4s description of the lungs of stonecutters \u201cin\nwhom he found heaps of sand that in running the knife through the pulmonary vesicles he thought he was cutting through some sandy body. In 1870, Visconti introduced the term silicosis, derived from\nthe Latin silex, or flint. It has been known by many other names, such as miner`s phthisis, stonecutter`s disease, potter`s asthma, and grinder`s rot. The principal sources of industrial exposure to\nsilica are free silica in mining, quarrying, and tunnelling, stonecutting, polishing, and cleaning monumental masonry, sandblasting, and glass manufacturing, and in foundry work, pottery, and\nporcelain manufacturing, brick lining, boiler scaling, and vitrous enamelling. Patients with chronic disease may be asymptomatic with an abnormal chest radiograph or have dyspnoea. In some cases, the\nonset of dyspnoea means a complication, such as progressive massive fibrosis, tuberculosis, or airway disease. Cough may accompany the disease or mean chronic bronchitis, tuberculosis, or lung\ncancer. In chronic silicosis, lung function may be normal, or there may be an obstructive, restrictive, or a mixed obstructive/restrictive pattern. Impairment of function is faster in accelerated\ndisease. In acute disease, impairment of gas exchange is a prominent feature. The characteristic radiologic abnormality seen in patients with silicosis consists of small, well-circumscribed nodules\nthat are usually 2-5mm in diameter but range from 1 to 10mm, mainly involving the upper and posterior lung zones. The appearance of large opacities or hyperattenuating areas over 1cm in diameter\n(progressive massive fibrosis) indicates the presence of complicated silicosis. These masses tend to develop in the midzone or periphery of the upper lung and migrate toward the hila, leaving over\ninflated emphysematous spaces between the conglomerate mass and the pleura. They are often bilateral, symmetric, can demonstrate calcification, and, more rarely, cavitation. The borders of these\nmasses tend to be more irregular than truly ill-defined. The irregularities are the result of strand of fibrotic reaction around the conglomerate masses. The opacities tend to be homogeneous since\nthey represent large masses of fibrotic reaction. A heterogeneous appearance should be the result of no normal intervening alveoli, and there is no evidence of air bronchogram effects. Comparison\nwith old films is essential to eliminate the possibility of a new superimposed process. Egg-shell calcifications in hilar and mediastinal lymph nodes are occasionally seen. CT features are similar to\nthose seen on standard radiographs, but coalescence of nodules and the development of conglomerate masses can often be detected at an earlier stage. Conglomerate masses of complicated silicosis can\nbe associated with disruption of normal vessels and bulla formation. CT is also better at revealing gross disruption of pulmonary parenchyma in the upper lung zones in complicated disease.",
    "differential_diagnosis": "Silicosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004493/000001.JPG?itok=TEfd5kgC",
            "caption": "high resolution CT showing multiple well defined small nodules and conglomerate masses in the upper lungs"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004493/000002.JPG?itok=rd53a72h",
            "caption": "high resolution CT showing bilateral conglomerate masses associated with architectural distortion, and migration towards the hilum; numerous micronodules are also present in both lung."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004493/000003.JPG?itok=HyKkMSFK",
            "caption": "high resolution CT showing bilateral conglomerate masses associated with architectural distortion, and migration towards the hilum; numerous micronodules are also present in both lung."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004493/000004.JPG?itok=dpuGmC6P",
            "caption": "high resolution CT showing calcifications in mediastinal and hilar lymph nodes"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/4493",
    "time": "14.12.2007"
  },
  "4494": {
    "case_id": 4494,
    "title": "Thin-walled lung cysts",
    "section": "Chest imaging",
    "age": "30",
    "gender": "female",
    "diagnosis": "Pulmonary lymphangioleiomyomatosis",
    "history": "A 30 years old female patient presented with progressively worsening shortening of breath and exertional dyspnoea that had been present for the past 6 months.",
    "image_finding": "A 30 years old female patient presented with progressively worsening shortening of breath and exertional dyspnoea that had been present for the past 6 months. The symptoms were associated with a dry\ncough, pleuritic pain, and occasional wheezing. The patient denied recent episodes of fever, night sweats, or hemoptyses or any changes in weight or appetite, and there was no prior history of\nasthma, angina, or pneumothorax. On physical examination the woman was afebrile and in no acute distress. The lungs had equal air entry bilaterally with no wheezing and minimal crackles over the\nbases. The chest radiograph had a reticular pattern that appeared more prominent at the bases. High resolution computed tomography scan showed innumerable, small, well-defined, thin-walled cysts\nevenly distributed throughout both lungs fields. The intervening lung parenchyma was normal, and no pulmonary nodules were detected. To secure the diagnosis an open lung biopsy was performed. Cross\nsections of lung tissue showed spongy red-brown parenchyma with multiple scattered 1-2mm cystic spaces. Histologic examination showed multiple cysts and a lacy whorled pattern of modified smooth\nmuscle proliferation around bronchi, bronchioles, and blood vessels. This modified smooth muscle proliferation appeared to extend into the walls of adjacent alveolar ducts and alveoli with the\nformation of septal nodules. The pathologic process was diffuse and the diagnosis of lymphangioleiomyomatosis was established.",
    "discussion": "Lymphangioleiomyomatosis (LAM) is a rare multisystem disease characterized by progressive proliferation of immature-appearing smooth muscle cells in the lung parenchyma and along axial lymphatic\nvessels in the chest and abdomen. There is cystic destruction of the lung parenchyma. Spindle cells proliferation can also involve the hilar, mediastinal, and extra thoracic lymph nodes. Involvement\nof the lymphatics can lead to chylous pleural effusion or ascites. LAM occurs almost exclusively in women of childbearing age, usually between 17 and 50 years old. LAM commonly manifests as\nexertional dyspnoea and recurrent pneumothorax. During the course of the illness, there may be non-productive cough, hemoptyses, chylous pleural effusion, or chylous ascites. Obstruction of pulmonary\nvenules causes vascular congestion and hemoptyses, and lymphatic obstruction leads to chylothorax and chylous ascites. Spirometry studies in LAM patients demonstrate chronic airway obstruction with\nincreased lung volume and decreased CO2 diffusion. The plain radiographic manifestations of LAM include reticular, reticulonodular, miliary, and honeycombing patterns. The radiological\nfindings may precede, accompany, or postdate other manifestations of the disease, such as pneumothorax and chylous pleural effusion. On high-resolution computed tomography patients characteristically\nshow numerous thin-walled lung cysts, surrounded by relatively normal lung parenchyma. These cysts usually range from 2mm to 5cm in diameter, but they can be larger. Their size tends to increase with\nprogression of the disease. In mild disease the cysts usually measure less than 5mm. In patients who have more extensive disease, in which 80% or more of the lung parenchyma is involved, the cysts\ntend to be larger, most being more than 1cm in diameter. Cysts in LAM exhibit a variety of shapes, including round, polygonal, and ovoid. Round cysts are most commonly reported with polygonal shapes\nfound in increasing numbers in patients with more severe parenchymal involvement. The walls of the cysts are thin and faintly perceptible, ranging up to 4mm in thickness. The cysts are distributed\ndiffusely throughout the lungs, and no lung zone is spared. The lung parenchyma between the cysts appears normal. In some cases, however, a slight increase in linear interstitial markings,\ninterlobular septal thickening, or patchy areas of ground glass opacity are also seen. Small nodules are occasionally seen but are not a prominent feature of this disease. Other features of LAM\ninclude hilar, mediastinal, and retrocrural adenopathy. Not surprisingly, pleural effusions, pneumothoraces, or both are frequently identified and can be helpful in distinguishing LAM from Langerhans\nhistiocytosis. Ill-defined areas of increased attenuation may result from haemorrhage or oedema, as both are known complications of LAM. Pulmonary haemorrhage occurs in 8%\u201314% of women with\nLAM. Involvement of the venules may result in total occlusion of the vessels, causing pulmonary venous hypertension and hemoptyses. Although improvement has been reported clinically after treatment\nwith progesterone, tamoxifen, or other antiestrogen agents, ablation of ovarian function after administration of luteinizing-release hormone analogues, radiotherapy, or oophorectomy, responses to\nsuch treatments are variable. Most patients die within 5 to 10 years of the onset of symptoms. Thereby LAM is now listed as an indication for lung transplantation.",
    "differential_diagnosis": "Pulmonary, lymphangioleiomyomatosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004494/000003.jpg?itok=CtvEPHYA",
            "caption": "- High resolution computed tomography scan showed innumerable, small, well-defined, thin-walled cysts (arrows) evenly distributed throughout both lungs fields, with relative sparing of lung apices"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004494/000004.jpg?itok=SwunbrMt",
            "caption": "- High resolution computed tomography scan showed innumerable, small, well-defined, thin-walled cysts evenly distributed throughout both lungs fields."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004494/000005.jpg?itok=PZaMNYCF",
            "caption": "High resolution computed tomography scan showed innumerable, small, well-defined, thin-walled cysts (arrows)  evenly distributed throughout both lungs fields, with relative sparing of lung apices"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004494/000007.jpg?itok=XcVZZl5N",
            "caption": "High resolution computed tomography scan showed innumerable, small, well-defined, thin-walled cysts (arrows) evenly distributed throughout both lungs fields, with relative sparing of lung apices"
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004494/000008.jpg?itok=iP_hu5ac",
            "caption": "- High resolution computed tomography scan showed innumerable, small, well-defined, thin-walled cysts (arrow) evenly distributed throughout both lungs fields, with relative sparing of lung apices"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/4494",
    "time": "04.05.2006"
  },
  "4510": {
    "case_id": 4510,
    "title": "A Case of Mediastinal Non-Seminomatous Germ Cell Tum",
    "section": "Chest imaging",
    "age": "50",
    "gender": "male",
    "diagnosis": "Mediastinal Non-Seminatous Germ Cell Tumour",
    "history": "A patient with increasing shortness of breath, night sweats, lethargy and headaches.",
    "image_finding": "A 50 year old gentleman had presented with 3 week history of breathlessness, night sweats, poor appetite, headache and lethargy. A chest X-ray was done which revealed bilateral rounded opacities\nraising the possibility of metastatic disease. A CT scan of the brain, thorax, abdomen and pelvis was arranged which revealed multiple pulmonary lesions and a right sided pleural effusion. It showed\na mass in the anterior mediastinum measuring about 6.5 cm and also showed a hypodense lesion in the liver. The brain CT revealed a number of enhancing lesions with surrounding oedema. His blood tests\nshowed very high tumour markers with B-HCG of >250,000 IU/L, LDH of 2200 IU/L and AFP of 3 KU/L. An ultrasound of both testes was arranged which did not show any testicular primary. A\nhistopathological diagnosis was not possible as the patient was very unwell but based on the radiological findings and high B-HCG levels a diagnosis of mediastinal non-seminamatous germ cell tumour\nwith metastases to lungs, liver and brain was made and he was started on chemotherapy.",
    "discussion": "The mediastinum is the most common site of extragonadal germ cell tumour. They can also be seen in other sites like retroperitoneum and sacrococcygeal region. They constitute about 10-15% of all\nmediastinal neoplasms. The malignant mediastinal germ cell tumour (GCT) can be divided into seminomas and non-seminomatous type. Non-seminomatous GCT tumours are almost exclusively seen in men and\nthey can be associated with Klinefelter\u2019s syndrome. They can present with chest pain, cough, dyspnoea, fever, weight loss and anorexia. Most common site in mediastinum is anterosuperior\ncompartment and they tend to grow rapidly and metastasise early. Blood tests usually reveal high B-HCG and AFP levels. Elevation of B-HCG is higher in patients with mediastinal nonseminomatous GCT\nthan in those with primary metastatic testicular tumours and can be used as a marker to assess response to treatment and to detect recurrence. Most of the patients have high LDH levels though it is a\nnon-specific marker. These tumour markers provide diagnostic and prognostic information. Histopathology is crucial to diagnosis but if it is not possible because of poor general condition then\ntreatment can be started even without biopsy in the presence of radiological findings and high serum markers. Imaging plays important role in the diagnosis and further management. It helps to\nidentify the mass, define its extent and presence of metastatic disease. A chest X-ray may show enlargement of the mediastinum and the tumour may appear lobular in outline. It may also reveal lung\nmetastases. A testicular ultrasound should be arranged in all cases with an extragonadal germ cell tumour. CT scan is the imaging of choice. In all patients CT of the thorax, abdomen and pelvis\nshould be performed. Contrast enhanced CT helps to characterise the mass and also gives information on involvement of adjacent structures. The mediastinal non-seminomatous GCT may be seen as large,\nirregular masses situated in the anterior mediastinum. They often appear as asymmetrical, heterogeneous masses and the adjacent fat planes may be obliterated. There may be multiple areas of contrast\nenhancement interspersed with areas of reduced attenuation following necrosis and haemorrhage within the tumour. Contrast rim enhancement of the tumour and septations may be seen. The CT also shows\nmetastases to lung, liver, lymph nodes and bones. Other findings that may be identified include encasement & compression of mediastinal blood vessels, pericardial effusion, involvement of chest\nwall and gynaecomastia. An important differential diagnosis would be anterior mediastinal lymphoma. The mainstay of treatment is chemotherapy. The patients may require postchemotherapy surgical\nresection. With cisplatin-based chemotherapy the prognosis may range between 50-70%. Indicators of poor prognosis are high B-HCG levels (>50,000 IU/L), AFP >10,000 ng/L, LDH elevation ten times\nof normal and presence of nonpulmonary visceral metastases.",
    "differential_diagnosis": "Mediastinal, Non-Seminatous, Germ, Cell, Tumour",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004510/000001.jpg?itok=iTgXQmcX",
            "caption": ""
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004510/000002.jpg?itok=IOYKPltf",
            "caption": ""
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004510/000003.jpg?itok=o4OiR3FS",
            "caption": ""
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/4510",
    "time": "01.08.2007"
  },
  "4516": {
    "case_id": 4516,
    "title": "Miliary Tuberculosis",
    "section": "Chest imaging",
    "age": "75",
    "gender": "female",
    "diagnosis": "Miliary Tuberculosis",
    "history": "A 75 year-old female patient presented with weakness, weight loss and anorexia for three weeks, in association with dyspnea and low grade fever during the last week. On physical examination, she\nappeared chronically ill and on chest auscultation crackles were noted.",
    "image_finding": "A 75 year-old female patient presented with weakness, weight loss and anorexia for three weeks, in association with dyspnea and low grade fever during the last week. On physical examination, she\nappeared chronically ill and on chest auscultation crackles were noted. Chest radiography showed a reticular-nodular pattern, with multiple tiny nodules, of only few milimeters in diameter,\ndisseminated throughout both lungs (figure 1). Chest CT was performed and revealed multiple micronodules, some of them with apparent ill-defined margins, scattered uniformly throughout the lung\nparenchyma (figure 2). High-resolution CT was performed to show parenchymal changes more precisely. It was demonstrated that those nodules were well-defined and randomly distributed (figure 3), some\nof them abuting the pleura. There was no evidence of cavitation, pleural effusion or lymphadenopathy. The diagnosis of miliary tuberculosis was proposed and confirmed with positive blood cultures.",
    "discussion": "Miliary tuberculosis (TB) may be seen in both primary and post-primary disease. Mycobacterium tuberculosis entering the blood from the primary complex or from the lymph nodes may become disseminated\nto numerous extrapulmonary sites (urogenital system, bones, meninges, adrenal glands, bowel, etc). Very often, hematogenous dissemination throughout the lungs \u2013 miliary TB \u2013 is present.\nIn adults it can also occur by recent infection or by reactivation of quiescent focus of infection. This condition is more frequent in the elderly, children younger than 2 years old and in\nimmunocompromised patients (1). The chest radiography plays an important role in the diagnosis but is limited because of its low sensitivity and by the fact that the classic appearances of diffuse\nsmall (2-3mm) nodules, evenly disseminated, may not appear until late in the course of the disease. Other additional findings are lymphadenopathy and parenchymal consolidation, particularly in\nchildren (1). Chest CT and particularly high resolution CT (HRCT) allow early diagnosis. Miliary TB results in a very fine nodular or reticulonodular pattern on HRCT. The majority of nodules measure\n1 to 3 mm in diameter and have a random distribution (present in the subpleural and perivascular regions), without cephalocaudal or central-to-peripheral predominance. They can be distinguished from\nnodules seen in association with endobronchial spread because of their smaller size, uniform diameter, even distribution throughout the lung and because they are unassociated with evidence of\nbronchial wall thickening (2). Macronodular opacities may be found and usually result from the confluence of several granulomas or airspace nodules. Areas of ground-glass opacification may be also\nfound, with a variable extension and patchy appearance. A preexisting tuberculosis lesion or consolidation is present in about 50% of the patients. Sometimes, a nodular thickening of interlobular\nsepta can result in a \u201cbeaded septum\u201d appearance similar to lymphangitic carcinomatosis (1, 3). The main differential diagnosis are other disseminated granulomatous (such as fungal\ndisease) and viral infections, hematogenous metastases, silicosis or coal-worker\u2019s pneumoconiosis (CWP) and Langerhans\u2019 histiocytosis (1, 3). Most fungal diseases result in CT and HRCT\npatterns of disease indistinguishable from those of mycobacterial infections, including miliary nodules. The causative agents are usually endemic in some areas and the findings highly depend on the\nimmune status of the patients (2). Metastatic deposits range from fine miliary nodules to mass lesions several centimeters in diameter. The size of metastatic lesions may, in instances, allow for\nspeculation on the origin of the primary tumor. The miliary form is mostly associated with primary tumor in thyroid, lung or breast (4). Silicosis and CWP are pathologically distinct entities with\ndiffering histology, however the radiographic and HRCT appearance are similar and cannot be reliably distinguished. The earliest finding is the presence of small, well-defined nodules (usually 2-5mm)\nscattered throughout both lungs, with a predominance for the upper lobes, tipically in centrilobular (peribronchiolar) and subpleural locations. Depending on the profusion of the nodules in a\nseemingly random distribution, it may be impossible to distinguish it from miliary TB (perivascular nodules) (5). The combination of pulmonary nodules (usually in a peribronchiolar centrilobular\nlocation) and cysts is virtually diagnostic of pulmonary histiocytosis. However, nodules are the earliest finding and each feature can occur solely (5).",
    "differential_diagnosis": "Miliary, Tuberculosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004516/000005.JPG?itok=Q-JVFKM4",
            "caption": "Multiple diffusely distributed small nodules, with few mm, disseminated throughout both lungs."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004516/000002.jpg?itok=Oj_h860T",
            "caption": "Upper lobes. Multiple micronodules, scattered uniformly throughout the lung parenchyma, some with apparent ill-defined margins, scattered uniformly throughout the lung parenchyma without cephalocaudal or central to peripheral predominance."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004516/000003.jpg?itok=_IEl2-Ig",
            "caption": "Lower lobes. Multiple micronodules, scattered uniformly throughout the lung parenchyma, some with apparent ill-defined margins, scattered uniformly throughout the lung parenchyma without cephalocaudal or central to peripheral predominance."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004516/000004.jpg?itok=yJ4qjy5L",
            "caption": "HRCT scan (slice thickness of 1mm and a high resolution kernel) at the same level of figure 2b, shows multiple well-defined, perivascular micronodules (circle) in a random distribution, some of them abuting the pleura (arrows)."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/4516",
    "time": "07.03.2007"
  },
  "4594": {
    "case_id": 4594,
    "title": "Scimitar syndrome: diagnosis with Fast MR imaging",
    "section": "Chest imaging",
    "age": "47",
    "gender": "female",
    "diagnosis": "Scimitar syndrome,",
    "history": "The patient was admitted with dyspnea, angina pectoris and cough. Her past history was noticeable for a predisposition to recurrent respiratory tract infections.",
    "image_finding": "She underwent a routine chest X-ray that revealed reduced volume of the right lung with mediastinal shift to the right side, and a pathologic shadow in the right lung with a vertical course towards\nthe right cardio-phrenic angle. A contrast-enhanced CT scan of the chest, performed to evaluate for a possible pulmonary mass, showed an abnormal pulmonary venous drainage from the right lung via a\nlarge scimitar vein draining infra diaphragmatically to the IVC. The left sided pulmonary venous drainage was normal. However, the right lung was hypoplastic. No other anomaly including arterial\nsupply to the right lung, bronchial arteries, or dextrocardia was identified. The MRI study was performed by a 1.5 T scanner (Gyroscan intera, Philips, Holland) using a synergy body coil. The\nmorphological study included Balance-Turbo field-echo, axial, saggital and coronal images (T2-weigthed GRE sequences). Gadolinium was not used. Scan time was only 25 seconds for each plain (TR/TE:\n3.0/1.5, flip angle: 80, matrix: 256 x 256, slice thickness of 8.0, interpolated: 4 mm, field of view 450/1,6, NSA: 1). The MRI clearly delineated the anomalous pulmonary venous connection to the IVC\njust above the diaphragm associated with a hypoplasic right lung.",
    "discussion": "The scimitar syndrome was first described in autopsy specimens in 1836 [1]. It is a complex lesion in which anomalies of both heart and lungs affect management and prognosis. The scimitar syndrome is\ncharacterized by an anomalous right pulmonary vein that generally drains the entire right lung to the IVC [2]. The anomalous pulmonary trunk, termed the scimitar vein, usually passes anterior to the\nhilum of the right lung, and enters into the IVC just superior to the hepatic veins. In the most instances, associated anomalies are right lung hypoplasia with marked mediastinal shift, and\ndextrocardia. The atrial septum is usually intact, however, occasionally a defect may be present [3]. In the present case, the right lung hypoplasia was the only associated anomaly. The\n\u201cScimitar sign\u201d is a characteristic chest X-ray finding often seen in patients with scimitar syndrome. The right pulmonary venous connection to the IVC forms a shadow along the right\nheart border that mimics the shape of so called \u201cscimitar\u201d, a Turkish sword. Although the scimitar sign is an important diagnostic finding, the vein may not be visible on chest X-ray if\nit is small or obscured by the heart shadow [2]. In the present case, fast MRI accurately demonstrated all of the abnormal vascular findings. The meandering pulmonary vein with total drainage into\nthe IVC was nicely visualized in a very short period of time such as 25 seconds. Fast MRI provides the definite diagnosis in seconds without necessitating contrast injection, which obviates further\nstudies and unnecessary procedures that may entail considerable morbidity for the patient",
    "differential_diagnosis": "Scimitar, syndrome,",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004594/000001.jpg?itok=JOUb_fr7",
            "caption": "Figure 1a, b:  a, coronal b, axial Balance-FFE MR imaging demonstrating a large vertical \u2018Scimitar\u2019 vein draining into the inferior vena cava"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004594/000002.jpg?itok=cK8LrSOn",
            "caption": ""
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/4594",
    "time": "27.02.2006"
  },
  "4650": {
    "case_id": 4650,
    "title": "Salt water aspiration",
    "section": "Chest imaging",
    "age": "61",
    "gender": "female",
    "diagnosis": "Pulmonary oedema precipitated by salt water aspiration.",
    "history": "A 61 year old lady was participating in a triathalon when she aspirated sea water. She developed increasing shortness of breath and was subsequently admitted to hospital. Chest x-ray demonstrated\npulmonary oedema secondary to aspiration of salt water.",
    "image_finding": "A 61 year old lady was participating in a triathalon and whilst swimming she aspirated sea water. She then developed a cough productive of pink, frothy sputum and increasing shortness of breath. She\nmanaged to complete the triathalon however was subsequently admitted to hospital with severe dyspnoea. On examination she was noted to be tachypnoeic with a respiratory rate of 30. On auscultation\nthere were fine inspiratory crepetations noted to both mid-zones. Oxygen saturations were reduced at 88% on room air. Arterial blood gas measurement on room air demonstrated type one respiratory\nfailure with a PaO2 of 7.4 KPa. C reactive protein was elevated at 240 mg / L. Sputum culture was negative. Chest X-ray (figure 1) demonstrated an acute pulmonary oedema. She was managed\nsymptomatically with oxygen therapy and quickly recovered over the following 48 hours.",
    "discussion": "Aspiration while still conscious causes a respiratory syndrome which is clinically evident as fatigue, dyspnoea, panic reactions, cough and occasionally vomiting[1]. Experimental studies have shown\nthat physiological changes include increased ventilation, tachypnoea, increased resistance, decreased compliance and hypoxia[2]. In salt water aspiration pulmonary oedema is the initial consequence.\nThis is as a result of disruption of the alveolar-capillary membrane by salt water. Some patients can develop progressive or delayed pulmonary oedema leading to ARDS. An associated condition is salt\nwater aspiration syndrome which is seen in divers[3]. This occurs when micronized salt water mist is inhaled into the lungs. The hypertonic salt water results in fluid shifts into the alveoli leading\nto ventilation / perfusion abnormalities and intrapulmonary shunting. In severe cases this may result in hypovolaemia, haemoconcentration and electrolyte abnormalities. Classic chest radiographic\nfindings in severe near drowning consist of alveolar oedema with extensive \"fluffy\" areas of increased opacity that tend to coalesce throughout both lungs. In mild near drowning, findings range from\nnormal to confluent irregular perihilar areas of increased opacity in a subsegmental or segmental distribution with peripheral sparing[4].This patient met the criteria for 'acute lung injury' with a\nPaO2 / FiO2 ratio < 300 mm Hg. Treatment is based on improving oxygenation and patients frequently require ventilation[5].",
    "differential_diagnosis": "Pulmonary, oedema, precipitated, by, salt, water, aspiration.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004650/000001.jpg?itok=OGq3bilC",
            "caption": "Chest x-ray on admission"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004650/000002.jpg?itok=1txffWZf",
            "caption": "Chest X-ray on discharge"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/4650",
    "time": "20.01.2008"
  },
  "4670": {
    "case_id": 4670,
    "title": "Dyspnoea in a patient with Crohn\\&#039;s Disease",
    "section": "Chest imaging",
    "age": "52",
    "gender": "female",
    "diagnosis": "Drug induced Extrinsic Allergic Alveolitis",
    "history": "Dyspnoea in a patient with Crohn's Disease commenced on Mesalazine",
    "image_finding": "The patient had presented 2 months earlier with a history of diarrhoea. Crohns disease was diagnosed after appropriate investigations. She was commenced on Mesalazine 1g tds and given a reducing course of prednisolone with resolution of her symptoms. Five weeks later she presented to her General Practitioner with a history of cough and dyspnoea. She was prescribed successive courses ofAmoxicillin and Cephalexin with no improvement. At this point she presented to Accident and Emergency in obvious distress, being severely dyspnoeic and unable to speak. She was on no medication except mesalazine and was a non smoker. There was no history of inhaled antigen exposure. A chest X-ray was considered normal but she was hypoxic (PaO2=7.8 kPa). Her White Cell Count was minimally elevated at 11.3 with a normal eosinophil count. The admitting physicians considered diagnoses of atypical pneumonia or pulmonary emboli and a CT pulmonary angiogram was performed. This excluded embolic disease but the lung windows demonstrated ill defined centrilobular nodules and ground glass shadowing compatible with Extrinsic Allergic Alveolitis (figures 1a,1b,1c). This was not a diagnosis considered prior to the CT scan. Aminosalicylates such as mesalazine have a rare side effect of causing acute alveolitis. Mesalazine was stopped and the patient commenced on oralPrednisolone. The patient symptoms markedly improved as did her pulmonary function tests. The Transfer factor increased from 48% to 69% nearly 6 weeks after stopping mesalazine. A follow up CT also demonstrarted significant (Figure 4) improvement and she was subsequently discharged from respiratory clinic.",
    "discussion": "Acute extrinsic allergic alveolitis is an abnormal immunologic reaction, usually to inhaled allergens, which produces an alveolar inflammation, ground-glass opacification, and consolidation. Its distribution is predominantly in the upper and middle zones (sparing the lower lobes) and ill-defined centrilobular nodules may be identified.1 This disease may have typical high-resolution CT findings that, in the appropriate clinical setting, can be sufficiently characteristic to allow a confident diagnosis without the need for a lung biopsy.2 Because the findings vary with the stage of the disease, correlation with clinical history is critical in the assessment of patients with hypersensitivity pneumonitis.1 The different patterns on HRCThave been correlated with the stage of disease, histological findings, and, in some cases, with pulmonary function test abnormalities. These patterns include centrilobular nodules, ground glass opacification (GGO), air-space consolidation, mosaic perfusion, air trapping, mixed opacities, and fibrotic changes.2 Whilst there is no single pathognomonic CT feature of extrinsic allergic alveolitis, there is a characteristic constellation of abnormalities, which provide support for an otherwise uncertain clinical diagnosis.3 Air-trapping is a common finding in sub-acute extrinsic allergic alveolitis on CT and its detection is enhanced by performing expiratory scans. 4 In our patient a hypersensitivity pneumonitis was not considered in the differential diagnosis on presentation. Despite receiving several prior courses of antibiotics on hospital admission an atypical pneumonia was still considered most likely diagnosis though the clinicians were keen to exclude a pulmonary embolus. The CTPA excluded pulmonary embolus but showed typical findings of allergic alveolitis and the temporal correlation between Mesalazine exposure and symptoms was clear with no other possible drug or antigen cause. This is characterised by the appearance of clinical symptoms within months of drug administration and the disappearance of symptoms upon drug discontinuation. These cases usually do not require intensive steroid treatment.5 Bronchoalveolar lavage may be used to assess possible extrinsic allergic alveolitis but the results may depend on the time elapsed since antigen exposure.6 It is well recognised that drugs may induce a variety of toxic reactions within the lungs and indeed the lung is one of the most commonly involved organs.7 They may induce an alveolitis and with continued drug exposure result in fibrosis. Mesalazine is known, though rarely, to cause an allergic alveolitis (Drug Product Information, Ferring Pharmaceuticals). Reactions caused by this drug range between Pulmonary infiltrates and eosinophilia, Organising pneumonia \u00b1 bronchiolitis obliterans (BOOP),Granulomatous interstitial lung disease, Bronchospasm, Eosinophilic pleural effusion and Chest pain.8 9 10 11 With increasing use of potentially lung toxic medication an increasing role of imaging with High Resolution CT is in diagnosing and monitoring possible toxicity. Various sources of information are available to review the literature on drug induced lung disease such as www.pneumotox.com.",
    "differential_diagnosis": "Drug, induced, Extrinsic, Allergic, Alveolitis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004670/000001.jpg?itok=7By0dyOg",
            "caption": "Ill defined centri-lobular nodules."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004670/000002.jpg?itok=-AaR69sH",
            "caption": "Ill defined centri-lobular nodules."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004670/000003.jpg?itok=r69KCQKs",
            "caption": "Ill defined centri-lobular nodules."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004670/000004.jpg?itok=pOkc4wPP",
            "caption": "HRCT performed 4 weeks after cessation of Mesalazine. This shows ill-defined centrilobular nodules persist, but there is significant improvement."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/4670",
    "time": "23.05.2008"
  },
  "4671": {
    "case_id": 4671,
    "title": "Haemoptysis and Dyspnoea in an Asthmatic Patient",
    "section": "Chest imaging",
    "age": "29",
    "gender": "male",
    "diagnosis": "Allergic Bronchopulmonary Aspergillosis",
    "history": "Haemoptysis, dyspnoea and pleuritic chest pain in a patient with asthma and eczema.",
    "image_finding": "The patient presented with three weeks history of chest pain, pleuritic in nature, associated with dyspnoea. He also had a mild cough productive of dark green sputum. He also complained of occasional\nnight sweats. Later he developed haemoptysis. There was no history of weight loss or skin, joint or eye problems. His past medical history consisted of asthma, eczema, hay fever and a nasal\nseptoplasty at the age of 15. His current medication included Seretide, Bricanyl and Elocon Ointment. He was a non-smoker and had no pets at home and had an office based job. Clinical examination was\nnormal with no chest signs. A chest X-ray was performed which showed bilateral perihilar infiltrates (figure 1). An HRCT was performed demonstrating extensive abnormal changes. Consolidation was seen\ninvolving much of the upper lobes (figure 2). Areas of increased density were noted medially within the right upper lobe, the left upper lobe and also the left lower lobe. These corresponded to\ndilated branching bronchi and the appearances were of high density mucoid impaction (figures 3a,3b), characteristic of fungal infection and Allergic Bronchopulmonary Aspergillosis ( ABPA ). Several\nproximal air filled dilated bronchi were also seen with some more peripheral dilatation also present. Ill defined central lobular nodular nodules were seen within the lower lobes. The patient\nsubsequently underwent bronchcoscopy which demonstrated large white mucus/fungal plugs which were removed. Aspergillus was identified/cultured from this. The patients Xray following treatment\nreturned almost to normal and symptomatically he improved markedly.",
    "discussion": "The initial literature report of the Allergic bronchopulmonary aspergillosis (ABPA) in the United Kingdom was in 1952. The prevalence of ABPA is as high as 1% to 2% of patients with persistent asthma\nif screening is carried out, though even higher rates have been reported. In cystic fibrosis, the prevalence of ABPA ranges from 2% to 15%. ABPA is sometimes recognised in patients with allergic\nfungal sinusitis, though such an association is unusual. ABPA has been identified in patients with hyper-IgE syndrome and chronic granulomatous disease.1 Aspergillus Fumigatus (although\nother speciecies of genus Aspergillus may cause Aspergillosis2) can cause a wide spectrum of pulmonary complications. It may colonise pre-existing cavities to form mycetomas. In asthmatic\npatients, it may lead to a hypersensitivity reaction involving eosinophilic infiltration of the bronchial wall and mucoid impaction (a condition called allergic bronchopulmonary aspergillosis\nnormally has a relapsing remitting course which may mimic asthmatic attacks) or granulomatous inflammation (bronchocentric granulomatosis). In the immunocompromised host, Aspergillus may invade blood\nvessels, causing hemorrhagic infarction (angioinvasive aspergillosis), or it may cause tracheobronchitis, bronchiolitis or pneumonia (airway invasive aspergillosis), as well as abscess formation with\nor without adjacent tissue invasion. Each of the manifestations of Aspergillus infection has a distinct histologic and high-resolution computed tomography (CT) appearance.3 At CT,\nsaprophytic aspergillosis (aspergilloma) is characterized by a mass with soft-tissue attenuation within a lung cavity. The mass is typically separated from the cavity wall by an airspace (\"air\ncrescent\" sign) and is often associated with thickening of the wall and adjacent pleura. CT findings in allergic bronchopulmonary aspergillosis consist primarily of mucoid impaction and\nbronchiectasis involving predominantly the segmental and subsegmental bronchi of the upper lobes.4 The mucus may be of increased density, as in this case due to the accumulation of heavy\nmetals by the fungus.5 Findings seen more commonly in patients with allergic bronchopulmonary aspergillosis than in patients with asthma alone include bronchiectasis, centrilobular\nnodules, and mucoid impaction (p < 0.01, chi-square test), In asthmatic patients, bronchiectasis affecting three or more lobes, centrilobular nodules, and mucoid impaction are findings on\nhigh-resolution CT that are highly suggestive of allergic bronchopulmonary aspergillosis.6 In an acute presentation ABPA can present as simple consolidation and bronchocoele formation and\natelectasis can be seen. In chronic ABPA more established bronchiectasis and scarring is usually found. Chronic asthmatic patients, who can have symptoms identical to ABPA , can have bronchial\ndilatation but it is usually mild, cylindrical and distal. ABPA can also present with bronchial dilatation without mucus plugs. It is recognised that a proportion of patients with ABPA have normal CT\nappearances with no bronchial dilatation.",
    "differential_diagnosis": "Allergic, Bronchopulmonary, Aspergillosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004671/000005.jpg?itok=Zej-qIby",
            "caption": "Digital CXR showing bilateral perihilar infiltrates"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004671/000007.jpg?itok=0d144HXk",
            "caption": "High density mucus plugs, characteristic of ABPA."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004671/000008.jpg?itok=vPpwaknX",
            "caption": "High density mucus plugs, characteristic of ABPA."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004671/000009.jpg?itok=sCToqvXO",
            "caption": "consolidation and bronchial dilatation."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/4671",
    "time": "07.05.2007"
  },
  "4718": {
    "case_id": 4718,
    "title": "ctopic Mediastinal Thyroi",
    "section": "Chest imaging",
    "age": "40",
    "gender": "female",
    "diagnosis": "Ectopic Mediastinal Thyroid",
    "history": "A 40-year-old woman presented with a history of mild dyspnea and asthenia with 15 days of evolution. Clinical examination demonstrated a decrease of the pulmonary sound in the inferior right\nhemithorax.",
    "image_finding": "A 40-year-old woman presented with a history of mild dyspnoea and asthenia with 15 days of evolution. Clinical examination demonstrated\n  decreased of the pulmonary sound in the inferior right hemithorax. Laboratory data were within normal limits and her past medical history was unremarkable.\n\n\n  The chest x-ray and the CT showed an oval soft-tissue density mass in the right anterior mediastinum, with well-defined margins and regular\n  contour, measuring 11x9x10cm. On CT the mass was slightly heterogeneous with hypoattenuated areas and small punctate calcifications, showing mild enhancement after contrast medium injection. On MR\n  imaging the lesion was heterogeneous with predominantly intermediate signal intensity on T1-weighted images and slightly hyperintense on T2-weighted images. Areas with high signal intensity on\n  T1-weighted images and high signal intensity on T1- and T2-weighted fat saturation sequences, were present, probably corresponding to fresh hemorrhage. The lesion was well demarcated from the\n  adjacent mediastinal structures without displacing them\n\n\n  At surgery a large well capsulated tumor was found in the right anterior mediastinum, which was removed. The result of the histological\n  analysis was an ectopic thyroid gland with nodular hyperplasia and no evidence of malignancy.\n\n\n  Ultrasonographic examination of the cervical thyroid and scintigraphy (99mTc) were done after surgery. They revealed enlargement\n  of thyroid right lobe, diffuse heterogeneity and a cold nodule in the right lobe. A total thyroidectomy was performed and the histopathological results indicated bilateral diffuse nodular\n  hyperplasia. Scintigraphy did not show any other site of ectopic functioning thyroid tissue.",
    "discussion": "Ectopic thyroid is an uncommon embryological aberration characterized by the presence of thyroid tissue at a site other than in its\n  pretracheal region.\n\n\n  The thyroid develops as an endodermal bud from the anterior floor of the pharynx and descends down on either side of the trachea to its\n  pretracheal site where it fuses with the caudal prolongation of the fourth pharyngeal pouch to form the thyroid gland.\n\n\n  According to the time of the disturbance during embryogenesis, ectopic thyroid may develop at various sites from the base of the tongue to\n  the thyroglossal duct. 90% of the cases are situated in the tongue at the foramen cecum and ectopic thyroid is the only functional thyroid tissue in 70%.\n\n\n  Mediastinal thyroid tissue has occasionally been reported to arise from a displacement of the thyroid remnants into the mediastinum with the\n  heart as it migrates downward.\n\n\n  Lesions that occur in a cervical thyroid gland can also be found in ectopic glandular tissue including goiter and different types of\n  carcinoma.\n\n\n  Although 15% of all goiters involve the mediastinum only in 1% of the cases the mediastinal goiter develops from ectopic thyroid\n  tissue.\n\n\n  Ectopic mediastinal thyroid tissue is usually asymptomatic, but especially after pretracheal thyroidectomy it may become symptomatic.\n  Symptoms are usually due to compression of adjacent structures.\n\n\n  The differential diagnosis for our case, a mass predominantly involving the anterior mediastinum, includes germ cell tumors (teratoma),\n  thymic lesions (thymoma), lymphoma, and thyroid lesions including goiter. In our patient CT and MR could not show any connection from the thyroid isthmus or lower poles to the mediastinal\n  mass.\n\n\n  The aspects on CT and MR imaging are variable depending on the heterogeneity of adenomatous or colloid multinodular goiter, which is\n  composed of solid matrix, colloid cysts, blood degradation products, fibrosis, and calcifications. Calcifications are well visualized on CT, and they are commonly encountered in goiter. The MR\n  imaging signal intensities on T1- and T2-weighted images are a depiction of the different tissue components including follicular colloid (either low or high T1 and T2); fibrosis (low T1 and T2);\n  blood (variable T1 and T2 depending on stage of blood degradation), and calcium (signal void). The enhancement characteristics are similar to the normal thyroid tissue in the pretracheal location,\n  which, in suspicious cases, may be a clue to the diagnosis.\n\n\n  A radionuclide thyroid scan is confirmatory when the diagnosis is suspicious.\n\n\n  Ectopic mediastinal thyroid should be kept in mind when examining a patient with a mass in the anterior part of the mediastinum, even if the\n  patient has a pretracheal thyroid gland.",
    "differential_diagnosis": "Ectopic, Mediastinal, Thyroid",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004718/000001.jpg?itok=xKs8J4cl",
            "caption": "Fig 1 \u2013 Posteroanterior chest radiography revealed a large oval soft tissue mass, with well defined margins, projected in the middle and inferior portions of the right hemithorax. The lesion obliterates the right cardiac border and form obtuse angles with the mediastinal contour."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004718/000002.jpg?itok=uEjRqXu-",
            "caption": "Fig 2 \u2013 In the lateral chest radiography the lesion was located in the anterior mediastinum."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004718/000003.jpg?itok=iZS22tHf",
            "caption": "Fig 3 - Thoracic computed tomography showing a soft tissue density mass in the anterior mediastinum measuring 11x9x10cm. The lesion is slightly heterogeneous with some hypoattenuating areas and small punctate calcifications, showing mild enhancement after contrast medium injection."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004718/000004.jpg?itok=HvwuN8zM",
            "caption": "Fig 4 \u2013 Thoracic MR: axial T1-weighted image showing that the lesion is heterogeneous with predominantly intermediate signal intensity with some areas of high signal intensity."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004718/000005.jpg?itok=FHeJF1Yq",
            "caption": "Fig 5 - Thoracic MR: axial fat-suppressed T2-weighted image showing that the lesion is slightly hyperintense. Some areas with high signal intensity on T1-weighted images and high signal intensity on fat-suppressed T2- and T1-weighted sequences (Fig. 6), can be detected, probably corresponding to fresh hemorrhage."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004718/000006.jpg?itok=bJ53KklD",
            "caption": "Fig 6 - Thoracic MR: axial fat-suppressed T1-weighted image showing the presence of some hyperintense areas that can also be detected on T1-weighted images (fig 4) and on fat-suppressed T2-weighted sequence (fig. 5)."
          }
        ]
      },
      {
        "number": "Figure 7",
        "subfigures": [
          {
            "number": "Figure 7",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004718/000007.jpg?itok=jH5dfSzf",
            "caption": "Fig 7 - Thoracic MR: coronal T1-weighted image showing the tumor well demarcated from the adjacent mediastinal structures and thoracic wall without displacing them"
          }
        ]
      },
      {
        "number": "Figure 8",
        "subfigures": [
          {
            "number": "Figure 8",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004718/000008.jpg?itok=EWj3SOUc",
            "caption": "Fig 8 - Thoracic MR: sagital T1-weighted image showing the large mediastinal tumor occupying most of the right hemithorax."
          }
        ]
      },
      {
        "number": "Figure 9",
        "subfigures": [
          {
            "number": "Figure 9",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004718/000009.jpg?itok=sh1nysDQ",
            "caption": "Fig 9 \u2013 Microscopic appearance of the ectopic thyroid tissue with the typical follicles filled with colloid (H&amp;E stain)."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/4718",
    "time": "07.03.2007"
  },
  "4734": {
    "case_id": 4734,
    "title": "Pleural Mesotheliom",
    "section": "Chest imaging",
    "age": "60",
    "gender": "male",
    "diagnosis": "Pleural mesothelioma with lymph nodal and bony metastases.",
    "history": "60 years old man, ex smoker, developing a respiratory failure unresponding to specific treatment.",
    "image_finding": "The patient, an ex smoker without history of asbestos exposure, due to dry cough associated with dyspnoea, underwent a chest X-ray, that revealed basal congestion of the right lung and pleural\nreaction. After an antibiotic therapy cycle of Ceftriaxon, clinical conditions didn\u2019t improve and the subsequent radiogram showed a general worsening of pulmonary state, characterized by\nincreased pleuric effusion. Besides, spyrometric tests demonstrated a respiratory failure of restrictive type. Afterwards, the patient underwent computed tomography of the chest that revealed an\nadvanced state of a malignant pleural affection of the right lung, characterized by volume loss of right hemi-thorax, a circumferential involvement of the hemitorax, chest wall, mediastinum and\ndiaphragm. The study revealed also some osteolytic areas involving sternum body, C7, D2 and D11.",
    "discussion": "Malignant pleural mesothelioma (MPM) is an uncommon neoplasm that arises from the pleura and, rarely, from peritoneum or pericardium. It\u2019s the most frequent primary neoplasm of the pleura. MPM\nis strongly linked to asbestos exposure: approximately 80% of these lesions occurs in individuals with documented history of asbestos exposure. For these individuals, the average latence period is 35\nyears. Other etiologic factors are involved: exposure to other mineral fibers, chronic inflammation, heredity, irradiation, viruses and there is also an influence of cigarettes smoking.\nHistologically MPM may be epithelial, mesenchimal or mixed. Radiologically, it usually shows some pathognomonic signs: nodular pleural thickening, unilateral pleural effusion, interlobar fissure\nthickening, pleural calcifications and coarctation of the affected hemitorax. MPM is locally aggressive, with frequent invasion of the chest wall, mediastinum and diaphragm. Lymph nodes metastases\noccur in 50% of cases, including hilar, mediastinal, anterior dyaphragmatic and internal mammary nodes. The most frequent sites of metastases are bone, adrenal glands and kidneys. Several factors\nhave been shown to correlate with reduced survival time: intrathoracic lymph nodes metastases, distant metastatic disease and exstensive pleural involvement. The prognosis is poor: 12 months of\nmedian survival time. Computed tomography is the primary imaging modality used for the diagnosis and staging of MPM thanks to its sensitivity in detecting MPM pathognomonic signs.",
    "differential_diagnosis": "Pleural, mesothelioma, with, lymph, nodal, and, bony, metastases.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004734/000001.JPG?itok=8TXP7-I2",
            "caption": "The thick nodular, pleural mass impinges on mediastinal structures."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004734/000002.JPG?itok=Aan1s0sZ",
            "caption": "The pleural mass surrounds the entire right lung, and decreases its volume."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004734/000003.JPG?itok=3qznsjPI",
            "caption": "Parietal pleura thickening, also adjacent to pericardium."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004734/000004.JPG?itok=m1seDIJP",
            "caption": "Osteolytic area of sternum body."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004734/000005.JPG?itok=_QetTlQe",
            "caption": "Involvement of mediastinal lymph nodes."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/4734",
    "time": "06.02.2008"
  },
  "4810": {
    "case_id": 4810,
    "title": "Pulmonary embolism after histoacryl injection for bleeding gastric varices.",
    "section": "Chest imaging",
    "age": "68",
    "gender": "male",
    "diagnosis": "Pulmonary embolization of lipiodol after sclerotherapy for bleeding gastric varices",
    "history": "Obturation of gastric varices with endoscopic injection of polymerizing agents mixed with lipiodol is an established treatment modality. Sometimes this mixture may accidentally lodge in nearby or\nremote vessels with various consequences. We report a case of uneventful renal vein and pulmonary embolism after intravariceal injection of the tissue adhesive Histoacryl.",
    "image_finding": "A 68-year-old man with hepatitis B virus cirrhosis and portal hypertension was admitted to our hospital after two episodes of upper GI haemorrhage. On endoscopy huge gastric varices (type II) with\nadherent blood clot were found at the fundus of the stomach and endoscopic injection sclerotherapy with N-butyl-2-cyanoacrylate (Histoacryl) as a 1:1 mixture with the contrast agent Lipiodol\nfollowed. On the following day the patient compained of pain over the left upper quadrant and flank; he also developed mild fever. The chest x-ray revealed multiple small opacities along the vessels\nat the apex and base of the left lung (Fig 1, 2a, 2b), which were not present on the pre-procedural x-ray and were attributed to pulmonary emboli. The lung perfusion scan did not show perfusion\ndefects. On the abdominal CT scan, most of the injected mixture was present in the gastric fundus while a portion of it had flowed to splenorenal shunts and the left renal vein (Fig 3a, 3b); however,\nno deterioration in renal function was observed. The patient responded well to treatment with parenteral nutrition and antibiotics; pain and fever had subsided by the following day. On the subsequent\nchest x-rays the radiopaque emboli showed progressive resolution until their complete disappearance. Repeated abdominal CT scans revealed progressive disappearance of the lipiodol opacities and\nshrinkage of the gastric varices after the second year as well (Fig 4a, 4b). The patient remains alive and with compensated liver function 4 years after the procedure.",
    "discussion": "Endoscopic intravariceal injection of polymerizing agents is used as an alternative treatment for bleeding gastric varices [1-4] and is regarded as a highly effective first-choice therapy [1]; it is\nalso considered cost-effective compared to other treatments [5,6]. N-butyl-2-cyanoacrylate (Histoacryl) and its analogues are characterized by their ability to polymerize on contact with weak bases\nsuch as blood. When injected into a varix, the glue hardens plugging the lumen and leading to varix obturation. The glue is mixed with polymerization altering agents in order to delay glue\nsolidification and avoid gluing of the catheter into the vessel. Lipiodol is an oily contrast agent that not only renders the mixture radiopaque but has also the ability to delay the polymerization\nreaction [7]. Injection sclerotherapy with these agents has been associated with acute and long term complications such as embolism, bacteremia with infection, and development of oesophageal\nstrictures [8]. Endoscopic glue injection has also been associated with the formation of retrogastric abscess and visceral fistulae; the latter may be due to the ulcerogenic effect of Histoacryl to\ntissue [9,10]. Embolism after glue injection is an infrequent complication; the most commonly reported cases pertain to pulmonary embolism [11,12]. When not mixed properly with the glue, lipiodol may\nfollow the blood flow and lodge into the collateral vessels or pulmonary arteries. Lipiodol breaks down to free fatty acids before it is completely expelled; these acids have chemotoxic effects and\nmay cause chemical injury to the lungs [13]. Although massive [11] or even fatal [14] pulmonary embolism have occured, affected patients usually have mild symptoms or are completely symptom-free and\ntherefore embolism may remain undiagnosed [15,16]. In our case although many tiny particles of lipiodol and a significant embolus was depicted in the chest x-ray the lung perfusion was negative, a\nfinding that is in accordance with other notices concluding that many emboli do not occlude the pulmonary vessels [17]. In the most extensive study of pulmonary embolism after Histoacryl\nsclerotherapy, Hwang and al. [15] found that radiographically evident pulmonary embolism was observed in 6 (4,3%) of 140 patients. These patients received a higher volume of liquid acrylate, were\neither mildly symptomatic or asymptomatic and in most of them the radiographic abnormalities showed complete or partial resolution. Systemic embolism has also been described; reported cases include\ncerebral stroke [18], portal vein embolism [19] and splenic infarction [20]. Possible causes include inadvertent injection into pulmonary veins (when treating oesophageal varices) or systemic\narteries. This leak may also occur through a portopulmonary shunt, pulmonary arteriovenous shunt or atrial septal defect. [21] Pulmonary embolism should be always considered when a patient who\nreceived intravariceal glue injections presents with respiratory symptoms. Use of contrast medium for thoracic CT should be avoided when a PE is suspected as the contrast may mask the radiopaque\nemboli [16]. Clinicians should inform the radiologist about the patient\u2019s history and previous glue injections so that appropriate techniques are used to reach the correct diagnosis of glue\nembolism.",
    "differential_diagnosis": "Pulmonary, embolization, of, lipiodol, after, sclerotherapy, for, bleeding, gastric, varices",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004810/000001.jpg?itok=pOZSKNXG",
            "caption": "Chest x-ray obtained on the first post-procedural day showing cylindrical opacity in the apex of left lung and many tiny others in the bases."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004810/000002.jpg?itok=LQ1LVJ1W",
            "caption": "Zoom image of the left apex shows the radiopaque emboli to better advantage (arrowheads)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004810/000003.jpg?itok=vqMQywNn",
            "caption": "Contrast-encanhed CT of the abdomen after the procedure: lipiodol is seen into some of the gastric varices (V)."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004810/000004.jpg?itok=MSsTZQFs",
            "caption": "Zoom image of the base of the left lung shows the radiopaque emboli to better advantage (arrowheads)."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004810/000005.jpg?itok=wHspQuiV",
            "caption": "Contrast-encanhed CT of the abdomen after the procedure shows lipiodol into   the splenorenal shunt (SR) and the left renal vein (arrowhead)."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004810/000006.jpg?itok=TZ24A0pZ",
            "caption": "A CT scan obtained during the portal venous phase shows the varices (V) before the procedure."
          }
        ]
      },
      {
        "number": "Figure 7",
        "subfigures": [
          {
            "number": "Figure 7",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004810/000007.jpg?itok=ITtUPeq4",
            "caption": "Contrast enhanced CT scan (portal venous phase) obtained at the same level as 4a, three years after the sclerotherapy with Histoacryl, shows complete disappearance of the varices."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/4810",
    "time": "13.12.2007"
  },
  "4840": {
    "case_id": 4840,
    "title": "Two cases of aortic intramural hematoma, without trauma history.",
    "section": "Chest imaging",
    "age": "65",
    "gender": "male",
    "diagnosis": "Intramural hematoma Stanford type A and B.",
    "history": "The first patient was 65 years old and was admitted to the emergency department due to a loss of conscience episode and sudden chest pain. The second patient was 53 years old and was admitted due to acute chest and back pain.",
    "image_finding": "A 65-year-old patient was referred to the hospitals emergency department due to an episode of loss of conscience and a sudden onset of chest pain. He had a medical history of hypertension. On clinical examination there was a suspicion of aortic dissection. The multislice computed tomography (MDCT) scan obtained before contrast material administration, demonstrated a crescent shaped area along the right lateral wall of the ascending aorta that showed higher attenuation than that of blood. No contrast enhancement effect of the area was seen on the MDCT scan obtained after contrast material administration. No intimal flap was demonstrated. He also underwent magnetic resonance imaging. The T2 weighted dark blood sequence, demonstrated a high signal semicircular area along the wall of the ascending aorta. T1 weighted sequence after intravenous contrast material showed no enhancement of this area. The diagnosis was intramural hematoma of the ascending aorta-Stanford type A. The patient was successfully treated with elective grafting of the ascending aorta. The second patient also presented with acute chest and back pain and had a medical history of hypertension. He had a MDCT scan before contrast material administration that showed a crescentic area within the descending aortic wall that was of high attenuation owing to contained blood. This crescentic area extended along the wall of the descending aorta and showed no enhancement after contrast material administration. The diagnosis was intramural hematoma of the descending aorta-Stanford type B. The patient was successfully treated with medical therapy.",
    "discussion": "As first described by Krukenburg in 1920 (1), intramural hematoma (IMH) of the thoracic aorta without ulcerating arteriosclerotic plaque (known also as penetrating ulcer) is synonymous with aortic dissection without an intimal tear that would lead to communication with the true aortic lumen. It is caused by spontaneous rupture of the aortic vasa vasorum with propagation of subintimal hemorrhage (2). Consequently, intramural hematoma weakens the thoracic aorta and may progress to either outward rupture of the aortic wall or inward disruption of the intima, which leads to ommunicating aortic dissection (2,5). The clinical presentation of intramural hematoma is indistinguishable from that of communicating aortic dissection and the early diagnosis of intramural hematoma is necessary so that appropriate treatment is begun before complications develop. Computed tomography (CT) and magnetic resonance (MR) imaging are the diagnostic imaging techniques of choice. CT demonstrates a crescent shaped area along the wall of the aorta that shows higher attenuation than that of blood. MR imaging not only visualizes blood sequestration but also allows assessment of the age of the hematoma based on the formation of methemoglobin. Nienaber et al reported that subacute IMH revealed high signal intensity on both T1- and T2- weighted images caused by methemoglobin formation (3). Murray et al reported that MR images of patients who had early subacute complications showed signal intensity changes of hematoma that were consistent with recurrent bleeding (4). In clinically stable patients magnetic resonance imaging is widely recognized as the imaging modality of choice for the assessment of thoracic aortic disease. Some authors have recommended that type A intramural hematoma requires early surgery because it tends to develop classic overt dissection and/or rupture (5). Results of surgery and medical therapy, however, in patients with type B intramural hematoma have not varied at a 30 days to 1 year follow-up time (2). In this case the diagnosis of intramural hematoma in both patients was established with the Multislice CT scan. MR imaging confirmed the initial diagnosis in the patient with the type A intramural hematoma.",
    "differential_diagnosis": "Intramural, hematoma, Stanford, type, A, and, B.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004840/000001.jpg?itok=koRhH2T9",
            "caption": "Crescent shaped area along the right lateral wall of the ascending aorta, that shows higher attenuation than that of blood (arrow). Intramural hematoma of the ascending aorta-Stanford type A."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004840/000002.jpg?itok=vCqv3Vii",
            "caption": "No contrast enhancement effect of the crescent shaped area is seen (arrow). No intimal flap is demonstrated."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004840/000003.jpg?itok=hPa1rHa-",
            "caption": "Intermediate signal intensity semicircular area along the wall of the ascending aorta (arrow)."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004840/000004.jpg?itok=zGmEp3XA",
            "caption": "No enhancement of the aortic wall is demonstrated."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004840/000005.jpg?itok=6d3pc0oz",
            "caption": "Crescentic area within the descending aortic wall that is of high attenuation owing to contained blood."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004840/000006.jpg?itok=sogLAtLQ",
            "caption": "Extension of the intramural hematoma along the wall of the descending aorta, Stanford type B."
          }
        ]
      },
      {
        "number": "Figure 7",
        "subfigures": [
          {
            "number": "Figure 7",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004840/000009.jpg?itok=76j2Ryhl",
            "caption": "The crescentic area within the descending aortic wall shows no enhancement."
          }
        ]
      },
      {
        "number": "Figure 8",
        "subfigures": [
          {
            "number": "Figure 8",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004840/000010.jpg?itok=-BhFi1Uo",
            "caption": "No enhancement of the aortic wall is demonstrated."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/4840",
    "time": "27.03.2008"
  },
  "4865": {
    "case_id": 4865,
    "title": "Morgagni&#039;s  Hernia appearing as a right cardiophrenic opacity on Chest Xray",
    "section": "Chest imaging",
    "age": "39",
    "gender": "male",
    "diagnosis": "Morgagni's Hernia",
    "history": "Morgagni's Hernia presenting as a right cadiophrenic opacity on Chest Xray in an adult",
    "image_finding": "We report a case of a 39 yr old asymptomatic male patient, presenting for a routine CXR from his primary care physician because of a history of asbestos exposure due to his work as a builder. CXRrevealed an opacity in the right cadiophrenic angle which was not present on his previous radiogrpah of two years ago. Initially this was reported to be partial collapse of the right middle lobe/suspected mass lesion. He was referred to his chest physician for urgent investigation for a suspected intrathoracic carcinoma. He then had a contrast enhanced, multislice computed tomography withmultiplanar reconstruction. This identified a non-enhancing fatty mass with a connection to the mesenteric fat via a small defect in the anterio-medial portion of the diaphragm: a Morgagni's hernia",
    "discussion": "Morgagni's hernia is a rare type of diaphragmatic hernia in which abdominal contents herniate into the thoracic cavity through a defect between the xiphoid and costochondral attachments of the diaphragm. It accounts for about 5% of diaphragmatic hernias.1It is more common on the right side due to extensive pericardial attachment to the diaphragm on the left side.2Though congenital in origin, it usually presents in the middle aged and is more common in the obese.3Congenital diaphragmatic hernia was first reported by Lazarus Riverius in 1679 following a post mortem examination of a 24 yr-old male.4The patients are usually relatively asymptomatic and the lesions are commonly detected on a plain x-ray. The diagnosis is confirmed with a CT or ultrasound or by contrast studies. Especially multiplanar CT reformations are highly useful as they can demonstrate the diaphriagmatic defect and the herniating structures (including e.g. identification of linear opacities corresponding to omental vessels).Nakamura et al.5 have shown that a MRI can detect the transthoracic herniation of contents, thereby confirming the diagnosis in doubtfulcases. The learning point of our case is that a Morgagni's hernia should be considered as part of the diferential diagnosis of an opacity in the right cardiophrenic angle. Other causes of right cardiophrenic opacity on CXR include pericardial cyst, hydatid cyst, pericardial fat pad (especially in overweight patients, steroid therapy and Cushing syndrome), lymphadenopathy and thymic tumours6",
    "differential_diagnosis": "Morgagni's, Hernia",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004865/000004.jpg?itok=f7tCkf5f",
            "caption": "Defect in anterior diaphragm"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/4865",
    "time": "23.06.2008"
  },
  "4921": {
    "case_id": 4921,
    "title": "Pleural effusion in HIV",
    "section": "Chest imaging",
    "age": "45",
    "gender": "female",
    "diagnosis": "Adenocarcinoma of unknown primary",
    "history": "45 year old female with HIV presented to the ER with a 2 week history of productive cough, and left sided pleuritic chest pain with worsening shortness of breath for 2 days prior to presentation.\nImaging studies revealed a massive left sided pleural effusion with mediastinal shift.",
    "image_finding": "45 year old female with HIV presented to the ER with a 2 week history of cough productive of clear sputum, left sided pleuritic chest /back pain, and worsening shortness of breath for 2 days prior to\npresentation. Patient has been HIV positive for 15 years and her CD4 count was greater than 500, two weeks prior to admission. Also, her viral load was undetectable at that time. She had a 25 pack\nyear history of smoking. Review of other systems was negative except for progressive weight loss over the last one year. CXR and CT scan showed massive left sided pleural effusion with right sided\nmediastinal shift. On admission, thoracentesis was performed with removal of about 1.6 litres of bloody pleural fluid, with significant improvement in patient's dyspnea. Cell counts and chemistries\nof the pleural fluid showed an exudative process with lymphocyte predominance. Cytology of the fluid revealed adenocarcinoma. Further work-up was initiated to identify the primary. Mammogram and CT\nscan of the abdomen/pelvis were done which did not show any findings suggestive of malignancy. A repeat CT scan of the chest after thoracentesis and chest tube placement did not show any mass or\nsignificant lymphadenopathy to suggest primary lung cancer or lymphoma. During the later course of her hospitalization, patient underwent talc pleurodesis.",
    "discussion": "A pleural effusion is an excessive accumulation of fluid in the pleural space. Pleural effusions are almost always abnormal and the cause of such effusions should be determined. A diagnostic\nthoracentesis should be attempted in most cases to determine the cause of the effusion, unless there is a clear explanation for it ( for eg., bilateral symmetric effusions in a patient with CHF).\nEffusions can be exudative or transudative and the differentiation is made on the basis of Light's criteria (exudative when the PF/Serum protein ratio >0.5 or PF/Serum LDH ratio is >0.6 or\nPleural Fluid LDH level is greater than 2/3rd the upper limit of normal serum LDH). In the setting of HIV, like in this case, the most common causes of pleural effusion are Kaposi's sarcoma,\nTuberculosis and parapneumonic effusion. This patient had a bloody effusion and as a result, Pulmonary embolism, and malignancy were considered in the differential diagnosis, although the suspicion\nfor PE in this patient was low. Other common causes of pleural effusion in HIV are cryptococcosis, and primary effusion lymphoma. Pneumocystis carinii infection uncommonly presents with pleural\neffusion and is less likely the etiology in a patient with CD4 count greater than 500. In a prospective study by Miller and colleagues, out of 58 HIV patients presenting with pleural effusions,\nKaposi's sarcoma (19 cases), parapneumonic effusion (16 cases), and Tuberculosis (8 cases) were the top three causes. Kaposi's sarcoma and Non-Hodgkin's Lymphoma constitute about 90% of the\nmalignancies reported in HIV patients. However, in the general population, the three tumors that cause approximately 75% of all malignant pleural effusions are lung carcinoma, breast carcinoma, and\nlymphoma. Patients with malignant pleural effusion are treated symptomatically for the most part, since the presence of a malignant effusion indicates disseminated disease and most malignancies\nassociated with pleural effusion are not curable with chemotherapy. The only symptom that can be attributed to the effusion itself is dyspnea. If the patient's lifestyle is compromised by dyspnea,\nthen pleurodesis may be considered, which was the case in our patient.\nThis case underscores the importance of including malignancy (either metastatic or primary lung cancer in addition to the malignancies commonly seen with HIV) in the differential diagnosis of pleural\neffusions in HIV patients.",
    "differential_diagnosis": "Adenocarcinoma, of, unknown, primary",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004921/000001.jpg?itok=nkOyhd_n",
            "caption": "Admission CT scan of chest showed massive left sided pleural effusion with mediastinal shift to the right suggestive of tension and atelectasis of the left upper lobe. There was minimal aeration of the anterior segment of the left lower lobe."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004921/000002.jpg?itok=ESMuC4G8",
            "caption": "Massive left sided pleural effusion with mediastinal shift to the right."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004921/000003.jpg?itok=9s0qlStq",
            "caption": "Significantly improved left sided pleural effusion after chest tube placement."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004921/000004.jpg?itok=t5QaAjsj",
            "caption": "Improved aeration of the left lung after chest tube placement."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/4921",
    "time": "26.08.2008"
  },
  "4924": {
    "case_id": 4924,
    "title": "Spontaneous Pneumomediastinum",
    "section": "Chest imaging",
    "age": "25",
    "gender": "male",
    "diagnosis": "Spontaneous pneumomediastinum in absence of oesophageal or other pathology.",
    "history": "A 25-year-old man presented in shock and previous mild epigastric pain and dyspnea",
    "image_finding": "A 25-year-old man was referred to our clinic in shock of unknown explanation. A few hours previously he had complained of mild dyspnea and epigastric pain. There was no previous history of illness or\ntrauma. On antero-posterior chest x-ray there was no evidence of free air in the mediastinum. Computed tomography scanning of the mediastinum showed air around the descending aorta, esophagus,\ntrachea and in the anterior mediastinum.Barium swallow showed no evidence of esophageal rupture. The patient recovered fully and he was discharged home 6 days after his admission.",
    "discussion": "Spontaneous pneumomediastinum is a a benign condition diagnosed rarely in patients below the age of 18 years. The incidence is difficult to evaluate because the disease frequently is unrecognized.\nIts incidence ranges from 1 in 800 to 1 in 42,000 patients presenting at hospital emergency units. The pathophysiology consists of an increased pressure gradient between the intraalveolar and\ninterstitial spaces enhances air leakage from small alveolar openings and ruptured alveoli into the perivascular adventitia causing interstitial emphysema. Acute onset of chest pain is the usual\nclinical presentation. A single chest x-ray usually is sufficient to make the diagnosis of this entity. Anteroposterior chest radiographs typically show a vertical lucent line along the left side of\nthe heart and aortic arch, showing the pleura as a fine opaque line. CT is useful, because the anatomic location of the air may be discovered on cross-sectional display. Especially air can be found\naround the great vessels of mediastinum, esophagus and trachea. Barium swallow is always indicated to eliminate esophageal perforation and to rule out the presence of a radiotransparent foreign body.\nGenerally, spontaneous pneumomediastinum is self limiting. Analgesics, bed rest, and treatment for coughing are appropriate The air usually reabsorbs within a few days.",
    "differential_diagnosis": "Spontaneous, pneumomediastinum, in, absence, of, oesophageal, or, other, pathology.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004924/000002.jpg?itok=Bfa-e7lo",
            "caption": "free air anterior to the aortic arch"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004924/000003.jpg?itok=pm4ApdAK",
            "caption": "free air near the descending aorta"
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004924/000004.jpg?itok=XE26fvI_",
            "caption": "air around esophagus"
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004924/000005.jpg?itok=-7JO10nc",
            "caption": "air around the lower part of esophagus"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/4924",
    "time": "04.06.2008"
  },
  "4949": {
    "case_id": 4949,
    "title": "PRIMARY MALIGNANT LYMPHOMA OF THE STERNUM",
    "section": "Chest imaging",
    "age": "44",
    "gender": "male",
    "diagnosis": "Sternal primary malignant lymphoma",
    "history": "Anterior chest wall mass",
    "image_finding": "The patient was referred to our hospital because of two-month history of anterior chest wall mass, without pain and no fever. Physical examination revealed a anterior chest mass. Enhanced CT scan\nshowed a homogeneous soft-tissue-density mass, 2 x 3 x 4,5 cm in size, arising from the sternum (fig 1). The mass destroyed the sternum without extension into the subcutaneous tissues, or mediastinal\nspace (fig 2). There were no pulmonary lesions or mediastinal nodes. Sternocostal joints were intact. A bone tumour or infection were suspected. No further lesions were detected by bone scintigraphy.\nThe patient underwent an open surgical biopsy. Histology revealed a malignant non-Hodgkin lymphoma classified as diffuse large B-cell lymphoma. Therapy consisted of 6 CHOP cycles, followed by\nradiotherapy. After therapy there was a complete regression of the disease. The most interesting aspect of this case is involvement of the sternum as the solitary manifestation of the primary\nmalignant lymphoma.",
    "discussion": "Primary non-Hodgkin bone lymphoma (NHL) is a rare condition which represents a low percentage of both the malignant primary bone tumours and non-Hodgkin extranodal lymphoma. Patients with primary NHL\nof bone commonly present with local bone pain, soft tissue swelling, and a mass or a pathological fracture. There is a slight male preponderance, and most patients are over 45 - 50 years of age (1).\nPrimary NHL of bone can arise in any part of the skeleton, but long bones are the most common sites of presentation. To our knowledge, this is the first case of solitary primary malignant\nnon-Hodgkinien lymphoma of sternum in the English literature. Plain radiographs often revealed osteolysis or osteosclerosis lesion (2). Computed tomography studies are more sensitive than plain\nradiographs, lesions appear radiolucent, permeative or destructive, with or without sclerosis, and demonstrate a soft-tissue mass. Magnetic resonance imaging of the primary lesion demonstrates low\nsignal intensity on T1-weighted images and high signal intensity on T2-weighted images, and is more sensitive than computed tomography for detecting a soft-tissue mass (2). Primary bone lymphoma is\nhighly curable with a combination of chemotherapy and radiotherapy (3).",
    "differential_diagnosis": "Sternal, primary, malignant, lymphoma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004949/000002.jpg?itok=q0ldFBNK",
            "caption": "Enhanced sagittal reconstruction CT scan shows sternal mass without extension into the subcutaneous tissues or mediastinal space."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/4949",
    "time": "01.08.2007"
  },
  "4975": {
    "case_id": 4975,
    "title": "Posttraumatic diaphragmatic hernia misinterpreted as an empyema of the ple",
    "section": "Chest imaging",
    "age": "54",
    "gender": "male",
    "diagnosis": "Posttraumatic diaphragmatic hernia",
    "history": "Diaphragmatic rupture is frequently not recognized at the time of trauma, and an early correct diagnosis is made in less than 50% of cases (1). We present a patient with a postraumatic diaphragmatic hernia, first misinterpreted as an empyema of the pleura caused by a suspected colopleural fistula.",
    "image_finding": "A 54 \u2013 year old male Caucasian was admitted from a peripheral hospital with acute onset of diffuse abdominal pain. A blunt thoracic trauma was reported three months ago. Physical examination revealed painful deep abdominal palpation. The laboratory findings showed elevated amylase (694 U/l, normal range 8-53 U/l) and lipase (>3000 U/l, normal range < 60 U/l). Leucocytes (6.0 /\u00b5l, normal range 4-10) and C reactive protein (",
    "discussion": "Anatomically, the diaphragm is composed of two parts: the lumbar diaphragm and costal diaphragm. The diaphragm is a dome-shaped, musculotendinous structure located at the bottom of the pleural cavity and at the top of the abdominal cavity. It consists of a central tendon, with right and left leaflets composed of striated muscles. Three large openings disrupt the continuity of the diaphragm: the aortic, esophageal, and inferior vena caval apertures. The diaphragm is covered by parietal pleura and peritoneum except for the bare area of the liver. Early diagnosis and repair of diaphragmatic ruptures are preferable. Pursuant to the literature, initial plane radiographs allow diagnosis of 27%\u201360% of left-sided injuries but only 17% of right-sided injuries (3). Elevation of the hemidiaphragm, distortion or obliteration of the outline of the hemidiaphragm, and contralateral shift of the mediastinum are suspicious of hemidiaphragmatic rupture. Differentiation of a herniated liver through a diaphragmatic tear from other causes of elevated diaphragm such as pleural effusion, atelectasis, pulmonary contusion or laceration remains difficult (4). Detection of diaphragmatic injuries has improved with multislice CT (MSCT) and additional multiplanar reconstructions. Frequently with CT, it is difficult to identify the margins of the hemidiaphragm following thoracic traumabecause of pleural effusion, particularly in small tears and in the absence of herniation of intraabdominal viscera. We demonstrate a misinterpretation of contrast enhanced CT of an extrapulmonary lesion at the posterolateral site of the left thorax. Because of an air-fluid-level and a \u201cpseudocapsule\u201d a radiologist in a peripheral hospital interpreted these findings as an empyema of the pleura due to a postinflammatoric pleurocolonal fistula. Obviously, the ventral contiguous fatty tissue was been missed. This fact gives the clue of a noninflammatoric lesion, because anempyema never shows fatty tissue around its capsule. Spiral CT proved to be valuable in the detection of diaphragmatic injuries with a sensitivity of 71% (78% for left-sided injuries and 50% for right-sided injuries), a specificity of 100%, and an accuracy of 88% for left-sided injuries and 70% for right-sided injuries (5). The most common direct findings are discontinuity of the hemidiaphragm, intrathoracic herniation of abdominal contents, and the dependent viscera sign (6). An indirect sign of herniation is indicated by the presence of a focal constriction of the bowel orthe stomach at the site of herniation, the so-called \u201ccollar sign\u201d (5). The dome of the diaphragm is a difficult area to visualize with CT, as the plane of the scan is tangential to the diaphragm. Another pitfall may be a posterolateral defect, which is detected with CT in approximately 6% of asymptomatic adults (7). Recently, MR imaging improved due to the development of faster imaging sequences. Nevertheless MRI is not recommended as the first imaging modality in emergency radiology because of a long acquisition time compared to MSCT (6). In conclusion, the presented case reveals the difficulties in diagnosing diaphragmatic ruptures. All subtle signs have to be examined very carefully to avoid misinterpretation and any artificial harm to the patient.",
    "differential_diagnosis": "Posttraumatic, diaphragmatic, hernia",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000004975/000003.JPG?itok=0phEp22O",
            "caption": "Fig. 1a-c: Spiral CT scans with contrast media of a 54 - year old patient. Window level and center level of Fig. a and c 500 HU and 40 HU. Window level and center level of image b -1200 HU and -600 HU. (a/c): Extrapulmonary lesion at the posterolateral site of the left thorax with an air-fluid-level (arrow); fatty tissue around the lesion (arrowhead). (b): Diaphragmatic rupture at the posterolateral site of the diaphragm with herniation of colon (arrow)"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/4975",
    "time": "08.04.2008"
  },
  "4984": {
    "case_id": 4984,
    "title": "Thymic Hodgkin Disease",
    "section": "Chest imaging",
    "age": "30",
    "gender": "female",
    "diagnosis": "Thymic Hodgkin Disease.",
    "history": "A 30 year-old female presented to our institution with breathing difficulty. At physical exam we noted the presence of a supraclavicular mass and a superior vena cava syndrome.",
    "image_finding": "A 30 year-old female with breathing difficulty, a supraclavicular mass and a superior vena cava syndrome presented to our institution. She had no previous imaging examinations. The patient reported that the mass appeared 3 months ago, but with no symptoms. The mass had gained a considerable size in the last two weeks. Laboratory studies were normal except for an elevated lactic deshydrogenase enzyme (731 UI/L). A contrast enhanced computed tomography (CT) was performed followed by a biopsy based on the images findings.",
    "discussion": "Nodular sclerosing Hodgkin disease ( NSHD ) is the most common cell type to involve the anterior mediastinum and thymus. It affects patients in a bimodal age distribution; a peak in adolescence and another after the fifth decade. It occurs more often in women. The first typical finding is the presence of a palpable supraclavicular or cervical lymphadenopathy. Others present fever, night sweating or weight loss. CT may show either mass effect on or invasion of vital mediastinal structures, and also of pleura, lung or chest wall. Masses frecuently show a homogeneous soft tissueattenuation. If the mass has a large size, it can also show hemorrhage, necrosis, or cyst formation. On MR imaging, the mass shows a homogeneous low signal intensity similar to muscle on T1-weighted sequences and a mixed or high intensity, similar to fat, on T-2 weighted sequences. On this last sequence, tumoral edema, inflammation and areas of necrosis or cyst formation show a higher signalintensity.",
    "differential_diagnosis": "Thymic, Hodgkin, Disease.",
    "figures": [],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/4984",
    "time": "23.06.2008"
  },
  "4994": {
    "case_id": 4994,
    "title": "Varicella Pneumoni",
    "section": "Chest imaging",
    "age": "17",
    "gender": "female",
    "diagnosis": "Varicella Pneumonia",
    "history": "Shortness of breath and cough for 2 days.",
    "image_finding": "A 17 year old patient presented with a 2 day history of dyspnoea, cough and vesicular rash. Chest X-ray (fig.1) showed widespread patchy opacities. High resolution computed tomography of the lungs\n(fig. 2a, b, c, d) showed widespread ill defined nodular opacities with surrounding ground glass attenuation distributed randomly. There is smooth interlobular septal thickening in the upper zones.\nThe combination of the rash and the HRCT appearances suggested a diagnosis of Varicella Pneumonia. Follow up high resolution computed tomography of the lungs (fig. 3a, b, c, d) showed resolution of\nthe nodular air space shadowing and development of small calcified granulomas confirming the diagnosis of Varicella Pneumonia.",
    "discussion": "Varicella is a common contagious infection in childhood with increasing incidence in adults.1,2 Varicella pneumonia, although rare, is the most serious complication that affects adults. It\nhas a reported incidence in healthy adults that is 25-fold greater than in children.3 Most cases of varicella-zoster virus pneumonia in adults occur in immunocompromised patients. The\nplain chest film differs slightly from that seen with other viral infections.4 The pneumonia causes multiple 5 to 10 mm ill-defined nodules that may be confluent and may come and go in\ndifferent areas of the lung. The small, round consolidations usually resolve within a week after the disappearance of the skin lesions, but they can persist for months. In a few patients the lesions\ncalcify and remain indefinitely as numerous, well-defined, randomly scattered, 2 \u2013 3 mm, dense calcifications in otherwise normal lungs.5 HRCT can be helpful in the diagnosis of\nviral pneumonia.6 Findings on HRCT include numerous 1-10 mm well-defined and ill-defined nodules throughout both lungs. Other findings include nodules with surrounding ground-glass\nattenuation, patchy ground-glass attenuation and consolidation, and coalescence of nodules.7 Similar imaging findings can be seen in other viral pneumonias, such as cytomegalovirus,\ninfluenca virus or measles virus pneumonia and differential diagnosis remains challenging. Varicella pneumonia that results in respiratory failure or progresses to the institution of mechanical\nventilation carries a significant morbidity and mortality despite intensive respiratory support and antiviral therapy. When used in addition to appropriate supportive care and early institution of\nantiviral therapy, corticosteroids appear to be of value in the treatment of previously well patients with life-threatening Varicella pneumonia.9",
    "differential_diagnosis": "Varicella, Pneumonia",
    "figures": [],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/4994",
    "time": "13.12.2007"
  },
  "5047": {
    "case_id": 5047,
    "title": "3-D demonstration of an intrathoracic rib",
    "section": "Chest imaging",
    "age": "21",
    "gender": "male",
    "diagnosis": "Intrathoracic rib.",
    "history": "A 21-year-old, asymptomatic patient referred to our department for the definition of a pathological chest radiograph.",
    "image_finding": "An asymptomatic, 21-year-old, male patient admitted to our hospital with a pathological chest radiograph (Fig. 1). The chest radiograph showed a broad linear dense band that extended\ninferiorlaterally from the level of the third intercostal space to the level of the posterior portion of the 10th rib. A CT scan with a 4-slice G.E Lightspeed 3.x was performed and confirmed the\nposterior, extrapleural location of the lesion (Fig.2). The structure was articulated with the 4th thoracic vertebral body and a small fibrous diaphragmatic attachment was visualized (Fig.3),\nsuggesting the possibility of an intrathoracic rib. The bone window demonstrated the bony cortex of the lesion and the diagnosis of an intrathoracic rib was made. A 3-D reconstruction in an Advantage\nWorkstation 4.0( adw GE 4.0), with a 5mm slice thickness (Fig. 4)undoubtedly confirmed the diagnosis.",
    "discussion": "Intrathoracic rib (IR) represents a rare congenital anomaly of the thoracic cage (1) . Usually the supernumerary ribs occur unilaterally, more commonly on the right side. In most cases they are\nasymptomatic, but some patients may have a fibrous diaphragmatic attachment that can cause restrictive ventilatory defect ( 2, 3 ). About 40 cases were found in a review of the literature (2) but\nonly five have been demonstrated with CT (1, 2, 4 , 5) . To our knowledge only two reports have been referred to the 3-D demonstration of an intrathoracic rib (2,5). According to one hypothesis the\nanomaly is a result of incomplete fusion between components halves of adjacent sclerotomes during embryogenesis (1). CT has many advantages in demonstrating this specific thoracic congenital anomaly.\nIt can depict the cortical bone, the extrapleural location and the usual extension from rib or vertebra and also show the potential fibrous diaphragmatic attachment (1). The three-dimensional\nreconstruction demonstrated with high accuracy the origin and extent of intrathoracic rib and would therefore appear to be the modality of choice for localization (2). The significance of recognizing\nthe IR lies in the fact that it is an innocuous thoracic anomaly which should not be mistaken for either a parenchymal or pleural lesion or even an artifact (1),thus preventing unnecessary\nexaminations and surgery.",
    "differential_diagnosis": "Intrathoracic, rib.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005047/000005.jpg?itok=5EFc-1TK",
            "caption": "A plain chest radiograph showing a broad linear radiodense band in the right hemithorax (white arrows) that extends from the level of the third intercostal space to the anatomic position of the posterior arch of the 10th rib."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005047/000006.jpg?itok=IG45tqIn",
            "caption": "A CT scan of the thorax, with 5 mm slice thickness, showing the posterior and extrapleural location (black arrow) of the hyperdense linear lesion of the right hemithorax."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005047/000012.jpg?itok=gAFLN77W",
            "caption": "A multiplanar reconstruction (MPR) demonstrating the connection of the described bony structure -rib (upper arrow) to the diaphragm with a thin fibrous attachment (lower arrow)"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005047/000013.jpg?itok=0YK2DW8O",
            "caption": "A 3-D reconstruction with a 5 mm slice thickness demonstrating undoubtedly the presence of an intrathoracic rib articulated with the 4th thoracic vertebra"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/5047",
    "time": "27.03.2008"
  },
  "5060": {
    "case_id": 5060,
    "title": "Spontaneous pneumomediastium following an alcoholic binge",
    "section": "Chest imaging",
    "age": "24",
    "gender": "male",
    "diagnosis": "Spontaneous pneumomediastium following presumed alveolar rupture",
    "history": "A 24 year old man presented with spontaneous chest pain and neck swelling after an alcoholic binge.",
    "image_finding": "A 24 year old bricklayer presented the evening after a 28 unit alcohol binge during which he had vomited once with no immediate symptoms and had gone to bed three hours later. On waking, he complained of chest pain and a 'thickened neck'. He had no significant past medical history. Physical examination revealed surgical emphesema around his neck but no other abnormal signs. In particular he was afebrile and normotensive. Initial chest radiograph showed pneumomediastinum (Figure 1) but no other abnormal signs, and blood tests were unremarkable. On the suspicion of an oesophageal rupture he was commenced on broad spectrum antbiotics and a chest CT perfomed with the prior administration of 50mls of niopam 300 orally (Figure 2). The CT showed extensive mediastinal air seen from the level of the gastro-oesophageal junction up into the root of the neck, but no extraluminal leakage of contrast. The absence of oesophageal perforation was confirmed by theperformance of a gastrografin swallow in the erect, supine, left and right decubitus positions on the day subsequent to admission (Figure 3). The patients symptoms settled over the next few days and he was discharged to uneventful outpatient review.",
    "discussion": "The causes of pneumodiastium separate naturally according to the origin of the mediastinal gas, whether from respiratory system, digestive tract, from outside the body, or generated in situ as a result of gas forming infection. Respiratory causes include spontaneous alveolar rupture (subsequent to coughing, vomiting or other rise in intrathoracic pressure - which may be associated with conditions such as asthma, croup, exercise, pneumonia, diabetic ketoacidosis, pulmonary fibrosis, parturition, mechanical ventilation and compressive chest trauma) [1]. The air leak tracks alongpulmonary interstitium to the mediastium via the hila, but is usually only visible on the chest radiograph if adjacent lung is opacified by some pathological process. Natural contrast against soft tissues makes the air visible once it reaches the mediastinum. On CT imaging, by contrast, air in the bronchovascular interstitium may often be seen as a dark line between aerated lung and bronchial/vascular walls. Occasionally other routes for air to access the mediastinum from the chest arise, for example subsequent to pneumothorax, chest drain insertion, mediastinoscopy or as asequel to bronchial laceration. Perforation of the pharynx, oesophagus, duodenum, colon or rectum can allow gas originating from the digestive tract to end in the mediastinum. The originating structures are usually either mediastinal themselves or retroperitoneal, allowing gas to track from retroperitoneum to mediastinum via the diaphragmatic hiatus. In our patient the differential diagnosis is between alveolar rupture and oesophageal rupture secondary to vomiting (Boerhaave's syndrome). As a complete oesophageal tear allows contaminated material into the mediastinum andpleural space with likely mediastinitis, the early detection of a leak is of critical importance so that surgical repair can be contemplated without delay; the mortality of mediastinitis is 20-30% [2]. Alveolar rupture, by contrast is a benign self-limiting process that requires no specific therapy [3]. Fortunately for our patient it was the latter diagnosis that applied.",
    "differential_diagnosis": "Spontaneous, pneumomediastium, following, presumed, alveolar, rupture",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005060/000002.jpg?itok=MudYbMK0",
            "caption": "Pneumomediastium and no other abnormality is demonstrated"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005060/000003.jpg?itok=C232n2Sf",
            "caption": "Extensive mediastinal gas is demonstrated"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005060/000004.jpg?itok=Z56BdK2b",
            "caption": "No contrast leak is present"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/5060",
    "time": "23.10.2008"
  },
  "5101": {
    "case_id": 5101,
    "title": "Mucoepidermoid carcinoma of the lung",
    "section": "Chest imaging",
    "age": "40",
    "gender": "male",
    "diagnosis": "A high-grade mucoepidermoid carcinoma of lung",
    "history": "A 40-year-old man suffered from productive cough and mild dyspnea for one month. Physical examination showed decreased breathing sound and localized crackles at his right basal lung.",
    "image_finding": "Chest radiographs revealed a mass at right pulmonary hilum with suspicious atelectasis of right middle and lower lobes (Fig.1). Chest CT scan showed a mass at right pulmonary hilum, extending along\nand within intermediate, right middle and lower lobe bronchus, and a necrotic lymph node at subcarinal region (Fig. 2). Associated obstructive pneumonia with partial collapse of right middle and\nlower lobes was noted. Fiberbronchoscope showed a mass over the orifice of right middle lobe. Transbronchial biopsy was done and histology revealed atypical epithelial proliferation. Brain CT and\nbone scan showed no distant metastasis. The patient received right middle and lower bilobectomy and mediastinal lymph node dissection. Grossly, the tumor (2.8\u00d72.5\u00d72.2 cm) was\nwell-defined, yellowish to whitish color, and soft to elastic (Fig. 3). The tumor invaded the intermediate bronchus, middle and lower lobar bronchi. One plaque-like tumor was noted at the\nintermediate bronchus and bifurcation of middle and lower bronchi. The lumen of middle and lower lobar bronchus was partially obstructed by the tumor. Obvious obstructive pneumonia was seen\nperipheral to the hilar area. Most dissected hilar lymph nodes were involved by the tumor. Microscopically, the tumor exhibited a high-grade mucoepidermoid carcinoma of lung (Fig. 4). It composed of\nanaplastic tumor cells with pleomorphic nuclei. Marked hemorrhage and necrosis were seen. The tumor invaded from the submucosa area through the bronchial wall into peripheral soft tissue, lung\nparenchyma and regional lymph node with section margin involvement. The patient expired 18 months later after the initial diagnosis.",
    "discussion": "Mucoepidermoid tumor, first reported by Smetana et al. in 1952 [1], is an uncommon airway tumor, accounting for only 0.1% to 0.2% of the primary lung malignancies [2]. The tumor is believed to be\noriginated from the minor salivary glands lining the tracheobronchial tree [3]. It is composed of mucinous-secreting, epidermoid, and intermediate cells [3]. Patients with mucoepidermoid carcinoma\nrange in age from 4 to 78 years, but nearly half are younger than 30 years [3,4]. There is no gender bias. The symptoms are frequently related to irritation or obstruction of the tracheobronchial\ntree, therefore recurrent episodes of pneumonia, dyspnea, asthma, cough, and less commonly, hemoptysis are the most frequent presenting complaints even in the 20 to 30% of patients who are\nasymptomatic [5]. In our case, productive cough and dyspnea were the major symptoms. On chest radiographs, the tumor frequently appears as a central mass with or without postobstructive pneumonia\nand/or peripheral atelectasis or as a solitary pulmonary nodule [5]. Yousem and Hochholzer [3] revealed radiographs of 58 patients with tracheobronchial mucoepidermoid carcinoma, presenting with a\nsolitary nodule or mass in 41 cases (71%) and pneumonic consolidation in 16 cases (28%); one case showed no abnormality on chest radiographs. Prediction of the endoluminal location of the tumor is\nplausible at CT scan. On CT, the mass appears as a smooth surfaced, mildly enhancing, endobronchial mass which confirms to the branching airway [5]. High-grade lesions may have a more ragged,\ninvasive appearance. Punctate calcification can be seen in up to 50% of lesions [5]. The tumors usually cause airway disease, such as distal bronchial dilatation with mucoid impaction,\npostobstructive pneumonia, air trapping, subsegmental atelectasis. Similar findings were noted in our case, but no punctate calcification was noted. The tumors can be classified as low-grade or\nhigh-grade mucoepidermoids on the basis of their histologic appearance [6]. Low-grade malignant tumors are mainly cystic components and microscopic invasion into pulmonary parenchyma is common. These\ntumors are smooth polypoid endobronchial masses, well confined within the bronchial wall. High-grade tumors usually show areas of solid growth. Atypia, mitotic activity and necrosis are\ncharacteristic and regional lymph node involvement is more frequent. These tumors are irregular in shape and focal parenchymal involvement is common. In our case, the tumor revealed obvious\nhemorrhage and necrosis. Findings of CT scan well delineated the high-grade appearance of the tumor, such as irregular solid mass with parenchyma involvement and hilar lymphadenopathy. Low-grade\nmucoepidermoid carcinoma can be cured following complete resection. The 5-year survival rate accounts for 80%. High-grade carcinoma results in worse prognosis (5-year survival rate, 31%). Previous\nreport indicated that survival correlated well with the presence of regional lymph node metastasis [7]. In conclusion, mucoepidermoid tumor is an uncommon airway tumor, which occurs most common in\nyoung adult. CT scan is a good imaging modality in evaluation endobronchial tumor and its extension.",
    "differential_diagnosis": "A, high-grade, mucoepidermoid, carcinoma, of, lung",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005101/000001.jpg?itok=3jfdZl3e",
            "caption": ""
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005101/000002.jpg?itok=q2SN7gG-",
            "caption": ""
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005101/000003.jpg?itok=X1ibBi22",
            "caption": ""
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005101/000004.jpg?itok=3qJJIfWk",
            "caption": ""
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005101/000005.jpg?itok=sTjXlcJ-",
            "caption": ""
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005101/000006.jpg?itok=sAHM8xMW",
            "caption": ""
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005101/000010.jpg?itok=-m-_feFc",
            "caption": ""
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/5101",
    "time": "19.02.2008"
  },
  "5107": {
    "case_id": 5107,
    "title": "Osteofied lung metastases due to tibioperoneal osteosarcom",
    "section": "Chest imaging",
    "age": "33",
    "gender": "male",
    "diagnosis": "Ossified lung metastases due to tibioperoneal osteosarcoma",
    "history": "Patient with dyspnea, weakness and swelling of right tibia (history of myositis ossificans). Chest roentgenogram and computed tomography were performed.",
    "image_finding": "A 33 year-old farmer was admitted to\n  hospital with dyspnea and weakness, after he had sprayed with weed killer. He had a smoking history of 30 pack/yrs. Physical examination revealed reduction of respiratory murmur of left lung and\n  swelling of his right tibia. The patient had a previous history of myositis ossificans proved with biopsy at the age of 29 yrs. Laboratory investigations revealed mild anemia (Ht 32,5%) with\n  haemoglobin of 11.1g/dl, WBC 20.000, ALP 1179, ESR 105 and 96% oxygen saturation. The chest roentgenogram showed complete opacification of the left hemithorax and multiple nodules of different\n  density and size in the right lung. The chest CT scan disclosed bilateral pleural collections. The left one was significantly larger and was accompanied by complete atelectasis of the left lung. CT\n  revealed a large number of ossified nodules both in the atelectatic left lung and in the expanded right lung (figure 1, 2). In the right lung a significant number of nonossified nodules was\n  demonstrated. The radiologic findings were combatible with ossified and nonossified hematogenous lung metastases most probably secondary to osteosarcoma. A roentgenogram and a CT scan of the right\n  tibia (figure 3) were performed and showed osteoblastic bone destruction-reaction with invasion of the medullary cavity accompanied by a large soft tissue mass (31cm x 19cm x14cm) with coarse\n  calcifications consistent with tibioperoneal osteosarcoma.",
    "discussion": "Multiple different size\n  lung nodules are compatible with metastases. A large variety of neoplasms can produce calcified or ossified lung metastases. Calcification refers to the deposition of calcium salts in tissues, in\n  contrast to ossification, which indicates bone tissue formation (calcification in a collagen matrix), with or without marrow elements (1). Pulmonary metastases of osteogenic sarcoma are considered\n  to result from bone formation (1). Calcification / ossification in metastases arises through a variety of mechanisms: bone formation in tumor osteoid, calcification and ossification of tumor\n  cartilage, dystrophic calcification and ossification of tumor cartilage, dystrophic calcification and mucoid calcification. The sarcomas that are most commonly reported in the literature to develop\n  calcified or ossified lung metastases are osteogenic sarcoma, chondrosarcoma, synovial sarcoma and giant cell tumor (2). Among carcinomas, the papillary and mucinus adenocarcinomas are the\n  histological types most likely to develop calcified lung metastases (2,3). Extremely unsual neoplasms that have also been reported to produce calcified lung metastases are malignant mesenchymoma,\n  fibrosarcoma of the breast and medullary carcinoma of the thyroid (2). Sarcoma is the prototype tumor for pulmonary metastasectomy, as more than 70% of patients with sarcoma metastatic to the lung\n  have the lung as the sole site of metastasis. Calcification can also develop at the site of pulmonary metastases that have vanished after successful chemotherapy. This chemptherapeutic effect can\n  be manifested as persistent nodules that, on histologic examination show only necrosis and fibrosis without residual viable neoplastic tissue. Metastatic testicular neoplasms are particularly prone\n  to this outcome (4). A number of benign causes can also produce multiple calcified pulmonary nodules: histoplasmosis, amyloidosis, alveolar microlithiasis, mitral valve stenosis, tuberculosis,\n  varicella and silicosis (1). Central, laminated, popcorn or diffuse calcifications are characteristic of benign solitary lung nodules. Since calcified/ossified lung metastases can strongly resemble\n  granulomas or hamartomas, a reasonable suspicion of malignancy is necessary when evaluating calcified/ossified pulmonary nodules (2).",
    "differential_diagnosis": "Ossified, lung, metastases, due, to, tibioperoneal, osteosarcoma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005107/000013.jpg?itok=17VjCAIw",
            "caption": "Figure 1 a:\nCT scan on lung window (a) and mediastinal window without contrast (b) at the level of the upper lobe. Multiple non-calcified and calcified nodules of different size in the right lung and calcified nodules within the atelectatic left lung are seen. Bilateral pleural effusions are seen."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005107/000014.jpg?itok=i9rZeUVk",
            "caption": "Figure 1 b:\nCT scan on lung window (a) and mediastinal window without contrast (b) at the level of the upper lobe. Multiple non-calcified and calcified nodules of different size in the right lung and calcified nodules within the atelectatic left lung are seen. Bilateral pleural effusions are seen."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005107/000015.jpg?itok=kV5YHUqg",
            "caption": "Figure 2 a: \nCT scan on lung window (a), mediastinal window without contrast (b) and mediastinal window with contrast (c) at the level of the lower lobe. Multiple non-calcified and calcified nodules of different size in the right lung and calcified nodules within the atelectatic left lung are seen. Note the enhancement of the atelectatic lung after intravenous contrast mdedium injection (c). Bilateral pleural effusions are noted."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005107/000016.jpg?itok=mrBj846Z",
            "caption": "Figure 2 b: \nCT scan on lung window (a), mediastinal window without contrast (b) and mediastinal window with contrast (c) at the level of the lower lobe. Multiple non-calcified and calcified nodules of different size in the right lung and calcified nodules within the atelectatic left lung are seen. Note the enhancement of the atelectatic lung after intravenous contrast mdedium injection (c). Bilateral pleural effusions are noted."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005107/000017.jpg?itok=1doHEs5B",
            "caption": "Figure 2 c: \nCT scan on lung window (a), mediastinal window without contrast (b) and mediastinal window with contrast (c) at the level of the lower lobe. Multiple non-calcified and calcified nodules of different size in the right lung and calcified nodules within the atelectatic left lung are seen. Note the enhancement of the atelectatic lung after intravenous contrast mdedium injection (c). Bilateral pleural effusions are noted."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005107/000018.jpg?itok=uqOYwtZC",
            "caption": "Figure 3 a:\nTwo sequential axial CT scans of the right tibia and fibula showing extensive coarsely calcified \u2013 osteofied amorphous soft tissue mass surrounding the diaphyses of the two bones (a) and infiltration of the bone marrow of both bones (b)."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005107/000019.jpg?itok=nspmLbpH",
            "caption": "Figure 3 b:\nTwo sequential axial CT scans of the right tibia and fibula showing extensive coarsely calcified \u2013 osteofied amorphous soft tissue mass surrounding the diaphyses of the two bones (a) and infiltration of the bone marrow of both bones (b)."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/5107",
    "time": "13.02.2008"
  },
  "5188": {
    "case_id": 5188,
    "title": "Recurrent pulmonary infections with extensive bronchiectatic changes of lung structure in a patient with syndrome of chronic mucocutaneous candidiasis",
    "section": "Chest imaging",
    "age": "36",
    "gender": "female",
    "diagnosis": "Diffuse bronchiectatic changes in a patient with chronic mucocutaneous candidiasis.",
    "history": "Patient presented with fever (38\u00baC) and productive cough a month ago.",
    "image_finding": "The patient has a history of several hospital admissions since early childhood, due to reccurent pulmonary infections as well as sinusitis, treated surgicaly twice. Repeated thoroughly investigations\nin several clinics since the age of 28, have failed to show the existence of an underlying systemic disease. A CT examination revealed severe destructive bronchitis, early bronchiectatic changes of\nthe left lower lobe and lingula. Most of her pulmonary infections were due to common bacteria, except in one admission were Aspergillus was isolated. At the age of 31 she developed extensive\nulcerative lesions of the face and buccal mucosa, which have been proved to be non-specific granulomas under biopsy. Liver biopsy revealed non-specific granulomatous hepatitis. Cultures from face and\nsputum isolated Candida. Thorough immunologic investigation indicated that neutrophil function was entirely normal while T-cell subset in response to delayed hypersensitivity had some problems with\nvery low titer to Candida. Thus it was concluded that the patient suffered from a rare syndrome of chronic mucocutaneous candidiasis. She underwent a life-long treatment with fluconazole which had\nexcellent results on skin lesions. Prophylactic therapy with trimethoprim-sulfamethoxazole was also applied for bronchiectasis.",
    "discussion": "Chronic mucocutaneous candidiasis is a rare complex syndrome characterized by persistent and recurrent Candida albicans infection of mucous membranes, skin and nails. There are several subgroups of\npatients with chronic mucocutaneous candidiasis and these can be identified by associated disorders such as immunodeficiency (cellular or humoral deficiency, partial or complete), autoimmune\ndiseases, endocrinopathies, thymoma (1). Children suffering from chronic mucocutaneous candidiasis also presented with a remarkable susceptibility to non candidal infections, with reccurent bacterial\npneumonias and bronchiectasis being the major cause of morbidity and mortality (2). Interpretation of hepatic granulomata is problematic since they occur not only in patients with systemic\ngranulomatous disease, but also in a variable number of patients with undrlying liver disease and in a heterogenous group of patients with disorders that appear to be of neither hepatic nor\ngranulomatous in nature (3). Bronchiectasis is associated with a variety of predisposing conditions and no specific correlation to Candida infection (4). Bronchiectatic changes were identified with\nHRCT (the imaging modality of choice for demonstrating or ruling out bronchiectasis and its extent) (5) after repeated pulmonary infections in early adulthood. Several immunodeficiency states are\ncurrently investigated in early childhood for patients presenting with reccurent pulmonary infections. In our patient there was not detected any primary immunodeficiency disease (6). We provide an\nillustrative case report and discussion on a patient suffering from diffuse bronchiectatic changes since early childhood with an underlying disease of chronic mucocutaneous candidiasis and\nconcomitant reccurent pulmonary infections. Regarding the imaging technique, 3mm collimation scans was obtained at 3mm intervals through the chest with a window level of -700 HU anda a width of 1000\nHU. Bronchiectatic changes are seen widespread in both lungs, but more pronounced at the lower lobes. There is failure of the bronchi to taper towards the periphery and are often visualized in close\nproximity to the costal pleura. Increased bronchial wall thickness is apparent. The morphology of bronchiectatic changes are mainly cylindrical with signet-ring and \"tram line\" configuration. There\nare small centrilobular nodules widespread that represent thickening of the bronchial wall or filling of dilated bronchioles with granulation tissue, mucus or pus. There was not detected pleural or\npericardial fluid nor pathological enlarged mediastinal lymph nodes.",
    "differential_diagnosis": "Diffuse, bronchiectatic, changes, in, a, patient, with, chronic, mucocutaneous, candidiasis.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005188/000001.JPG?itok=Tup2ag2n",
            "caption": "Chest HRCT: Bronchiectatic changes more pronounced in lower lobes"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005188/000002.JPG?itok=eP_M_T1o",
            "caption": "Chest HRCT: Bronchiectatic morphology of lung parenchyma with small centrilobular nodules"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005188/000003.JPG?itok=Ag87TXuT",
            "caption": "Chest HRCT: Failure of bronchi to taper towards the periphery"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005188/000005.JPG?itok=rPg3njt9",
            "caption": "Chest HRCT: Bronchiectatic changes of cylindrical morphology with signet-ring and a \\\"tram line\\\" configuration."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005188/000005.JPG?itok=rPg3njt9",
            "caption": "Chest HRCT: Bronchiectatic changes of cylindrical morphology with signet-ring and a \\\"tram line\\\" configuration."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/5188",
    "time": "01.08.2007"
  },
  "5202": {
    "case_id": 5202,
    "title": "A thin line in the right lower lung field: which fissure ?",
    "section": "Chest imaging",
    "age": "35",
    "gender": "male",
    "diagnosis": "Sagittaly oriented anetrior minor fissure.",
    "history": "An adult male patient underwent a plain chest x-ray for a routine work check up, which revealed the presence of a thin ondulating line in the medial aspect of the lower right pulmonary field, in the\nparacardiac region.",
    "image_finding": "Plain chest x-ray radiograph perfomed as a routine work check up, in an otherawise healthy male patient.",
    "discussion": "In this case (figures 1 and 2) we discuss the importance and prevalence of the fissures of the lower right lung region, and whether the\n  thin line seen in this case (Figure 1-2) is an inferior accessory fissure, an accessory fissure of the right middle lobe, or a sagittally oriented anterior minor fissure.\n\n\n  The minor fissure of the right lung separates the middle lobe from the upper\n  lobe, and its anterior aspect of the minor fissure tends to be more caudal than the posterior aspect, thus causing the appearance of two parallel lines in the frontal chest x-ray examination\n  (1).\n\n\n  \u00a0\n\n\n  It is well known that the inferior accessory fissure is the most commonly seen\n  accessory fissure, as reported from autopsy studies, plain x-ray radiographs of the chest (2), CT of the thorax (3) and HRCT of the lungs (5), its frequency on HRCT being reported at 20% in the\n  right lung (4).\n\n\n  The inferior accessory fissure, which separates the mediobasal segment of the\n  lower lobe from the remainder of the lower lobe, originates from the posterior aspect of the major fissure and runs from superomedial to inferolateral (3) occasionally extending supero-medially and\n  even reaching the hilum, thus in our opinion, with a fairly different course than on this case.\n\n\n  \u00a0\n\n\n  The accessory fissure of the middle lobe, seen in 2% of HRCT (4), is an\n  accessory fissure between the lateral and medial segment of the middle lobe. Whether the fissure seen in this case is really an accessory fissure of the middle lobe could be determined with\n  absolute certainty only with a CT examination; we consider this hypothesis unlikely though, because the course of the accessory fissure of the middle lobe is more lateral, as seen on other\n  published cases (5,6). It appears as a vertical line, usually straight or slightly ondulated, arising at the costal surface of the middle lobe and running towards the hilum from an anterolateral\n  position to a posteromedial one (4).\n\n\n  \u00a0\n\n\n  The third possibility, which we consider the possible right answer for this\n  fissure, is a sagittally oriented anterior minor fissure, which has been\n  reported firstly by Gross in 1988 and confirmed by CT by the same author\n  (7).\n\n\n  The importance of considering the different possible answers we have exposed\n  lies in the fact that in each of them lies the potential of a wrong diagnosis.\n\n\n  It might be taken for a scarring or atelectasic line thus representing the\n  outcome of a previous disease condition, or a misplaced major or minor fissure, thus implying a volume loss.\n\n\n  The most serious diagnostic mistakes might arise when there is a pathologic\n  condition in the adjacent lung parenchyma, as right upper lobe disease (in the case of the sagittal anterior minor fissure) may simulate a mediastinal mass, or disease in the medial segment of the\n  middle lobe (should it be mistaken for an accessory middle lobe fissure), or even disease affecting the lower lobe, if it were mistaken for an inferior accessory fissure.",
    "differential_diagnosis": "Sagittaly, oriented, anetrior, minor, fissure.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005202/000001.JPG?itok=vdy9wTc4",
            "caption": "Frontal chest radiograph, showing an ondulating thin line, in the lower right lung field, adjacent to the right cardiac border."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005202/000002.JPG?itok=eKHGy_kt",
            "caption": "Detail of the frontal chest radiograph"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005202/000003.jpg?itok=UYXyx5eN",
            "caption": "Anatomical drawing (from Gross BH) showing the sagittaly oriented anterior minor fissure."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/5202",
    "time": "26.08.2008"
  },
  "5246": {
    "case_id": 5246,
    "title": "Bronchiectasis complicated with pyopneumothorax",
    "section": "Chest imaging",
    "age": "41",
    "gender": "male",
    "diagnosis": "Bronchiectasis complicated with left pyo-pneumothorax.",
    "history": "A 41 year old gentleman known to have bronchiectasis presents with 4 day history of cough with purulent sputum, shortness of breath and haemoptysis.",
    "image_finding": "A 41 year old gentleman presented to hospital with 4 days history of increasing shortness of breath (MRC dyspnoea scale-5), cough with green sputum and two episodes of haemoptysis. Patient had a past\nmedical history of :- 1) left sided empyema 20 years ago which was drained and treated with antibiotics, 2) Bronchiectasis was diagnosed 4 years ago when HRCT revealed extensive bronchiectatic\nchanges and volume loss in left lower lobe and minor changes in right middle and lower lobe. On this admission examination revealed tachycardia with pulse of 120/ min. and regular, pyrexia of 38\ndegree C, hypoxia with oxygen saturation of 89 % on air, respiratory rate 30 / minute and blood pressure 120/75 mm Hg. Respiratory system examination showed stony dullness and absent air entry in\nleft hemithorax. Inflammatory markers were raised - white cell count 20.5 *109/l (neutrophils 17.9 *109/l), CRP 311 mg/l on routine blood examination. Urea and electrolytes were\nnormal. Arterial blood gas FiO2 35 % - pH 7.39, pCO2 -5.46, pO2 -13.32, HCO3 -24.6, base excess -0.2. CXR revealed complete white out of left hemithorax\nand mediastinal shift to opposite side raising the possibility of massive pleural effusion or empyema. CT thorax revealed left pyopneumothorax. Patient was treated initially with left intercostal\ndrain, intravenous antibiotics and then had a limited decortication and was to be considered for lobectomy at a later stage.",
    "discussion": "Bronchiectasis has been defined as the abnormal and permanent dilatation and distortion of conducting bronchi and airway. Laennec first described it in1819. Bronchiectasis is categorized in the\nspectrum of chronic obstructive pulmonary disease (COPD); it is characterized by inflamed airways which collapse easily resulting in the air outflow obstruction and impaired clearance of the\nsecretions. Its prevalence increases with age and it is more common in females. This damage can be congenital or may be acquired. Various factors like cigarette smoking, foreign body aspiration,\nrheumatic disease etc. all contribute to the damage. Usual clinical manifestations include cough, dyspnoea, wheezing and daily production of mucopurelent sputum, lasting for months to years and\nfrequent visits to the hospital with repeated courses of antibiotic treatments. Patients with bronchiectasis have a longer duration of symptoms during exacerbations of COPD, a greater burden of\npathogenic bacterial pathogens in the lower airway, and increased sputum inflammatory markers but the frequency of attacks is not increased.1 CXR is abnormal in 90% of cases. Abnormal\nfindings include increased bronchovascular markings from peribronchial fibrosis and intrabronchial secretions, tram lines (parallel lines outlining dilated bronchi due to peribronchial inflammation\nand fibrosis), honeycombing, cystic areas with or without fluid levels and rib crowding from an atelectatic lung. High Resolution Computed Tomography (HRCT) is the gold standard test with sensitivity\nof 97%. Specific abnormality seen is dilation of airway more than 1.5 times the normal diameter.2 HRCT also shows 'signet ring' sign which is cross-sectional appearance of dialated\nbronchus abutting the pulmonary artery.3 Non specific abnormalities include airway dilation, bronchial wall thickening, plugging of airways by mucus, cysts indicating destructive disease.\nOther HRCT findings are lack of bronchial tapering, visualizing of bronchi within 1cm of costal pleura and adjacent to mediastinal pleura. Pulmonary function tests are done to assess the functional\nimpairment due to the disease. Treatment options include aggressive treatment of the acute episode with appropriate antibiotics for 7 to 10 days. Most commonly identified bacteria include H\ninfluenza, P aeurginosa and streptococcus pneumoniae. Facilitating removal of respiratory secretions in patients with bronchiectasis is beneficial.4 Role of surgery is in removal of\nsegments that are significantly damaged by the disease and are suspected in contributing to exacerbation, mucus impaction and in areas resulting in uncontrolled hemorrhage. There is role in removing\ndamaged lung involved with multi-drug resistant organism like Mycobacterium Tuberculosis.5 Lung transplantation is an option in advanced disease especially in cases associated with cystic\nfibrosis. Complications include recurrent pneumonia requiring hospital admissions, lung abscess, empyema, haemoptysis, progressive respiratory failure and corpulmonale. . Last two complications are\nmost common causes of pulmonary related deaths in bronchiectasis.",
    "differential_diagnosis": "Bronchiectasis, complicated, with, left, pyo-pneumothorax.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005246/000001.jpg?itok=Zcj0Zavg",
            "caption": "CXR showing complete white out of left hemithorax. Displacement of the heart and mediastinum to the right which would be compatible with massive left pleural effusion."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005246/000005.JPG?itok=ZlJXRh59",
            "caption": "CT done 4 years prior to current admission showing extensive bronchiectatic changes in left lower lobe"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005246/000002.jpg?itok=fEEoMkYJ",
            "caption": "CT thorax demonstrates large left pleural collection with very little aerated left lung. Multiple pockets of gas seen within the collection."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005246/000006.JPG?itok=eUtJOBu9",
            "caption": "CT thorax (lung window) showing large left pleural collection with multiple pockets of gas."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005246/000003.jpg?itok=VBtze0W8",
            "caption": "CT thorax showing large left pleural effusion with left lower lobe bronchiectatic changes."
          },
          {
            "number": "Figure 2e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005246/000007.JPG?itok=jyg3TOmE",
            "caption": "CT thorax (lung window) showing large left pleural effusion with left lower lobe bronchiectatic changes."
          },
          {
            "number": "Figure 2f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005246/000004.jpg?itok=OmuRn-nF",
            "caption": "CT thorax after drainage of effusion with chest drain. There is still multiloculated anterior pyo-pneumothorax. The left lung shows significant re-expansion."
          },
          {
            "number": "Figure 2g",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005246/000008.JPG?itok=NFMRqqy9",
            "caption": "CT thorax (lung window) after drainage of effusion with chest drain. There is still multiloculated anterior pyo-pneumothorax. Left lower lobe shows significant bronchiectatic changes. Signet Ring sign (blue arrow) can be seen on right side"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/5246",
    "time": "07.02.2008"
  },
  "5288": {
    "case_id": 5288,
    "title": "Acute \u0130nterstitial Pneumonia Associated with Spontaneous Pneumothorax",
    "section": "Chest imaging",
    "age": "22",
    "gender": "female",
    "diagnosis": "Acute interstitial pneumonia",
    "history": "A 22 year old female patient presented to the emergency unit with a sudden onset of cough and dyspnea.",
    "image_finding": "There was no history of exposure to toxic agents; nor had the patient takenany drugs. The patient was reportedly non- smoker and there was no recent history of contact with house hold pets (cats,\ndogs or birds). Initial chest x-ray radiograph displayed diffuse patchy alveolar densities. CT scan showed bilateral diffuse septal interstitial thickening, ground glass appearance and areas of\nirregular patchy consolidation (fig.1). In addition bronchovasculer structures were distorted and traction bronchiectasis and right sided pneumothorax was evident (fig.2). The patient did not respond\nto 10 days of antibiotic and supportive treatment. After bronchoscopic biopsy and bronchioalveolar lavage yielded nonspesific results open lung biopsy was performed reporting non specific\ninterstitial pneumonia. Follow \u2013 up HRCT performed after 2 weeks displayed decreased alveolar infiltration and predominance of interstitial findings. Moreover, bilateral cystic lesions had\ndeveloped along with a bullous lesion within the right upper lobe (fig.3).",
    "discussion": "Acute interstitial pneumonia (AIP) is an idiopathic lung disease characterised by rapidly progressive dyspnea developing over days to weeks. AIP is synonymous with Hamman Rich syndrome. It is defined\nas rapidly progressive respiratory failure occuring in patients without pre-existing lung disease or extrathoracic disorders known to be associated with lung involvement. Patients with AIP have a\npoor prognosis, with reported mortality rates of 60-100%. The pathologic hallmark of AIP is diffuse alveolar damage. Histopathological investigation is always necessary for a definitive diagnosis of\nAIP.The chest radiographic and high-resolution CT scan manifestations of AIP are bilateral and sometimes patchy, and there are alveolar densities associated to areas of ground glass attenuation. But\nthese findings are nonspecific. Acute onset is a very important clue in the diagnosis of AIP. Traction bronchiectasis, bronchioloectasis, fibrosis and cysts (honey combing) develope with time. AIP is\nconsidered among idiopathic interstitial pneumonias.This kind of diseases are reported to occasionally develop acute complications such as pneumothorax and pneumomediastinum. If CT displays\nparanchymal and interstitial findings coupled with pneumothorax the initial differential diagnosis should include brochiolitis obliterans,AIP, idiopathic pulmonary fibrosis group disease, cystic\nfibrosis, langerhans cell histiocytosis, lymphangiomyomatosis, hypersensitivity pneumonia and pneumocysts jirovecii pneumonia.",
    "differential_diagnosis": "Acute, interstitial, pneumonia",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005288/000001.jpg?itok=EVd7ZkUA",
            "caption": "Axial CT showing bilateral diffuse ground glass  and patchy consolidation"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005288/000003.jpg?itok=p4VtV2E5",
            "caption": "HRCT scan showing interstitial thickening and cystic lesions on the  left upper lobe and a bullous lesion on the right upper lobe"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005288/000004.jpg?itok=l2uwpSOR",
            "caption": "Axial CT showing right sided pneumothorax and bronchovascular distortion"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/5288",
    "time": "26.02.2008"
  },
  "5294": {
    "case_id": 5294,
    "title": "Spontaneous intercostal lung herni",
    "section": "Chest imaging",
    "age": "72",
    "gender": "male",
    "diagnosis": "Spontaneous intercostal lung hernia",
    "history": "Lung herniation through the thoracic cage is uncommon and is usually secondary to surgery, penetrating injuries or blunt trauma. We present a case of spontaneous lung herniation through the lateral\nchest wall.",
    "image_finding": "A 72-year-old man presented to his General Practitioner with a cough, dyspnoea and wheeze. A week later he had an episode of severe coughing which produced left sided pleuritic chest pain and a large\narea of overlying bruising which was thought at the time to be secondary to a cough induced rib fracture. Several months later he re-presented with a subcutaneous swelling which increased in size on\nexpiration. On palpation the swelling was reducible and there was an underlying 10cm defect between the 8th and 9th ribs postero-laterally. A chest x-ray (CXR) at his first visit was normal, but a\nCXR after his second presentation confirmed a left lateral lung hernia, with no associated rib fracture (Figure 1). At the age of 4 years the patient had had a large right- sided burn associated with\nsome skin contracture. When 70 years old he developed a malignant fibrous histiocytoma in the burn area. This was excised and a partial thickness skin graft was taken from the left lateral chest\nwall, from the area which subsequently developed the lung hernia. There was no other significant past history apart from hypertension and a cholecystectomy when 64 years old. The FEV1 was 2.05 litres\n(88% of predicted) and the FVC 2.53 litres (83% of predicted). Repair of the chest wall defect was planned, with prior CT assessment (Figure 2), but the patient subsequently changed his mind. After 5\nyears follow-up there have been no complications or change in the size of the hernia.",
    "discussion": "A pulmonary hernia occurs when the lung parenchyma protrudes through an abnormal defect in the thoracic cage. Lung hernias can be classified as cervical (35%), intercostal (65%) or diaphragmatic\n(<1%) [1]. The latter is extremely rare due to the relative positive intra-abdominal pressure. The defect can be congenital (18%) [2] or acquired (82%). Congenital herniae are often cervical and\nacquired herniae usually occur following trauma or surgery [3,4], but occasionally occur spontaneously secondary to cough induced rib fracture [5]. They may present with chest pain or discomfort but\ntypically form a localised, sometimes crepitant, swelling which increases in size with forced expiration and is usually reducible. Presentation may occur at the time of the injury or after an\ninterval of several months. Spontaneous intercostal lung herniation is extremely rare in the absence of rib fracture [1,7]. In our patient the taking of a skin graft from the overlying area may be a\ncoincidence as it is difficult to conceive that this operation would lead to a defect in the underlying muscle. Thus it appears that this case is spontaneous and occurred following a severe coughing\nepisode probably associated with a chest infection. Surgery is usually reserved for large hernias, where there is a likelihood of incarceration or where it may contribute to ventilatory failure. It\nhas been suggested that repair should be undertaken after a delay of several months to allow spontaneous resolution [8]. The decision to offer repair of the defect was taken in the absence of any\nlarge body of evidence regarding the natural history of such herniae. Surgery was originally planned as it was considered that the hernia might increase in size or become incarcerated and the repair\nis relatively straightforward. Such repairs are usually open procedures but have been undertaken thoracoscopically [9, 10]. The defect may be repaired by a local plastic procedure or a synthetic\npatch if the tissues have become fixed [8]. Awareness of the condition is important to help avoid confusion with other conditions such as haematoma, infection or subcutaneous emphysema. Recognition\nmay avoid unnecessary investigation and invasive procedures. In this case the diagnosis is made from the inspiratory chest radiograph, though expiratory chest radiography may be helpful. Further\ncross-sectional imaging [11] was reserved for characterisation prior to planned repair.",
    "differential_diagnosis": "Spontaneous, intercostal, lung, hernia",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005294/000001.jpg?itok=vvfWgcal",
            "caption": "Lucency in the left chest wall  is continuous with the lung contained within the thorax, and contains lung vascular markings, confirming lung herniation, and excluding other processes such as subcutaneous emphesema or abscess."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005294/000002.jpg?itok=sQnfqM7f",
            "caption": "Axial view of the left lateral lung herniation"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/5294",
    "time": "15.09.2008"
  },
  "5295": {
    "case_id": 5295,
    "title": "Accessory tracheal bronchus",
    "section": "Chest imaging",
    "age": "42",
    "gender": "male",
    "diagnosis": "Right sided tracheal bronchus",
    "history": "A 42 year old gentleman presented with haemoptysis. He was found to have a right sided accessory tracheal bronchus both on bronchoscopy and CT . We discuss this anatomic variant and its clinical\nsignificance.",
    "image_finding": "A 42 year old gentleman presented with a single episode of haemoptysis , but no other associated symptoms. He was an ex-smoker. As a child he was prone to productive cough but there was no definite\nhistory of previous pneumonia or whooping cough. His chest radiograph and baseline blood tests were unremarkable. The patient underwent a bronchoscopy which showed an accessory bronchus arising\nposterolaterally from the mid trachea , but it was not possible to pass the bronchoscope through the vestigial orifice. Bronchial washings were negative for acid fast bacillli. CT confirmed the\npresence of an accessory tracheal bronchus arising from the right side of the trachea , running into a rudimentary pulmonary segement . He was referred on to the thoracic surgeons with view to\nremoving this extra segment in case it was the cause of haemoptysis and was predisposing to episodes of right upper lobe infection.",
    "discussion": "An accessory tracheal bronchus is not an uncommon anomaly . It has a prevalence of 0.1%- 2% for a right tracheal bronchus and 0.3%-1% for a left tracheal bronchus. A true tracheal bronchus is any\nbronchus originating from the trachea usually within 2-6 cm from the carina. It is an anatomic variant which can cause localised pulmonary problems. Tracheal bronchi are classified according to their\nsite of origin (fig 2a). An anomalous right upper lobe tracheal bronchus is called pre-eparterial as it arises proximal to the right main bronchus (which is eparterial). On the left side, the\nanomalous tracheal bronchus can either be pre-hyparterial or eparterial. In addition tracheal bronchi are described as supernumerary if they coexist with a normal type of branching or described as\ndisplaced if a branch of the upper lobe is bronchus is missing i.e it is a normal branch arising from an abnormal position. Displaced are commoner than supernumerary and involve the apical segment of\nthe right upper lobe and the apicoposterior segment on the left. Most tracheal bronchi are assymptomatic. In literature, however, clinical manifestations include recurrent local infections,\npersistent cough,stridor, haemoptysis. Bronchiectasis, atelectasis, cystic lung malformation and focal emphysema may co-exist.The presence of a clinically significant tracheal bronchus should be\nconsidered in any child with recurrent upper lobe pneumonia, especially on the right side. Also in intubated patients with right upper lobe complications such as collapse the diagnosis of a tracheal\nbronchus should be considered.",
    "differential_diagnosis": "Right, sided, tracheal, bronchus",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005295/000005.jpg?itok=3y0IurBW",
            "caption": "Axial CT image showing the origin of the right sided tracheal bronchus."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005295/000002.JPG?itok=HBhaPEC2",
            "caption": "Axial CT images showing the separate accessory bronchus  on the right side of the trachea"
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005295/000003.JPG?itok=gtEfuWif",
            "caption": "Coronal CT image showing the accessory bronchus arising from the right side of the trachea."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005295/000004.gif?itok=Dwc3UGCq",
            "caption": "Gray areas represent normal bronchial tree. Red areas represent the pulmonary arteries.\n1. Pre arterial (true right tracheal). \n2. Pre-eparterial  (right \\\"tracheal\\\"). \n3. Post eparterial. \n4. Eparterial (true left tracheal). \n5. Eparterial (left \\\"tracheal\\\"). \n6. Prehyparterial. \n7. Post hyparterial."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/5295",
    "time": "06.02.2008"
  },
  "5343": {
    "case_id": 5343,
    "title": "Unilateral  pulmonary edema after rapid re-expansion of spontaneous pneumothorax",
    "section": "Chest imaging",
    "age": "27",
    "gender": "male",
    "diagnosis": "Re-expansion pulmonary edema",
    "history": "A 27 year old, tall and thin, healthy man, with no underlying lung disease, came to the hospital complaining of right-sided pleurodynia lasting for 2 weeks, without remembering acute onset of thepain and the patient was generally in a good condition.",
    "image_finding": "After medical examination, the only pathological finding, was a decrease of vesicular murmur of the right lung. Chest x-ray demonstrated a large right-sided pneumothorax. Laboratory tests were normal(Fig. 1,2). He was then admitted immediately to the surgery room where a drainage catheter 40 F was inserted and a negative pressure was applied. A chest x-ray, 35 minutes later, showed completere-expansion of the right lung with diffuse bronchoalveolar infiltrations (Fig. 3). He was then symptomatic with acute dry cough, right pleurodynia and dyspnea, but he was hemodinamically stable. Achest x-ray 24 hours later revealed complete remission of pulmonary infiltrations (Fig 4).",
    "discussion": "Predisposing factors for re-expansion pulmonary edema are: 1) Prolonged duration of pneumothorax, 2) Large pneumothorax, 3) Young age (<40) and 4) Quick  re-expansion of the collapsed lung. 64% of the cases occur within the first hour after re-expansion and the remaining 36% within 24 hours. REPE may progress for 24-48 hours and may persist for 4-5 days,  but it usually resolves within the first week. Although REPE involves the whole re-expanded lung, there are cases involving both lungs or a lobe of the ipsilateral lung.  The seriousness of the situation varies from asymptomatic to lethal cardiopulmonary insufficiency in 20% of the cases. Clinically it may present with dyspnea, tachypnea, tachycardia, central  cyanosis, pleurodynia, hypotension, nausea, vomiting and dry or productive cough with frothy pink sputum.  Albumin concentration in the sputum of patients with REPE is high, approximating the levels of serum albumin, implying that the fluid of pulmonary oedema is exudate. The pathophysiological  mechanisms explaining REPE are:  1) Chronic hypoxia of the pulmonary capillaries, which causes pulmonary microvascular injury and increased permeability. This has been shown from studies in rabbits, which revealed increased  concentration of pro-inflammatory cytokines (TNF, IL-1) in the pulmonary oedema fluid. Free radical generation (OH, H2O2) during re-expansion and reoxygenation of the collapsed lung contributes to  the endothelial cell injury and increased permeability .  2) Loss and decreased production of surfactant.  3) Increased cardiac output after re-expansion of the chronically collapsed lung, which elevates hydrostatic pressure of the pulmonary capillaries.  4) Changes in lymphatic flow of the lungs.  Other conditions with rapid re-expansion of one lung may be complicated with REPE. These include evacuating thoracocentesis of big pleural effusion, removal of large mediastinal or intrathoracic  mass, repair of diaphragmatic hernia, removal of intrathoracic haematoma, removal of a huge intra-abdominal tumor and after one lung ventilation.",
    "differential_diagnosis": "Re-expansion, pulmonary, edema",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005343/000009.JPG?itok=G-ABifKz",
            "caption": "Figure 4. Complete remission of the pulmonary infiltrations after 24 hours. REPE was the only possible diagnosis. The position of the drainage catheter has been corrected."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005343/000010.JPG?itok=_6Y7QdVu",
            "caption": "Figure 1.Large right pneumothorax with deviation of the trachea to the left. Passive hyperemia of the left lung."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/5343",
    "time": "06.06.2008"
  },
  "5346": {
    "case_id": 5346,
    "title": "The Ranke complex: incidental finding at CT",
    "section": "Chest imaging",
    "age": "67",
    "gender": "male",
    "diagnosis": "Ranke complex",
    "history": "A 67 year-old male patient was submitted to our institution to perform a chest CT for staging of a rectum neoplasia.",
    "image_finding": "A 67 year-old male patient was submitted to our institution to perform a chest CT for staging of a rectum neoplasia. On the chest CT we found a 1 cm nodule in the anterior segment of the left upper\nlobe (figure 1), with irregular and ill-defined margins (figure 2), associated with a calcified, ipsilateral hilar lymph node (figure 3). Follow-up chest CT, six months later, showed no changes of\nthis lesion. This findings were compatible with a sequel of tuberculosis, the Ranke complex.",
    "discussion": "Inhaled tubercle bacilli initially evoke a focal, non specific alveolitis that converts to a tuberculosis\u2013specific inflammatory focus (Ghon focus). Spread of tubercle via the draining\nlymphatics may lead to enlargement of regional lymph nodes. In the great majority of cases this primary complex (Ghon focus and regional lymphadenitis) heals with fibrosis and may calcify (1, 2).\nGhon focus appears as a round opacity 3-10mm in diameter showing flocculent or homogenous calcification, usually located in the peripheral lung. It may be accompanied by flocculent calcification of\nthe ipsilateral hilar lymph nodes representing a healed primary complex (the Ranke complex). Occasionally, lymphangitic stranding connecting the primary focus with the hilar lymphadenitis forms a\ndumbbell-shaped opacity (1, 2). This finding correspond to a previous tuberculosis infection with no significant meaning.",
    "differential_diagnosis": "Ranke, complex",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005346/000001.jpg?itok=J66QXG9E",
            "caption": "Nodule in the anterior segment of the left upper lobe, with irregular and ill-defined margins."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005346/000002.jpg?itok=XV-VOITI",
            "caption": "Nodule in the anterior segment of the left upper lobe."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005346/000003.jpg?itok=SRvJdWxi",
            "caption": "Calcified left hilar lymph node."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/5346",
    "time": "26.03.2008"
  },
  "5350": {
    "case_id": 5350,
    "title": "Respiratory bronchiolitis \u2013 associated interstitial lung disease (RB-ILD)",
    "section": "Chest imaging",
    "age": "32",
    "gender": "male",
    "diagnosis": "Respiratory bronchiolitis \u2013 associated interstitial lung disease",
    "history": "Areas of ground-glass opacification and centrilobular nodules in a patient with respiratory bronchiolitis \u2013 associated interstitial lung disease.",
    "image_finding": "A 32 year-old\nmale patient, heavy smoker (average exposure of 35 pack-years), presented to our institution refering dyspnea and dry cough, for three months. He denied any professional, ambiental or drug exposure.\nCrackles and rhonchi on chest auscultation were noted on physical examination. Pulmonary function tests revealed obstructive abnormalities. The chest radiogram was unremarkable. High-resolution CT of\nthe chest was performed and showed ill-defined nodules, with a centrilobular distribution and upper lobe predominance (figure 1), associated with widespread areas of ground-glass opacification\n(figure 2) and a bulla in the anterior segment of the right upper lobe (figure 3). Scans at the end of expiration showed areas of air trapping (figure 4). The diagnosis of respiratory bronchiolitis\n\u2013 associated interstitial lung disease was made after performing a lung biopsy, which revealed pigmented macrophages within respiratory bronchioles. Both clinical symptoms and lung function\nanalysis improved significantly following smoking cessation.",
    "discussion": "Respiratory\nbronchiolitis, RB-ILD and desquamative interstitial pneumonia (DIP) are considered to be part of a spectrum of smoking-related lung injuries. As a clinical diagnosis RB-ILD is very rare and is\nassociated with patients who are heavy smokers (average exposure of more than 30 pack-years). This condition is thought to represent an exaggerated respiratory bronchiolitis response, resulting in\nsubstantial pulmonary symptoms, abnormal pulmonary function and imaging abnormalities (1, 2, 3). It is characterized histologically by bronchiolocentric accumulation of pigmented alveolar macrophages\nand fibrotic or cellular inflammatory changes of pulmonary interstitium (4). Fibrosis is minimal. DIP is also characterized by the presence of intra-alveolar macrophages, but the abnormalities are\nmore diffuse (1). In most cases RB-ILD manifestations are subclinical and detected coincidentally. Lung function analysis reveals only minor restrictive or obstructive defects in most cases, often\ncombined with hyperinflation (4).Chest radiograph is non-specific and may show bilateral lower zone reticular shadowing. HRCT features include extensive bilateral ground-glass opacities and\ncentrilobular nodularity, mostly in a patchy distribution. There may also be present bronchial wall thickening, very mild fibrosis with interlobular septal thickening, upper zone centrilobular\nemphysema and areas of reduced lung density due to air trapping (2, 3, 4). The CT findings of RB-ILD may be similar to those of hypersensitivity pneumonia (clinical differentiation facilitated by\nexposure history), non-specific interstitial pneumonia (NSIP), DIP, lymphoid interstitial pneumonia (LIP) and infections such as Pneumocystis carinii pneumonia. Apart from the presence of some\ndistinguishing clinical and imagiological features (such as cysts, which may be present in DIP and LIP), histological evaluation is often important (1, 3, 4). Complete recovery is usually possible\nwith smoking-cessation and corticosteroid therapy is usually not necessary (4).",
    "differential_diagnosis": "Respiratory, bronchiolitis, \u2013, associated, interstitial, lung, disease",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005350/000001.jpg?itok=F3PR58b1",
            "caption": "Poorly defined centrilobular nodules"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005350/000002.jpg?itok=KexHcCAf",
            "caption": "Widespread ground-glass opacification with some ill-defined centrilobular nodules"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005350/000003.jpg?itok=Thes96ZS",
            "caption": "Bulla in the anterior segment of the right upper lobe"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005350/000004.jpg?itok=O8zH54h2",
            "caption": "Areas of air trapping"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/5350",
    "time": "06.02.2008"
  },
  "5369": {
    "case_id": 5369,
    "title": "Herniation of the left lobe of the liver into the thorax via a large Hernia of Morgagni.",
    "section": "Chest imaging",
    "age": "25",
    "gender": "male",
    "diagnosis": "Intra-thoracic liver herniation via a large Morgagni's hernia.",
    "history": "We report an unusual case of herniation of the left lobe of the liver into the thorax via a large Morgagni's Hernia, and discuss the spectrum of diaphragmatic defects, the anatomy of the anterior portion of the diaphragm, and the clinical significance of such findings.",
    "image_finding": "A 25 year old male, who was being investigated for a possible soft tissue tumour of the left buttock, developed symptoms of right sided pleuritic chest pain. There was no associated shortness of breath, cough or recent chest infection. There was no history of recent or previous significant blunt trauma to the abdomen or chest. Because of his new symptoms a chest radiograph was done which unexpectedly revealed a large right paracardiac soft tissue density mass. A CT thorax was thus performed to investigate this further.",
    "discussion": "Diaphragmatic development occurs early in gestation via a fusion of the embryonic pleuroperitoneal membrane and the transverse septum. During the third week of gestation, the fusion of the transverse septum with the dorsal mesentery of the foregut creates two openings whereby the thoracic and abdominal contents meet. These openings close in the ninth week. Any process inhibiting the closure of these channels may lead to defects in the diaphragm, including congenital diaphragmatic hernia, hernia of Morgagni and diaphragmatic agenesis. The two main types of diaphragmatic hernia known are:the Bochdalek's hernia, involving the posterior portion of the diaphragm which is usually left sided, and Morgagni's hernia, involving the anterior diaphragm usually located on the right side. The Morgagni hernia was first described in 1761 and accounts for 3%-4% of all diaphragmatic defects. It is the least common of the congenital diaphragmatic Hernias (CDHs). Classically, viscera herniate through the sternocostal trigone, which is a triangular space between muscle fibres from the xiphisternum and the costal margin fibres that insert on the central tendon of the diaphragm. Herniation is less common on the left (2%) because of the presence of the pericardial sac. The omentum, colon and, rarely, the small bowel, stomach or liver may be found in the herniated sac. The majority of Morgagni hernias are diagnosed in children who usually present symptoms of pneumonia or sepsis. Although adult patients are usually asymptomatic, they may present with dyspnea, chest discomfort or pain, and chronic gastrointestinal symptoms. Less commonly, symptoms resulting from intestinal strangulation or obstruction and gastric volvulus formation have also been reported. Morgagni hernias may be diagnosed incidentally during either abdominal operation or on routine chest radiography. This may be suspected when a chest radiograph shows a paracardiac mass or a gas-fluid level at the mediastinum corresponding to the herniated bowel or stomach. The Morgagni hernia can be mistaken for lung consolidation or abscess, mediastinal tumour and pleuropericardial cyst. Congenital diaphragmatic defects in children have a high mortality due to pulmonary hypoplasia and pulmonary hypertension.Herniation of liver is a bad prognostic sign. While most symptomatic adult patients with left-sided diaphragmatic defects present with symptoms of visceral herniation, it is believed that right-sided agenesis occurs with few symptoms due to the presence of the liver preventing other viscera from herniating through the diaphragmatic defect. Diagnostic imaging modalities to assess diaphragmatic defects range from routine chest radiographs to magnetic resonance imaging. Contrast radiography may be of assistance in determining the presence of intrathoracic bowel herniation. Solid organ herniation may be more difficult to diagnose and may require computed tomography. Further imaging is necessary when symptoms are more subtle or patients are asymptomatic. In these instances, thin slices and multiplanar images can assist in tetsablishing the diagnosis. Ultrasound may be of complementary value by demonstrating the free edge of the diaphragm defect within pleural fluid or demonstrating liver herniation.",
    "differential_diagnosis": "Intra-thoracic, liver, herniation, via, a, large, Morgagni's, hernia.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005369/000001.jpg?itok=mqkC1_MC",
            "caption": "Chest Radiograph demonstrating the presence of a large round right sided well-defined paracardiac opacity."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005369/000007.jpg?itok=MywbbPM5",
            "caption": "Axial CT images through lower thorax  with intravenous contrast demonstrating the herniation of the left lobe of the liver together with the Gallbladder,and part of the stomach and transverse colon into the thorax via a ventral diaphragmatic defect."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005369/000002.jpg?itok=yUoqzxR4",
            "caption": "As above"
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005369/000003.jpg?itok=7oSQDZPh",
            "caption": "As above"
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005369/000006.jpg?itok=T-7SlhXn",
            "caption": "As above"
          },
          {
            "number": "Figure 2e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005369/000004.jpg?itok=VGeMLMmL",
            "caption": "As above"
          },
          {
            "number": "Figure 2f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005369/000005.jpg?itok=N43LU8cm",
            "caption": "As above"
          },
          {
            "number": "Figure 2g",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005369/000008.jpg?itok=RR1bbykR",
            "caption": "Coronal view of CT thorax showing the liver and gall bladder herniating into the thorax."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/5369",
    "time": "08.04.2008"
  },
  "5395": {
    "case_id": 5395,
    "title": "Lymphocytic interstitial pneumoni",
    "section": "Chest imaging",
    "age": "69",
    "gender": "male",
    "diagnosis": "Lymphocytic interstitial pneumonia",
    "history": "A 69 year-old male patient was referred to our department to perform a high\n  resolution CT of the lung (HRCT), because of exertional dyspnea, dry cough and asthenia.",
    "image_finding": "A 69 year-old male patient mentioned exertional dyspnea, dry cough and  asthenia, for about 1 year.  On pulmonary auscultation, bibasilar crackles were found. The pulmonary  function tests revealed a mixed pattern, with obstructive and restrictive ventilation disorder. Laboratory exams were unremarkable.  Chest radiography showed increased bilateral peri-hilar reticular markings  (figure 1).  The patient was referred to our department to perform a chest HRCT (1mm  collimation, 10mm intervals) which revealed multiple cysts with thin walls, widespread through both lungs (figure 2), associated with areas of ground-glass attenuation (figure 3). The distribution  of the cysts was predominantly perivascular (figure 4). Multiple ill-defined nodules with diameters of a few milimeters, in a centrilobular distribution, particularly in the upper lobes (figure 5) were also seen.  Interlobular septal thickening (figure 6) and intralobular reticulation (figure 5) were additional findings.  The diagnosis of lymphocytic interstitial pneumonia (LIP) was considered  and confirmed with lung biopsy.",
    "discussion": "LIP is a benign lymphoproliferative disease, characterized histologically  by an alveolar septal interstitium infiltration of lymphocytes and small to moderate numbers of plasma cells. (1) The infiltrate is often intense and diffuse involvement of the lung is  characteristically seen. (2)  Immunohistochemical analysis is important for distinguishing LIP from  low-grade lymphoma. If LIP is proved to be due to polyclonal lymphocyte proliferation, progression to lymphoma is quite uncommon. (1)  The inclusion of LIP in the classification of idiopathic interstitial  pneumonias is contentious as this condition seldom occurs as an isolated disease but is usually seen in association with other diseases such as collagen vascular disease, particularly  Sjogren\u2019s syndrome; lymphoma, most commonly low grade non-Hodgkin\u2019s B-cell lymphoma; and in children with human immunodeficiency virus infection. (2) However, it must be considered in  the clinical and radiologic differential diagnosis of diffuse lung disease, and its histologic pattern is unequivocally that of an interstitial pneumonia. (1)  The radiographic appearance is classically described as that of a bilateral  lower zone abnormality with reticular or reticulonodular shadowing (2). Less common findings include a nodular pattern, ground-glass opacities and air-space consolidation.  The dominant HRCT finding in LIP is usually diffuse bilateral ground-glass  opacity. Perivascular cysts or, less commonly, perivascular honeycombing can also be seen. Reticular pattern is seen in about half of patients. Fine nodules with a centrilobular distribution and  widespread consolidation may occur. Other findings may include thickening of the bronchovascular bundles, interlobular septal thickening and lymphadenopathy. (1, 2)  The differential diagnosis of diffuse lung diseases with primarily cystic  lesions include LIP, Langerhans cell histiocytosis (histiocytosis X), lymphangiomyomatosis (LAM), descamative interstitial pneumonia (DIP), centrilobular emphysema, end-stage interstitial fibrosis and Pneumocystis jiroveci (former P. Carinii) pneumonia (PJP).  Both histiocytosis and LIP are characterized by centrilobular nodules and  cystic airspaces. Distinguishing features of histiocytosis from LIP include the absence of interlobular thickening and lymphadenopathy, both of which are found in 82 and 70%, respectively, in  patients with LIP. (3)  The presence of many thin-walled, round, or geographic cystic airspaces  scattered throughout both lungs in a young woman is virtually pathognomonic of LAM. (3)  DIP is an uncommon condition that primarily affects cigarette smokers in  their 4th or 5th decades of life. Ground-glass opacification is present in all cases of DIP, with a lower-zone and peripheral distribution. Well-defined cysts may occur within  the areas of ground-glass opacification. The cysts are usually round, thin-walled and less than 2 cm in diameter. (1)  Emphysematous cystic air spaces have no perceptible walls and vessels are  characteristically seen at the centers of air spaces, with an upper lobe predominance. (3)  In end-stage interstitial fibrosis the lung volume is decreased and the  cysts show predominant subpleural distribution. (3)  PJP is the most common opportunistic infection in human immunodeficiency  virus (HIV)-infected patients. Cystic changes are frequently identified with CT in patients who have PJP, with an incidence of approximately 35% in several studies. Cysts associated with PJP are  variable in appearance and an upper lobe predominance is common. (4)",
    "differential_diagnosis": "Lymphocytic, interstitial, pneumonia",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005395/000001.jpg?itok=lc8QgzNW",
            "caption": "Accentuated peri-hilar reticular markings in both lungs."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005395/000002.jpg?itok=epG7Lraz",
            "caption": "Multiple thin walled cysts, widespread through both lungs (arrows)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005395/000003.jpg?itok=D2m_PzrT",
            "caption": "Area of ground-glass attenuation (circle)."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005395/000004.jpg?itok=DLI0r_2S",
            "caption": "Perivascular cyst (arrow)."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005395/000005.jpg?itok=SkhreLOq",
            "caption": "Upper lobes. Multiple ill-defined nodules with diameters of a few mm, in a centrilobular distribution (arrows) and intralobular reticulation (arrow-heads)."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005395/000006.jpg?itok=seIeyDda",
            "caption": "Interlobular septal thickening (arrows)."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/5395",
    "time": "23.05.2008"
  },
  "5401": {
    "case_id": 5401,
    "title": "Nodular form of Churg-Strauss syndrome",
    "section": "Chest imaging",
    "age": "37",
    "gender": "female",
    "diagnosis": "Churg-Strauss syndrome",
    "history": "Transient pulmonary nodules, erythematous nodular skin lesions, clinical history of uveitis and increasing severity of asthma symptoms.",
    "image_finding": "The patient, a 5 months ex-smoker, complained of erythematous nodular skin lesions, allergic rhinitis and referred recurrent episodes of uveitis since 5 years ago. She had a longstanding history of\nbronchial asthma since childhood and was being treated with bronchodilators and inhaled glucocorticoids sporadically, noticing more severe and persistent asthma symptoms. The clinical examination\nrevealed wheeze respiration, expiratory ronchi on lung bases, prolonged expiration and a palpable skin purpura. Routine laboratory tests were normal on admission (WBC 5,90\u00d7109/L; 3%\neosinophil count), but an elevated eosinophil (11%) and WBC (10,6\u00d7109/L) count was documented 1 month previously; the pulmonary function test revealed mild bronchial obstruction\n(FEV1 70%). The CT chest scan findings included multiple variable-sized (1-2cm-diameter) bilateral pulmonary nodules, mostly with peripheral distribution, predominantly in the lower lobes,\nwithout associated cavitation (figures 1). There was no evidence of lymphadenopathy. The CT scan of the paranasal sinuses showed sinusitis (figures 2). A chest radiograph was performed during\ntreatment without evidence of nodules (figure 3). Bronchoscopy demonstrated no abnormalities. Neither microorganisms, malignant cells nor eosinophils were found in the bronchoalveolar lavage. Skin\ntissue biopsy of a skin nodule in a leg revealed vasculitis and the presence of granulomas. A serum test for antineutrophil cytoplasmic antibodies (ANCAs \u2013c, MPO) was negative, with increased\nserum IgE levels (620mUi/mL). A systemic corticosteroid therapy was started for 12 months and after withdrawal of oral steroid a relapse with new lung nodules was reported (figures 4). The final\ndiagnosis, according to the American College of Rheumatology criteria was Churg-Strauss syndrome.",
    "discussion": "Churg-Strauss syndrome (CSS) is a granulomatous small-vessel vasculitis. It occurs almost exclusively in patients with asthma, most common in patients 30-50 years with no gender predilection. CSS\netiology is still unknown but allergic or immune pathogenesis for the disease was suggested by the presence of asthma, eosinophilia and elevated levels of serum IgE. Often patients have longstanding\nasthma, taking systemic corticosteroids, leading to the suggestion that the reduction of corticosteroid doses precipitates the \u201cunmasking\u201d of the symptoms of systemic vasculitis.\nClinically, there are three distinct phases: (1) prodromal phase of asthma, that may persist for many years, often preceded by allergic rhinitis; (2) marked peripheral blood eosinophilia and\neosinophilic tissue infiltrates resembling chronic eosinophilic pneumonia (may recur in years); and (3) life-threatening vasculitic phase. Although respiratory symptoms are the most common presenting\nfeature of CSS, the site of the vasculitic process is often outside the lungs, most commonly involving the peripheral nervous system, heart, skin, kidneys and gastrointestinal tract. Histological\nconfirmation of vasculitis involving one of these extrapulmonary sites differentiates CSS from patients with allergic bronchopulmonary aspergillosis (ABPA) or chronic eosinophilic pneumonia who can\nfulfill the criteria of CSS. The spectrum of thin-section thoracic CT abnormalities encountered in the inflammatory vasculitides is wide; most common findings consist of patchy nonsegmental bilateral\nareas of consolidation or ground-glass opacities (often with predominantly peripheral distribution characteristic of chronic eosinophilic pneumonia). Less common manifestations include multiple solid\nor less often cavitated 1- to 3-cm pulmonary nodules, small centrilobular nodules, and interlobular septal thickening. Radiologic differentiation of CSS from other entities of the pulmonary angiitis\nand granulomatosis group might be possible. Solitary or multiple parenchymal nodules with frequent cavitation or associated consolidation are the most common findings in Wegener\u2019s\ngranulomatosis, lymphomatoid granulomatosis and necrotizing sarcoid granulomatosis. Asthma is the first manifestation in virtually all patients and is accompanied by allergic rhinitis (70%). On\naverage a 3 year gap occurs between the onset of asthma and the development of vasculitis, but this can range from few months to 30 years. With the onset of the vasculitic phase, the asthma may\nincrease in severity or remit. The American College of Rheumatology developed a traditional format classification; the diagnosis of CSS can be made with 4 of the 6 criteria: asthma; blood\neosinophilia of >10%; neuropathy; nonfixed pulmonary consolidations; paranasal sinus abnormality; extravascular eosinophilia on biopsy. Skin rash is one of the most common features of the\nvasculitic phase of CSS, reflecting involvement of smaller vessels, and possible appearance of one or more of the following skin lesions: purpura, macular or papular erythematous rash, urticaria and\nsubcutaneous nodules. Active vasculitis without peripheral eosinophilia is possible since eosinophil blood levels fluctuate rapidly and widely. The serum IgE value is commonly raised. Between 60 and\n75% of patients are MPO-ANCA +, a most helpful diagnostic finding; MP3-ANCA + is very uncommon. Other common findings include constitutional symptoms (malaise, fatigue, flulike symptoms, weight loss,\nfever, myalgias), paranasal sinusitis, abdominal pain and diarrhea, GI bleeding and peripheral neuropathy, ophthalmologic involvement is less frequent.",
    "differential_diagnosis": "Churg-Strauss, syndrome",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005401/000001.jpg?itok=ScxFqDpR",
            "caption": "Initial 5mm slice CT lung scan at the level of the tracheal carina showing bronchial wall thickening in this patient with chronic asthma."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005401/000002.jpg?itok=0uc0muJ9",
            "caption": "Thin section CT scan at the level of bronchus intermedius shows patchy ground-glass attenuation and multifocal micronodular infiltrates of the right upper lobe."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005401/000003.jpg?itok=jUos6FfN",
            "caption": "Standard resolution CT scan at lung bases shows subpleural parenchymal nodule (1cm) at the left lower lobe within a discrete ground-glass opacity surrounding this lesion."
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005401/000004.jpg?itok=ruF8aalP",
            "caption": "Standard resolution CT scan at the lung bases shows the irregular margins of the nodular density at the right lower lobe, without cavitation."
          },
          {
            "number": "Figure 1e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005401/000005.jpg?itok=Ox-DtuYa",
            "caption": "Multifocal and predominantly peripheral lower lobe distribution of pulmonary nodules."
          },
          {
            "number": "Figure 1f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005401/000006.jpg?itok=7D4n9SxD",
            "caption": "Another nodular density at the left lung base."
          },
          {
            "number": "Figure 1g",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005401/000007.jpg?itok=S7seufjT",
            "caption": "High resolution lung CT showing another nodular density at the right lung base."
          },
          {
            "number": "Figure 1h",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005401/000008.jpg?itok=HMz-yMK_",
            "caption": "Another nodular density with lobular morphology at the right lung base."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005401/000009.jpg?itok=PmUyjOba",
            "caption": "Axial CT with bone windowing shows thickening of nasal mucosa and filling of ethmoidal cells."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005401/000010.jpg?itok=FkQtQ-bL",
            "caption": "Coronal CT showing mucosal disease affecting the maxillary and ethmoidal sinuses."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005401/000011.jpg?itok=lnHLUeAx",
            "caption": "Normal chest X-ray during corticosteroid treatment."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005401/000012.jpg?itok=-ozWeUcC",
            "caption": "Standard resolution CT chest scan after initial withdrawal of 1 year systemic corticosteroid therapy shows a relapsing new nodular opacity (2cm) at the left upper lobe."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005401/000013.jpg?itok=TMYTjeP4",
            "caption": "Standard resolution CT scan at the level of bronchus intermedius after 1 year of systemic corticosteroid therapy shows complete regression of pulmonary right upper lobe infiltrates."
          },
          {
            "number": "Figure 4c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005401/000014.jpg?itok=t-wqTi2g",
            "caption": "High resolution CT scan at lung bases."
          },
          {
            "number": "Figure 4d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005401/000015.jpg?itok=kErhQr_X",
            "caption": "High resolution lung CT showing  enlargement of a previous existing nodule at the left lower lobe, without associated cavitation. Almost complete disappearance of the multiple nodules at the right lower lobe."
          },
          {
            "number": "Figure 4e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005401/000016.jpg?itok=2gAz7u5L",
            "caption": "Non-fixed right lower lobe pulmonary nodules."
          },
          {
            "number": "Figure 4f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005401/000017.jpg?itok=8neMsFVf",
            "caption": "Non-fixed left lower lobe pulmonary nodule."
          },
          {
            "number": "Figure 4g",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005401/000018.jpg?itok=6Fk9JWjl",
            "caption": "Non-fixed right lower lobe pulmonary nodule."
          },
          {
            "number": "Figure 4h",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005401/000019.jpg?itok=h1M3ylGI",
            "caption": "Non-fixed right lung base pulmonary nodule."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/5401",
    "time": "26.02.2008"
  },
  "5533": {
    "case_id": 5533,
    "title": "Air under the diaphragm or Chilaiditi\u2019s Sign?",
    "section": "Chest imaging",
    "age": "52",
    "gender": "female",
    "diagnosis": "Chilaiditi\u2019s Syndrome and Caecal Volvulus",
    "history": "A patient with small bowel obstruction, had a chest x-ray showing air under the diaphragm, and the presumption was made that this patient had a perforation. The clinical picture did not tally with\nthis diagnosis. A CT scan revealed the ultimate answer, showing Chilaiditi\u2019s Sign.",
    "image_finding": "This patient presented with a three day history of colicky central abdominal pain and distension, with nausea and vomiting. Past medical history included hypertension and depression. There was no\nprevious history of any surgery. On examination she was uncomfortable but her observations were stable and she was not tachycardic. Her abdomen was soft with mild generalized distension, and\ntenderness in the epigastria and suprapubically. Bowel sounds were present but quiet. Her blood results showed a CRP of 31.5 and neutrophil 7.8 but were otherwise normal. An abdominal radiograph\nshowed distended loops of small bowel. A diagnosis of small bowel obstruction was made. Her chest radiograph showed air under the right hemi-diaphragm, and the presumption was made that this patient\nhad a perforation. When she was re-examined, her findings remained the same. The clinical picture did not tally with her radiological results. It was decided that she would be treated conservatively.\nA nasogastric tube was inserted and she was kept nil by mouth and started on intravenous fluids and analgesia. Twenty-four hours later, there was no change in her condition and she was sent for a CT\nscan of her abdomen and pelvis. The air under the diaphragm was in fact a dilated loop of bowel and further down in the right iliac fossa, a target-like lesion was seen and was thought to be an\nintussusception. The patient subsequently underwent a laparotomy under a general anaesthetic which revealed a caecal volvulus. This was removed surgically with a modified right hemicolectomy",
    "discussion": "Generally when we see air under the diaphragm the assumption is made that this may be due to a perforated viscus e.g. perforated duodenal ulcer, or perforated diverticulum. Chilaiditi\u2019s sign is\nusually the asymptomatic interposition of the bowel, commonly the hepatic flexure of the colon, between the liver and the right hemidiaphragm. Demetrius Chilaiditi first described this condition as\nan incidental radiological finding of hepatodiaphragmatic interposition of bowel in 1910. Chilaiditi\u2019s sign is seen in 0.1-0.25% of chest radiographs, and is frequently an incidental finding.\nIt is more common in males; and almost always in adults. It may be present intermittently and factors contributing to its occurrence include: Absence of normal suspensory ligaments, Abnormality of\nthe falciform ligament, Redundant colon, Aerophagia, Paralysis right hemidiaphragm, Chronic lung disease, Cirrhosis and Ascites. Chilaiditi\u2019s syndrome may involve: abdominal pain, constipation,\nvomiting, respiratory distress and anorexia. Chilaiditi\u2019s Syndrome is important because it can simulate pneumoperitoneum. Chilaiditi\u2019s syndrome has been reported to occur with a\ntransverse colon volvulus in Japan and a sigmoid colon volvulus in Turkey ; but only for the first time with a caecal volvulus in the UK . One element to scrutinize for is the haustral folds which\ncan establish the air beneath the diaphragm is contained within large bowel. There should equally be a paucity of lung markings within this area if the right hemidiaphragm is raised; although it is\nimportant to bear in mind that the anatomy of the diaphragm is dome shaped and that any elevation of the diaphragm due to a pneumoperitoneum will not always be evenly spread out, but may occur either\ncentrally or at the peripheral edge. Another feature to consider is the thickness of the diaphragm. The thickness on the left hemidiaphragm is usually an amalgamation of the right hemidiaphragm and\nthe wall of the stomach with an underlying gastric bubble. The thickness of the left hemidiaphragm should be less if it is just a simple pneumoperitoneum. If the thickness is almost equal to that of\nthe right; then it is suggestive of both a diaphragm and a bowel wall present, and Chilaiditi\u2019s sign is a possibility. A left lateral decubitus abdominal film may help in this distinction.\nConcomitant pneumoperitoneum may be more difficult to diagnose. If in doubt, an abdominal CT is advised. A target-like, or sausage like CT appearance is usually typical of intussusception; but in\nthis case, the target like lesion was a caecal volvulus. What is apparent on the CT scan is the axis around which the caecum has rotated.",
    "differential_diagnosis": "Chilaiditi\u2019s, Syndrome, and, Caecal, Volvulus",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005533/000002.jpg?itok=EoodqpJ7",
            "caption": "A supine abdominal x-ray showing dilated loops of small bowel"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005533/000001.jpg?itok=N3XKn8ZD",
            "caption": "Chest x-ray showing ?air under the diaphragm. Please note the thickness of the hemi-diaphragms on both sides, and also remeber to check for haustral markings and lung markings."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005533/000003.jpg?itok=AMwcRTYH",
            "caption": "CT Abdomen showing the liver being pushed to one side by the loop of colon with contrast"
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005533/000004.jpg?itok=4JWFkTw3",
            "caption": "CT Abdomen showing a dilated loop of colon with contrast interposing itself anterior to the liver"
          },
          {
            "number": "Figure 1e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005533/000005.jpg?itok=7tQl-oYw",
            "caption": "CT Abdomen/Pelvis showing a target-like mass. This was thought to be Intussusception prior to surgery."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/5533",
    "time": "02.08.2007"
  },
  "5550": {
    "case_id": 5550,
    "title": "Cleidocranial Dysostosis (CCD)",
    "section": "Chest imaging",
    "age": "50",
    "gender": "female",
    "diagnosis": "Cleidocranial Dysostosis or Dysplasia (CCD)",
    "history": "50 year old female with incidental finding in a routine x-ray",
    "image_finding": "The patient was admitted to the hospital for routine surgery. During the presurgery control, a chest x-ray examination was performed. The partial absence of the left clavicle, the complete absence of the right clavicle, along with small scapulae in the chest x-ray suggested the diagnosis of CCD. A supplementary head x-ray was performed which revealed a wide suturu frontalis metopica, absence of frontal sinuses and dental deformities. The patient was diagnosed to have CCD.",
    "discussion": "Cleidocranial Dysostosis (CCD) is a rare abnormal hereditary condition characterized by defective ossification of the cranial bones and by the  complete or partial absence of the clavicles. It is transmitted as an autosomal dominant trait. This condition also involves dental and vertebral anomalies. It is also called cleidocranial  dysplasia or Marie Sainton Disease.   The CCD is a condition usually suspected by the clinicians because of the characteristic clinical appearance though sometimes it appears as an  incidental finding in the chest and head x-ray. Radiological findings that suggest the presence of CCD in the chest x-ray are the complete or partial absence of the clavicles (usually the lateral  one third), small scapulae, glenoid fossa, spina bifida, persistence of synchondrosis between the vertebral bodies and neural arches, short ribs with a prominent downward slope, and inadequate  ossification of the sternum. The complete or partial absence of the clavicles allows the shoulders to be brought together.   The cranial x-ray may show a brachycephalic skull with increased biparietal diameter, frontal bossing, wide sutures, anterior fontanelle remaining  open in adults and underdeveloped sinuses and mastoids.   Other bone malformations can also be found such as broad appearance of tubular bones and anomalies of the bones of hands (long second and fifth  metacarpals, short middle phalanges and tapering terminal phalanges, cone shaped epiphyses, delay in skeletal maturation, supernumerary ossicles at different sites)   In some cases there is absence or delayed ossification of the pubic bones resulting in a wide pubic symphysis in adults and underdeveloped iliac wings. Also  coxa vara or coxa valga, deformities of femoral head and neck, as well as irregularities in the time of appearance, placement, quality and number of the teeth conclude the findings in  CCD",
    "differential_diagnosis": "Cleidocranial, Dysostosis, or, Dysplasia, (CCD)",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005550/000001.jpg?itok=28XxFx5p",
            "caption": ""
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005550/000002.jpg?itok=s5VzINTt",
            "caption": ""
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/5550",
    "time": "23.10.2008"
  },
  "5584": {
    "case_id": 5584,
    "title": "Penetrating ulcer of descending thoracic aort",
    "section": "Chest imaging",
    "age": "70",
    "gender": "male",
    "diagnosis": "Penetrating atherosclerotic ulcer of descending aorta",
    "history": "A 70 year old male, evaluated for known thoracic aortic aneurysm On clinical examination there were no suspicious signs or symptoms. The patient underwent a plain film and computed tomography examination.",
    "image_finding": "A 70 year old male was evaluated for a known thoracic aorta aneurysm. On clinical examination there were no suspicious signs or symptoms. The patient underwent a plain film which depicted a dilated thoracic aorta. Computed tomography examination showed a focal ulceration of descending thoracic aorta, with associated intramural hematoma. The imaging findings were compatible with penetrating atherosclerotic ulcer.",
    "discussion": "Penetrating atherosclerotic ulcer of the aorta is a distinct pathologic entity1.2, 3 defined as an atherosclerotic lesion with ulceration, which may have a clinical presentation that mimics aortic dissection. It occurs in elderly patients with advanced atherosclerotic disease. Typically penetrating ulcer occurs,1, 2, 3 in the middle or distal third of the thoracic aorta or upper abdominal aorta. They rarely are seen in the ascending aorta, where rapid blood flow from the left ventricle provides protection against atherosclerosis. Concomitant atherosclerotic aneurysms of the abdominal aorta are seen. It represents an atherosclerotic lesion with ulceration that penetrates the internal elastic lamina and allows hematoma formation within the media of the aortic wall. Involvement of the media can sometimes be complicated by aneurysmal dilatation or more rarely rupture1.2.3. The four stages in the formation of penetrating atherosclerotic ulcer are a) aortic atheroma, b) intimal plaque ulceration contained in intima c) medial hematoma with potential adventitial false aneurysm d) and transmural rupture1. Some authors havetheorized that most saccular aneurysms are caused by penetrating atherosclerotic ulcers 1. CT features include a focal ulcer with adjacent subintimal hematoma Penetrating atherosclerotic ulcer can be differentiated from aortic dissection by means of (a) the extensive atherosclerotic disease and ectasia in penetrating atherosclerotic ulcer and (b) the lack of compression of the aortic lumen in elderly persons with penetrating atherosclerotic ulcer. Treatment of penetrating atherosclerotic ulcer is medical therapy. Surgery is performed in patients who have hemodynamic instability, persistent pain, aortic rupture, distal embolization or rapid enlargement of aortic diameter. It is important to notice that surgical repair of penetrating ulcer is more complex and extensive that type B dissecting aneurysm. Aortic grafting for penetrating atherosclerotic ulcer may be associated with higher morbidity because of greater compromise of spinal cord during blood supply surgery.",
    "differential_diagnosis": "Penetrating, atherosclerotic, ulcer, of, descending, aorta",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005584/000001.jpg?itok=uf9F8YKe",
            "caption": ""
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005584/000002.jpg?itok=Dd9Vlh1-",
            "caption": ""
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005584/000004.JPG?itok=Q0Kuij8S",
            "caption": ""
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/5584",
    "time": "26.08.2008"
  },
  "5654": {
    "case_id": 5654,
    "title": "Pulmonary Actinomycosis mimicking lung malignancy",
    "section": "Chest imaging",
    "age": "62",
    "gender": "female",
    "diagnosis": "Pulmonary Actinomycosis",
    "history": "We report a case of pulmonary Actinomycosis who mimicked lung malignancy and showed intense uptake of 18-Flurodeoxyglucose PET/CT scan. The diagnosis was reached by histopathological examination of\nthe surgical specimen, the patient having undergone a right lower and middle lobectomy. We discuss the radiological features of Actinomycosis and the caveats of PET/CT scans.",
    "image_finding": "A 62-year-old lady was referred for a chest radiograph by her GP, following an eight month history of productive green phlegm. The initial chest radiograph showed a small dense soft tissue mass\nprojected over the right hilum. She had worked in a dairy farm, subsequently worked in a bacon farm. She smoked 20 cigarettes a day for 40 years (80 pack years). She also drank 42 units of alcohol a\nweek. Physical examination was unremarkable. A contrast enhanced CT of the Thorax was performed a week later which showed a 5cm diameter heterogeneous area (with a cystic core and some cavitation\nsurrounded by soft tissue density material) in a collapsed apical segment of the right lower lobe. This soft tissue area was crossing the oblique fissure into the upper lobe. A bronchoscopy and\nbronchial washings were unremarkable. The patient was subsequently referred for a CT-guided lung biopsy. The histological examination showed inflammatory changes and failed to show any\nmicroorganisms. A repeat CT Thorax 3 months later showed no change. A subsequent FDG-PET scan detected an abnormal peripheral uptake in the 5.4 cm right lower lobe mass with a central area of\nphotopaenia . There was no significant uptake in the hila or mediastinum, and no evidence of distant metastases. The patient was then referred for a right middle and lower lobe lobectomy. The\nhistology of the operated specimen revealed clumps of Actinomycosis organisms with filamentous forms. The patient was put on a 3 month course of antibiotic therapy.",
    "discussion": "Actinomycosis is a rare infection that was historically thought to be due to a fungus but now is considered to be due to branching filamentous, Gram-positive, anaerobic to microphilic, non\nspore-forming bacteria which are not acid-fast. The commonest species encountered is Actinomycosis Israelii.[1] Actinomyces species are present in normal oral flora frequently found at gingival\nmargins of people with poor oral hygiene and dental caries .Such are believed to be predisposing factors to pulmonary Actinomycosis; aspiration of saliva being the mechanism of spread.\nHistopathological examination of resected tissue may show the characteristic sulphur granules (yellowish granules of clustered mycelia) surrounded by polymorphonuclear cells and gram positive\nbranching filamentous organisms that stain positively with Gomori\u2019s Methenamine silver. Actinomycosis has a variable radiological picture [2,3]. More commonly on CT, there is a chronic\nsegmental airspace consolidation with central areas of low attenuation, peripheral enhancement, and associated pleural thickening. It behaves in an infiltrative manner not obeying interlobar fissural\nboundaries or tissue planes by producing proteolytic enzymes. There is often an associated pleural effusion, pleural thickening and also a collection of fluid in the extrapleural space resulting from\ndirect extension through the parietal pleura and the chest wall, called empyema necessitatis [4]. It involves the chest wall in a contiguous way forming a chest wall mass, with sinus tracts and can\ninvolve the adjacent ribs causing periosteal proliferation which can have a peculiar wavy configuration [5,6]. Actinomyces species also have a tendency to colonise devitalised lung tissue that may\nhave already been damaged by previous tuberculosis or other bacterial infections. In such cases, CT features include localised bronchiectasis and irregular bronchial wall thickening with irregular\nperibronchial consolidation,as the Actinomycosis exacerbates further the pre-existing bronchiectasis [7]. Endobronchial Actinomycosis is a rarer entity and tends to occur following secondary\ncolonisation of either a pre-existing proximal broncholith or an aspirated foreign body. On CT there is associated post obstructive pneumonic consolidation [8]. On rarer cases, it has been noted to\nextend into the abdomen through the diaphragm [9]. Its CT features can mimic other conditions apart from malignancy, including TB and Nocardiosis. In general clinical practice, FDG-PET/CT studies are\nbeing used increasingly to try and distinguish between benign and malignant pathology. FDG, however, is by no means a cancer specific agent, but simply an indicator of glycolytic metabolic activity\n[10]. There are only a few published FDG-PET studies on Actinomycosis [11]. A case report of an FDG-PET study in a patient with a left upper lobe mass invading the chest wall, with mediastinal\nlympadenopathy and a pleural effusion showed enhanced uptake within the left chest wall. Fortunately, yellow pus spontaneously dripped out following biopsy of the chest wall and this offered the\ndiagnosis of Actinomycosis on microbiological examination. An FDG-PET scan carried out on an asymptomatic patient for a whole body cancer screening revealed focal linear uptake in the left buttock. A\nmalignant tumour was suspected. However, at surgery an anorectal fistula with Actinomycosis and abscess formation was found [12].",
    "differential_diagnosis": "Pulmonary, Actinomycosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005654/000005.jpg?itok=LMBsZGuL",
            "caption": "Axial CT Thorax  images demonstrating a 5cm core cystic mass with areas of cavitation and an air bronchogram."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005654/000006.jpg?itok=01vSHT5a",
            "caption": "Sagittal CT Thorax images (lung window) demonstrating the right lower lobe mass extending across the horizontal fissure."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005654/000007.JPG?itok=HAsB9DJd",
            "caption": "CT ,PET and fusion PET/CT axial and coronal images demonstrating the right lower lobe mass showing intense high peripheral uptake with a central area of photopaenia.No hilar or mediastinal uptake."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005654/000009.JPG?itok=q5ge_Ys1",
            "caption": "Abscess cavity amid fibrosis within the superior segment of the right lower lobe."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005654/000010.jpg?itok=xM5OOoaa",
            "caption": "The eosinophilic colony of actinomycosis is present within the abscess cavity (H&amp;E, x100)."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005654/000011.jpg?itok=AC0fs_sB",
            "caption": "Colonies of Actinomycosis surrounded by a polymorph reaction."
          },
          {
            "number": "Figure 3d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005654/000012.jpg?itok=ZDorbxVf",
            "caption": "Filamentous meshwork of organisms. Grocott, x600."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005654/000013.jpg?itok=VvMh12KZ",
            "caption": "Posteroanterior chest radiograph demonstrating a right hilum soft tissue mass."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005654/000014.jpg?itok=4CoKnxvr",
            "caption": "Lateral chest radiograph demonstrating a soft tissue density pulmonary mass projected over the mid thoracic spine."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/5654",
    "time": "06.02.2008"
  },
  "5707": {
    "case_id": 5707,
    "title": "Imaging findings of pulmonary strongyloidiasis in an HIV infected patient",
    "section": "Chest imaging",
    "age": "46",
    "gender": "male",
    "diagnosis": "Pulmonary\nstrongyloidiasis in an HIV infected patient",
    "history": "A 46 year old HIV\npositive Portuguese man, presented with a 10 day history of shortness of breath, dry cough, fever and a sore throat. There was no history of recent foreign travel.",
    "image_finding": "A 46 year old HIV\npositive Portuguese man, presented with a 10 day history of shortness of breath, dry cough, fever and a sore throat. There was no history of recent foreign travel. Examination showed reduced air\nentry on the right side. A differential white cell count showed an eosinophil level of 0.1%. The patient was diagnosed with probable community acquired pneumonia and treated with Cefuroxime and\nClarithromycin. Septrin and Prednisolone were also started to cover for Pneumocystis pneumonia (PCP) but this was stopped after 24 hours when the CD4 count was found to be 301. The admission chest\nradiograph showed right upper lobe consolidation and patchy shadowing in the right base (Figure 1). HRCT showed a ground glass abnormality affecting the right upper lobe and posterior segment of\nright lower lobe. No lymphadenopathy or pleural disease was present (Figures 2 and 3). A bronchoscopy and bronchoalveolar lavage ( BAL) was performed to exclude PCP. The washings showed the presence\nof Strongyloides ( Figure 4) and the patient was subsequently treated with Ivermectin and recovered . The admission chest radiograph showed right upper lobe consolidation and patchy shadowing in the\nright base (Figure 1). HRCT showed a ground glass abnormality affecting the right upper lobe and posterior segment of right lower lobe. No lymphadenopathy or pleural disease was present (Figures 2\nand 3).",
    "discussion": "Strongyloides Stercoralis is a free living parasite which enters the patient\u2019s blood, travelling via the lung to the small intestine to\n  complete its life cycle. Within the small intestine, it develops into the adult form and reenters the blood stream causing auto infection. Strongyloides hyper infection occurs when disseminated\n  disease develops in immunocompromised persons. Given the prevalence of Strongyloides infestation in patients with HIV or AIDS, an increased number of reported hyper infection episodes should be\n  expected, however reported incidents remain rare. This may be related to the low index of suspicion and difficulty in obtaining a histological diagnosis. A positive ELISA serological test indicates\n  both past and present infection by detecting IgG antibodies to Strongyloides. Bronchoalveolar lavage with Gram and Papanicolau staining usually shows the filariform larvae.When a hyper infection\n  syndrome develops, a large number of the larvae migrate via the haematogenous route into the lungs and this leads to significant lung parenchymal damage. The plain radiographic features of\n  Strongyloides hyper infection are nonspecific and various patterns have been described. These include non segmental patchy infiltrates, nodular infiltrates mimicking PCP, lung abscesses, pleural\n  effusions and miliary nodular patterns mimicking tuberculosis.The diagnosis is usually made following bronchoscopy and bronchoalveolar lavage as in our patient. The chest radiograph may show no\n  abnormalities, however there is often evidence of a foreign body reaction with inflammatory pneumonitis and pulmonary interstitial haemorrhage when the larvae migrate from the capillary bed into\n  the alveoli in cases of autoinfection. These conditions reveal themselves as non specific interstitial linear and nodular shadowing. The more severe cases show up as patchy airspace shadowing\n  mimicking bronchopneumonia. Rarely, pleural effusions and cavitating lesions can also occur. The HRCT features are similarly non specific and generally reflect the present of a pneumonitis and\n  parenchymal haemorrhage. A feature that has also been described is the relatively rapid onset and resolution in areas affected when the migrating larvae move through the lung. Acute infection\n  classically results in a perihilar ground-glass infiltrate, often in a geographical distribution, with areas of affected lung interspersed by normal lung parenchyma. A linear or reticular\n  interstitial pattern is also frequently demonstrated, with thickening of the interlobular septae, which is often the feature that is slowest to resolve radiologically. The HRCT features in the case\n  we describe closely mimick the appearances of PCP pneumonia. The striking finding is the high early mortality as a direct or indirect result of the infection. This is higher than has been found in\n  other immunosuppressed patients. Presentation may occur many years after patients have left an endemic area for Strongyloides infection, emphasizing the need for an accurate travel history.",
    "differential_diagnosis": "Pulmonary, strongyloidiasis, in, an, HIV, infected, patient",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005707/000002.JPG?itok=WBUbnQS-",
            "caption": "Chest radiograph showing right upper lobe consolidation and ill-defined right postero-basal medial shadowing"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005707/000003.JPG?itok=Mjq4wQ6i",
            "caption": "HRCT thorax showing a right upper lobar distribution of ground glass opacification containing several areas of cystic change that raise the suspicion of PCP."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005707/000004.JPG?itok=Lgiyt1NS",
            "caption": "HRCT thorax through the basal areas showing a smaller region of ground glass opacification also containing areas of cystic change in the posteromedial segment of the right lower lobe."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005707/000005.JPG?itok=GMSMBrme",
            "caption": "BAL microscopy showing an adult Strongyloides worm surrounded by an inflammatory infiltrate"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/5707",
    "time": "06.06.2008"
  },
  "5715": {
    "case_id": 5715,
    "title": "Barium Bronchogram \u2013 Visualising a cause of Pneumonia.",
    "section": "Chest imaging",
    "age": "81",
    "gender": "male",
    "diagnosis": "(1) Pharangeal Pouch (2) Aspiration Pneumonia",
    "history": "We present the case of an elderly man who was investigated for recurrent pneumonia. Imaging revealed clearly the cause of his pneumonia.",
    "image_finding": "An 81 year old man was admitted to hospital for investigation after suffering from three episodes of pneumonia in six months. His past medical history revealed 18 months of dysphagia to both solids\nand liquids. A barium swallow was performed. Barium swallow demonstrated a large pharyngeal pouch. During this procedure the likely cause of recurrent pneumonia was also demonstrated by the patient\naspirating a large amount of barium. This is shown on a plain radiograph of the chest, with barium outlining the bronchial tree in both lower lobes of both lungs. Intensive physiotherapy was\nadministered and the patient remained asymptomatic undergoing an uneventful recovery. Stapling of the pharyngeal pouch was undertaken two weeks later.",
    "discussion": "Barium aspiration is an uncommon but well documented complication of upper gastrointestinal contrast studies1. It, as in this case, usually runs an benign course, however there are case\nreports of fatalities due to Acute Respiratory Distress Syndrome (ARDS) 2,3. There is also suggestion of barium aspiration as a cause of pulmonary fibrosis4.",
    "differential_diagnosis": "(1), Pharangeal, Pouch, (2), Aspiration, Pneumonia",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005715/000004.jpg?itok=34_33LXw",
            "caption": "Figure 4 - Chest radiograph showing resolution 10 days post procedure"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/5715",
    "time": "20.11.2007"
  },
  "5744": {
    "case_id": 5744,
    "title": "Pulmonary artery aneurysms in Beh\u00e7et&#039;s disease",
    "section": "Chest imaging",
    "age": "18",
    "gender": "male",
    "diagnosis": "Pulmonary artery aneurysms in Beh\u00e7et\u2019s disease",
    "history": "A 18-year-old male with a history of recurrent oral and genital aphthee, was admitted to our hospital for chest pain, dyspnea and haemoptysis.",
    "image_finding": "The chest X-ray revealed bilateral parahilar increased density. Computed tomography with a contrast angiogram revealed bilateral aneurysms of both main pulmonary arteries with thickening of the\ndilated vessel walls. The patient was treated with prednisone and cyclophosphamide.",
    "discussion": "Beh\u00e7et\u2019s disease is a systemic vasculitis of unknown etiology, which affects adults 18-40 years of ages and is twice as prevalent in men and women. Arterial involvement is a late complication of Beh\u00e7et disease, it occurres a median of 4 years after the initial diagnosis of Beh\u00e7et disease. Classically, arterial involvement occurs later than venous involvement, which often present concomitantly. Arterial involvement in Beh\u00e7et disease is observed in 3 to 5% of cases. It frequently consistes of multiple aneurysm. The pulmonary arteries are the second location of arterial involvement and the aneurysms are the most frequent in these arteries. Histological studies show active and / or residual lesions predominantly in the media, adventitia andaround the vasa vasorum. These parietal lesions can cause vessel wall distension with formation of aneurysms. Haemoptysis of varying degrees is the most common and predominant symptom of pulmonary aneurysms. This haemoptysis result from a rupture of aneurysm with erosion into a bronchus and developement of in situ thrombosis from active vasculitis. Chest X-ray shows the aneurysms as hilarprominences, polylobular or round opacities. CT-angiography is an excellent non invasive technique of diagnosis. It can reveal aneurysmal dilatation of the main pulmonary arteries or theirs branches and the thrombi in the lumen of these aneurysms. MRI and MRA offer the obvious advantage of multiplanar capability without the need for contrast injection. Pulmonary artery aneurysms are the leadingcause of death in patients with Beh\u00e7et\u2019s disease, with 30% of patients with aneurysms dying within 2 years and a 50% 2-year mortality after the onset of haemoptysis.",
    "differential_diagnosis": "Pulmonary, artery, aneurysms, in, Beh\u00e7et\u2019s, disease",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005744/000001.jpg?itok=_yjh0FIE",
            "caption": "Chest X-ray: bilateral parahilar increased density"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005744/000002.jpg?itok=EX2sZRuJ",
            "caption": "Contrast-enhanced computerized tomography scan demonstrating multiple large pulmonnary artery aneurysms with enhancement of the patent lumen and circumferential thrombus."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005744/000004.jpg?itok=I1aXpnit",
            "caption": "CT scan coronal image-depicting the aneurysms in the pulmonary arteries bilaterally at the hilar level."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/5744",
    "time": "26.08.2008"
  },
  "5844": {
    "case_id": 5844,
    "title": "Pulmonary abscess",
    "section": "Chest imaging",
    "age": "62",
    "gender": "female",
    "diagnosis": "Left pulmonary abscess.",
    "history": "A four week history of general malaise, left sided back pain, increasing dyspnoea and cough productive of purulent sputum.",
    "image_finding": "A 62-year-old female patient was admitted with a 4 week history of general malaise, left sided back pain, increasing dyspnoea and cough productive of purulent sputum. On examination she was pyrexic\n(38.4), tachycardic, tachypnoeic and hypoxic. Chest was dull to percuss over the left base with bronchial breathing also noted. Peripheral WCC was elevated at 13.0 x 109 / L with a\nneutrophilia of 11.94 x 109 / L. CRP increased at 246 mg/L. Arterial blood gas on room air; PaO2 9.52. Sputum and blood cultures were negative. Chest X-ray (CXR) was reported as showing a\ncystic lesion at the left base with an air-fluid level seen within it (figure 1). Contrast enhanced CT scan of chest demonstrated a fluid and air-filled cavity at the left lung base with an enhancing\nthick wall on coronal (figure 2) and axial images (figure 3). Patient was diagnosed with a left lower lobe lung abscess. Treatment was commenced with intravenous clindamycin and ciprofloxacin. The\npatient improved dramatically within twenty four hours of commencing antibiotic therapy . CXR after two weeks antibiotic therapy demonstrated a marked improvement in the left lower zone changes\n(figure 4) with a normalization of the WCC and CRP. The patient was subsequently discharged to complete a further four weeks oral antibiotic therapy. Follow-up CT performed at 3 months showed almost\ncomplete resolution of the abscess on the coronal (figure 5) and axial images (figure 6).",
    "discussion": "A lung abscess is defined as a circumscribed suppurative, necrotizing collection in the lung, which leads to cavity formation and a radiographic finding of an air fluid level in the cavity[1].The\nmain aetiological causes were pneumonia (30%), choking (16.8%), aspiration of a foreign object (10%), injuries (8%) and unknown (21%)[2]. In general, patients with lung abscesses will complain of\nsymptoms for at least 2 weeks prior to admission. Symptoms include intermittent fever, productive cough, general malaise, weight loss and night sweats[3]. Many of these features were described by\nthis patient. Once cavitation occurs it is common to have foul smelling sputum and infrequently haemopytsis. Hammond et al found a mean of 2.3 bacterial species per patient, anaerobes alone being\nisolated in 44% of cases, aerobes alone in 19%, and mixed aerobic and anaerobic in 22%[4]. Patients over 45 years with a lung abscess have a 30% association with neoplasm[3]. Primary squamous\ncarcinoma of the lung is the most common malignancy associated with abscess formation. The distinctive characteristic of a lung abscess on chest x-ray is the appearance of an air-fluid level (as in\nthis case) and an area of thick pneumonic consolidation usually precedes this. On CT an abscess is often a rounded radiolucent lesion with a thick wall and ill-defined margins. A CT scan provides\ndiagnostic information not available in chest x-rays in 47% of cases, and in 34% of cases it allows more accurate delineation of the extent of the disease[5]. Radiology techniques especially CT\nscanning are important in differentiating between a lung abscess and empyema. An abscess is, as above, typically round in shape with thick irregular walls and acute angles to the chest wall. An\nempyema is usually lenticular with lung compression and thin, uniform walls with obtuse angles to the chest wall. Differentiation is important as an empyema requires urgent insertion of a chest\ndrain[5]. The current antibiotic of choice is IV clindamycin or IV penicillin. One trial has found clindamycin to be associated with fewer treatment failures[6]. Intravenous antibiotics are continued\nuntil the patient has been afebrile for 4-8 days; then the switch is made to oral antibiotics. These are continued until the chest x-ray has shown resolution or the presence of a small stable lesion.\nMany require 6-8 weeks of therapy[7]. Complications of lung abscess include empyema formation resulting from a bronchopleural fistula, massive hemoptysis, spontaneous rupture into uninvolved lung\nsegments, and non-resolution of abscess cavity [3]. Surgery is very rarely required for patients with uncomplicated lung abscesses. The usual indications for surgery are failure to respond to medical\nmanagement, suspected neoplasm, or congenital lung malformation. The surgical procedure performed is either lobectomy or pneumonectomy.",
    "differential_diagnosis": "Left, pulmonary, abscess.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005844/000001.jpg?itok=vUaBNEiR",
            "caption": "Admission chest x-ray."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005844/000002.JPG?itok=mrfISU6y",
            "caption": "Coronal CT chest"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005844/000003.JPG?itok=Imcsmt_o",
            "caption": "Axial CT chest"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005844/000004.jpg?itok=V9KWGjXo",
            "caption": "Chest x-ray on discharge."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005844/000005.jpg?itok=2zQBH5DD",
            "caption": "Coronal CT chest post treatment"
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005844/000006.jpg?itok=ThmjgIEc",
            "caption": "Axial CT chest post treatment."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/5844",
    "time": "20.01.2008"
  },
  "5845": {
    "case_id": 5845,
    "title": "Pulmonary aplasi",
    "section": "Chest imaging",
    "age": "18",
    "gender": "male",
    "diagnosis": "Pulmonary aplasia",
    "history": "An\nasymptomatic young man, 18 years old, referred to our department for a routine chest radiograph that was necessary for his recruitment to the Army.",
    "image_finding": "An 18 year old man presented to our hospital to have a chest radiograph needed for his recruitment to the Army. He had no symptoms of pulmonary disease and mentioned a history of lung aplasia. The chest X-ray (not available; CT scanogram shown instead) revealed a remarkable decrease of the left lung parenchyma and a shift of the mediastinum to the left (Fig. 1). The left hemidiaphragm was elevated and the left intercostal spaces reduced. The lung parenchyma seemed significantly radiolucent (Fig. 2). He underwent a CT of the thorax and a CT angiography of pulmonary arteries. These imaging procedures demonstrated the absence of left pulmonary artery (Fig. 3) and left lung parenchyma as well as the occupation of the left apex by right lung displaced to the left (herniation) (Fig. 4). The mediastinum was clearly shown to be shifted to the left (Fig. 5) and the left main bronchus was found to be rudimentary and have a blind end (Fig. 6). The diagnosis of pulmonary aplasiawas confirmed. The appropriate reconstructions were made to demonstrate clearly the imaging findings (Fig. 7).",
    "discussion": "Pulmonary aplasia is a rather rare congenital anomaly of the thorax occurring with an incidence of 1:10000 births affecting equally either side. The abnormality is one of the three bronchopulmonary anomalies that describe congenital underdevelopment of one or more lobes of a lung. The triad includes pulmonary agenesis, aplasia and  hypoplasia 1. Concisely agenesis refers to complete absence of   parenchyma and its bronchus while aplasia includes the presence of a rudimentary bronchus ending in a blind pouch. The ipsilateral pulmonary vascular supply is absent in both pathological conditions. Pulmonary hypoplasia represents a decrease in the number or size of airways, vessels and alveoli which causes an abnormal and poor development of lobes or segments. In practice an etiologic, pathogenetic and clinical distinction between agenesis and aplasia is seldom apparent and the two terms are usually considered as synonyms 2. Clinical findings depend on the  degree of pulmonary abnormality and the presence of congenital malformations elsewhere such as malformations of the kidneys, the diaphragm and the chest wall. Usually patients with unilateral lung aplasia die in the neonatal period. Nevertheless there is a clear possibility to survive into adulthood, sometimes without symptoms 3. In asymptomatic patients, physical examination may reveal an asymmetry of the two sides of the thorax, a reduction in the respiratory movement and absence of air entry into the affected side. The number of individuals that survive with hypoplasia is undoubtedly much greater. Another cause of death for patients with agenesis is the predisposition to respiratory infections 4 that may prove to be fatal for them before they reach their teens. The radiographic findings of pulmonary aplasia are mainly characterized by total absence of aerated lung in one hemithorax. The markedly reduced volume of the pathological hemithorax is indicated by approximation of the ribs, elevation of the ipsilateral hemidiaphragm and shift of the mediastinum. Usually the contralateral lung is greatly overinflated and displaced along with the anterior mediastinum into the involved hemithorax 5, leading many times to diagnostic problems. CT of the thorax is the best way to solve these problems as well as estimate the degree of underdevelopment 6. MR imaging is equally appropriate to diagnose aplasia 7. Differential diagnosis includes some conditions that mimic it radiographically such as total atelectasis from any cause, severe bronchiectasis with collapse and advanced fibrothorax 8. The demonstration of a rudimentary bronchus and the absent ipsilateral pulmonary artery, as in our case, are adequate findings to confirm the diagnosis of pulmonary aplasia.",
    "differential_diagnosis": "Pulmonary, aplasia",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005845/000001.jpg?itok=PrJj_kiO",
            "caption": "The CT scanogram shows an opacification of the left hemithorax and a decrease of the left lung parenchyma. The mediastinum is displaced to the left. The trachea seems in normal position. The left hemidiaphragm is shown elevated and the left intercostal spaces seem reduced relatively to the right ones. The right lung appears radiolucent due to overinflation."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005845/000002.jpg?itok=SVWqGBkK",
            "caption": "The lateral projection shows a large retrosternal air space suggesting the displacement of the heart. The finding also confirms the right lung overinflation"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005845/000003.jpg?itok=hDF0b56m",
            "caption": "\u03a4he angiography shows the absence of left pulmonary artery"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005845/000004.jpg?itok=F2fGatqU",
            "caption": "\u03a4he absence of left lung parenchyma is confirmed. The right lung occupies the left pulmonary apex (herniation) and the trachea is not severely displaced."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005845/000005.jpg?itok=bzpowwvF",
            "caption": "\u03a4he heart and great vessels are clearly displaced to the left"
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005845/000006.jpg?itok=0Nqnhjrl",
            "caption": "\u03a4he rudimentary left bronchus ends in a blind pouch"
          }
        ]
      },
      {
        "number": "Figure 7",
        "subfigures": [
          {
            "number": "Figure 7",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005845/000007.jpg?itok=XFSWwSRT",
            "caption": "\u03a4he volume rendering technique demonstrates that the right lung herniates across the midline while the left lung parenchyma is clearly absent"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/5845",
    "time": "04.06.2008"
  },
  "5859": {
    "case_id": 5859,
    "title": "Multiple hydatid cysts of the lung",
    "section": "Chest imaging",
    "age": "9",
    "gender": "male",
    "diagnosis": "Hydatid disease of the lung",
    "history": "A 9 year old boy presented with chest pain and dyspnea. Chest x-ray and CT revealed multiple round intrapulmonary radio\n  opacities.",
    "image_finding": "The patient presented with chest pain and dyspnea. Chest X-ray revealed two nodular opacities in right lung and one in left lung (Fig 1). Thorax CT revealed two cysts in right lower and medium lobe of lung and one cyst in lingual lobe of left lung (Fig. 2, 3). The diagnosis of hydatid cysts was confirmed at surgery.",
    "discussion": "Hydatid disease (HD) is a worldwide zoonosis produced by the larval stage of the Echinococcus granulosus. The lungs are the\n  second most frequent site of hematogenous spread in adults and probably the most common site in children (15%\u201325% of cases). Pulmonary HC have a predilection for the right posterior lung\n  segments, with 60% of cases manifesting in the lower lobes. Bilateral involvement occurs in 20% of cases and multiple cysts in 30% Calcification in pulmonary cysts is very rare (0.7% of cases).\n  Pulmonary hydatic cysts may vary from 1 to 20 cm in diameter because of their compressibility, the lungs are the\n  only organ in which HC can grow so large. \n\n\n  Most cysts are acquired in childhood, remain asymptomatic for a long period of time, and are later diagnosed incidentally at chest\n  radiography.\n\n\n  Imaging appearances may vary due to the growth of the parasite and its relationship to adjacent lung tissue. Initially, lung HC\n  generally manifest as type I cysts, being oval or round and having well-defined borders. CT reveals the hypoattenuating nature of these lesions. Diagnosis is generally easily made in endemic\n  regions on the basis of typical location and imaging findings, but multiple cysts, like our case, can be misdiagnosed as metastases. Daughter cysts (type II) are rarely seen in lung HD. One of the\n  most common imaging findings in HC is the \u201cmeniscus sign,\u201d which occurs when cyst growth produces erosions in the bronchioles that are included in the pericyst; as a\n  result, air is present between the pericyst and the laminated membrane. Some authors consider this to be a sign of impending rupture and an indication for emergency thoracotomy. Air between the\n  endocyst and pericyst creates the \u201conion peel sign\u201d. If air continues to enter the cyst cavity, the two layers completely separate from each other. The collapsed and\n  crumpled endocyst floats freely in the most dependent part of the pericyst cavity and produces the \u201cwater lily sign\u201d. If the fluid is entirely evacuated by expectoration,\n  the remaining solid components will fall to the most dependent part of the cavity (\u201cmass within a cavity\u201d).\nComplications of lung HC include rupture of the cyst into the parenchyma and pleurall cavity. Bacterial infection of the cyst is the most serious complication commonly seen after rupture (air-fluid level inside the endocyst). The other complication of HC is recurrent acute pulmonary embolism, a rare complication that can be seen when a cyst directly involves the vena\ncava",
    "differential_diagnosis": "Hydatid, disease, of, the, lung",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005859/000001.jpg?itok=6EZL76MF",
            "caption": ""
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005859/000002.jpg?itok=w3IHrGyd",
            "caption": ""
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005859/000003.jpg?itok=9AVx_AkA",
            "caption": ""
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/5859",
    "time": "08.06.2008"
  },
  "5862": {
    "case_id": 5862,
    "title": "The Forgotten disease",
    "section": "Chest imaging",
    "age": "18",
    "gender": "female",
    "diagnosis": "Lemierre\u2019s syndrome",
    "history": "The patient presented with slowly worsening fever, arthralgias, mild sore throat and dyspnea.",
    "image_finding": "An 18 years old girl with prior history of idiopathic thrombocytopenic purpura (diagnosed when she was 10 years old and presently not medicated) was admitted to the hospital with fever, arthralgias, mild sore throat and dyspnea. Laboratory analysis on admission showed a non-specific inflammatory reaction with leukocytosis, elevated C-reactive protein and erythrocyte sedimentation rate. On physical examination there was inflammation of the left pharyngeal tonsil and right ankle oedema. The chest x-ray and ankle films taken on admission showed no significant changes.On day-3 after admission chest x-ray revealed an ill-defined consolidaton in the right lower hemithorax (Fig.1). Follow- up ankle x-ray films and ultrasonography disclosed soft tissue swelling and articular effusion (Fig.2 and 3).Thoracic helical CT scans were obtained before and after intravenous administration of contrast medium, followed by 1-mm high-resolution CT (HRCT) thoracic sections at 10-mm intervals. CT showed precise depiction of medium lobe consolidation and sparse bilateral lower lobe nodules 3 to 15 mm in diameter (some with cavitation), as well as right pleural effusion (Fig.4-5).Colour-Doppler ultrasonography (CDUS) of the neck (Fig. 6) and cervical CT displayed thrombophlebitis of an internal jugular vein on the left side and of the jugular vein on the right (Fig. 7-8).Throat cultures were negative for beta-haemolytic bacteria. Blood cultures were positive for Fusobacterium necrophorum.The patient was successfully treated with ceftriaxone disodium intravenously for a period of 3 weeks followed by therapy with amoxicillin with clavulanic acid orally for another 3 weeks.",
    "discussion": "Lemierre\u2019s syndrome denoted as a \u201cforgotten disease\u201d is an acute oropharyngeal infection followed by septic thrombophlebitis of the internal jugular vein (IJV) and metastatic infections, most frequently involving the lungs.Multisystemic involvement of Lemierre\u2019s syndrome may produce meningitis, septic arthritis, and intra-abdominal sepsis. It has been reported more frequently in teenagers and young adults.Fusobacterium necrophorum, an anaerobic, non-motile, Gram-negative bacillus, is the most common pathogen. Unlike other anaerobes, F necrophorum is frequently the sole pathogen although other aetiological organisms can occasionally be found. Infection of the posterior (vascular) compartment of the lateral pharyngeal (parapharyngeal) space is of primary importance and metastatic infections develop from this source.Clinically the interval between oropharyngeal infection and septicaemia is usually less than one week. In fact oropharyngeal symptoms may have improved by the time septicaemia develops. Lung involvement is common, including pulmonary infiltrates, pleural effusion, lung abscess, empyema, pneumatoceles and pneumothorax. Other sites of metastatic infection include joints, bone, liver,spleen, skin, soft tissues, kidney and meninges.As far as diagnosis is concerned a high degree of clinical suspicion is needed if symptoms from oropharyngeal infection or from any of the described sources of infection are accompanied or followed by data suggestive of IJV thrombophlebitis, sepsis or septic emboli. Persistent fever may be the only evidence of the syndrome, particularly during the earlier phases. Oropharynx examination findings may not be diagnostic and the syndrome is frequently not suspected until microbiology results are available. The clinical suspicion of IJV thrombophlebitis must be objectively confirmed.Computed tomography (CT) of the neck with contrast is the most useful investigation. It can reveal distended veins with enhancing walls, low attenuation intraluminal filling defects, and swelling of the adjacent soft tissues. It also assists in localising abscesses that require drainage. Ultrasonography is also very useful to demonstrate IJV thrombosis, however, it provides poor imaging beneaththe clavicle and under the mandible, and can miss a fresh thrombus with low echogenicity. Chest X-ray findings in patients with pulmonary septic emboli may show diffuse ill-defined infiltrates that appear as round opacities of the lung. These opacities are classically related to a branching vessel and may cavitate. High-resolution CT provides additional useful information, clearly showing wedge-shaped peripheral densities abutting the pleura to nodular and cavitary lesions. Abdominal ultrasonography is indicated when liver or splenic abscesses are suspected.The causative organism can be isolated from blood cultures or from other specimens processed anaerobically, if obtained before initiating therapy. When arthritis is present, fluid from the involved joints must be cultured.The differential diagnosis of infectious metastatic lesions to the lung is large and includes Wegener\u2019s granulomatosis, reactivated tuberculosis, metastases, bronchioloalveolar carcinoma, rheumatoid nodules, aspergillosis, and histiocytosis. Involvement of the pleural space, pneumatoceles, and ARDS related to septicemia also has been described.The mainstay of treatment is intravenous \u03b2-lactamase-resistant antibiotics directed at anaerobes. Anticoagulation therapy is controversial; it may be useful if septicemboli persist despite antibiotic therapy or if thrombosis propagates to the cavernous sinus.",
    "differential_diagnosis": "Lemierre\u2019s, syndrome",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005862/000002.jpg?itok=Q-PJAtFM",
            "caption": "Consolidation in the right lower lung."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005862/000003.jpg?itok=EKDleBU4",
            "caption": "Ankle x-ray showing soft tissue swelling and probable articular effusion"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005862/000004.jpg?itok=SGalILNf",
            "caption": "Ankle US showing soft tissue swelling and articular effusion"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005862/000005.jpg?itok=4okPH7Pi",
            "caption": "Middle lobe consolidation, ipsilateral lower lobe cavitating nodule  and right pleural effusion."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005862/000008.JPG?itok=GfgVrb8e",
            "caption": "Middle lobe consolidation and right pleural effusion."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005862/000009.jpg?itok=v8JE0psE",
            "caption": "Parcial thrombus of the internal jugular vein on the left side"
          },
          {
            "number": "Figure 5b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005862/000010.jpg?itok=hKNmOXIn",
            "caption": "Right Jugular vein thrombosis"
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005862/000011.jpg?itok=25d7itRo",
            "caption": "Partial thrombus of the internal jugular vein on the left side"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/5862",
    "time": "15.09.2008"
  },
  "5970": {
    "case_id": 5970,
    "title": "An anusual case of huge posterior mediastinal mass due to a thoracic schwannom",
    "section": "Chest imaging",
    "age": "20",
    "gender": "female",
    "diagnosis": "A huge thoracic schwannoma.",
    "history": "A 20-year-old female with a clinical history of persistent cough and voluminous rounded mass on the right side of the superior-posterior mediastinum seen on chest x-ray, underwent contrast-enhanced CT and MRI with the suspicion of a neurogenic tumor. Surgical excision and histopathology subsequently confirmed the diagnosis of a thoracic schwannoma.",
    "image_finding": "We report the case of a 20 year old female with a two month history of cough resistant to medical therapy. A chest x-ray showed a large smooth rounded mass in the right superior-posterior mediastinum. Contrast enhanced CT demonstrated a 6 cm well marginated oval mass located in the right pulmonary apex, lying anterolaterally to the vertebral bodies; CT did not reveal any extension into the spinal canal or vertebral bone changes. A thoracic MRI with FFE T1-weighted and TSE T2-weighted images, on coronal and axial planes, was performed to asses the involvement of the apical structures and of the spinal canal. MRI confirmed the presence of a solid mass contiguous with the visceral and parietal pleura with minimal pleural effusion; the mass was adjacent to, but not infiltrating, the right antero-superior mediastinum and the first dorsal vertebral bodies. After complete surgical excision of the thoracic mass, the histological examination revealed a typical benign Schwannoma (S100+).",
    "discussion": "Neurogenic tumors account for 9% of mediastinal masses in adults and 29% in children; they can derive from any tissue of the neural crest and thus from the peripheral nerves and nerves sheaths (Schwannoma, neurofibroma, malignant tumors of nerve sheath origin), sympathetic ganglia (ganglioneuroma, ganglioneuroblastoma and neuroblastoma) or paraganglionic nervous systems (chemodectoma, phaeocromocytoma). They can occur anywhere in the thorax, although almost all develop in the mediastinum. The majority are found in the costovertebral sulcus and are related to the sympathetic chain or the rami of intercostal nerves. They are often in close proximity to the spinal canal, can be multifocal and associated with cutaneous tumors of ectodermal origin. They can also derive from peripheral nerves such as the vagus, recurrent laryngeal, phrenic and brachial plexus. Schwannomas are tumors of the nerve sheaths. They are often found in individuals with neurofibromatosis or von Recklinghausen disease. These well-encapsulated, soft, yellowish tumors are attached to and extrinsically compress the peripheral nerves. Areas of cystic degeneration, low cellularity, haemorrhage and lipid laden myelin or spot calcifications give to these tumors, especially when large, an heterogeneous appearance. Microscopically, schwannomas are composed of spindle cells with twisted nuclei and amphophilic cytoplasm. The characteristic features include the presence of alternating Antoni A and Antoni B areas. Antoni A areas are composed of spindle shaped Schwann cells arranged in interlacing fascicles. Antoni B areas consist of a loose meshwork of gelatinous and microcystic tissue. S100 is strongly expressed by most cells of schwannoma. The cells also express Vimentin and myelin basic protein. On CT scan thoracic schwannomas appear as well-circumscribed, homogenous or heterogeneous masses and it is possible to detect the compressive effect on the surrounding structures. Punctate calcifications are occasionally visualized and low attenuation areas corresponding to hypocellularity, cystic degeneration, haemorrhage and myelin are often detected. Those tumours may demonstrate mild homogeneous, heterogeneous or peripheral contrast enhancement; occasionally their developement through intervertebral foramina into the spinal canal may lead to a \u201cdumbbell\" or \"hourglass\u201d appearence. On MRI scans these lesions often show non-homogeneous pattern with low signal intensity on T1-weighted images, especially at the centre of the mass, and areas of high signal intensity on T2-weighted images in the peripheral portion related to cystic degeneration. Non-necrotic areas also show an increased signal on T2-weighted images due to the hypocellularity characterizing Antoni B areas. Differential diagnosis has to be made with: - neurofibroma: this tumour is usually homogeneous, well marginated but not encapsulated and arises from the entire peripheral nerve component; - plexiform neurofibroma: a well defined, non encapsulated variant that infiltrates along the whole nerve trunk and is considered pathognomonic of Von Recklinghausen\u2019s disease; - malignant schwannoma: a mass bigger than 5 cm in diameter, irregularly shaped, rapidly growing and with edema and central necrotic areas; - synovial sarcomas; - granulomas; - haemoangiopericitomas.",
    "differential_diagnosis": "A, huge, thoracic, schwannoma.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005970/000003.JPG?itok=mZhPAa69",
            "caption": "Contrast-enhanced CT shows a as a well-circumscribed homogenous rounded mass, lying anterolaterally to the vertebral bodies; CT does not demonstrate any extension into the spinal canal or vertebral bone changes."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005970/000004.jpg?itok=xzTSzzyw",
            "caption": "Scout view of chest CT shows a large rounded mass at the right side of the supero-posterior mediastinum."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/5970",
    "time": "10.08.2008"
  },
  "5997": {
    "case_id": 5997,
    "title": "Localized fibrous tumor of the pleura mimicking a pleural effusion",
    "section": "Chest imaging",
    "age": "70",
    "gender": "female",
    "diagnosis": "Localized fibrous tumor of the pleura",
    "history": "A 70-year-old women presented to the Emergency Room with complaints of left sided chest pain with exacerbation during inspiration, dyspnoea and palpitations. She reported dry cough for three weeks,\nwithout fever.",
    "image_finding": "Past History: Three years ago, the patient had undergone mechanical mitral valve replacement and she was under anticoagulant treatment. Physical examination: dullness to percussion, with absent\nbreath sounds over the left hemithorax. A posteroanterior and lateral Chest radiograph (figure 1) on admission to the hospital showed homogeneous and well-circumscribed opacification occupying the\nlower two-thirds of the left hemithorax. The initial diagnosis of pleural effusion was made, and a difficult pleurocentesis yielded a little amount (20 ml) of bloody fluid. Then, a chest CT (figure 2\n) was performed and the initial diagnosis was modified at that moment, according to the CT findings. The interest of this case is the presentation of this Solitary Fibrous Tumour. In the emergency\nroom the patient was diagnosed of pleural effusion according to the symptoms, physical examination, chest x-ray and CT. The diagnosis of a septated pleural effusion was made by a non-experienced\nradiology resident on guard. Next day several experienced radiologists found clues for a different diagnosis: CT showed branching linear structures of enhancement within the lesion \u2013consistent\nwith intralesional blood vessels (figure 3)- and the CT numbers were similar to those of soft-tissue attenuation. Then, the possibility of a pleural tumour was taken into account. After a diagnostic\npleuroscopy, the patient underwent a thoracotomy, and a large lobulated gray-white mass with firm consistency occupying a great portion of the left hemithorax was encountered. The histologic\ndiagnosis was of localized fibrous tumor of the pleura.",
    "discussion": "Localized fibrous tumors are rare mesenchymal neoplasms that most commonly affect the pleura but have also been described in a number of other locations including the mediastinum and the lung.\nExtrathoracic localized fibrous tumors have been reported in the abdomen, the head and neck, and the central nervous system. Localized fibrous tumors of the pleura (LFTP), also known as benign\nmesotheliomas, localized fibrous mesotheliomas, and pleural fibromas, are rare tumors, accounting for less than 5% of all neoplasms involving the pleura. These tumors originate from submesoepithelial\nmesenchymal cells, and approximately 80% arise from the visceral pleura. They are not related to asbestos exposure. Although the most common primary pleural neoplasm is malignant mesothelioma,\nradiologists should also be able to identify the much rarer LFTP, as these two neoplasms have radically different prognoses. These tumors, commonly found in the dependent portions of the thorax, may\nrange from 1 to 39 cm in diameter. Large tumors usually displace rather than invade adjacent structures. Because of the presence of a vascular pedicle in 30-50% of patients, these tumors may show a\nchange in shape and location with changes in respiration or position. Benign and malignant subtypes of LFTP are recognized. On unenhanced CT scans, localized fibrous tumors show soft-tissue\nattenuation. MR imaging typically demonstrates intrathoracic lobular masses of heterogeneous signal intensity with both T1- and T2-weighted sequences. Internal low-signal-intensity septa on\nT2-weighted images are common. On CT and MR images, marked enhancement caused by the rich vascularization is usually seen with the administration of IV contrast material. CT and MR images may show\nassociated, regions of hemorrhage and necrosis, tumoral calcifications and pleural effusions. Rib erosion is rare. Although approximately half the patients with localized fibrous tumors of the pleura\nare asymptomatic, cough, chest pain, and dyspnea may be presenting symptoms, especially in patients with large tumors. Hypertrophic osteoarthropathy is seen in 4-35% of patients, and hypoglycemia is\nnoted in up to 5%. Atelectasis of the adjacent lung and mass effect on the mediastinum are common associated findings. The fibrous acellular nature of localized fibrous tumors makes diagnosis by\ntransthoracic needle biopsy difficult. Although there are no imaging features that definitively distinguish benign from malignant subtypes of LFTP, heterogeneity on cross-sectional images, mass\neffect, and pleural effusion may be slightly more common in malignant lesions.",
    "differential_diagnosis": "Localized, fibrous, tumor, of, the, pleura",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005997/000003.png?itok=6-CnqyVA",
            "caption": "Posteroanterior and lateral Chest radiograph show homogeneous and well-circumscribed opacification occupying the lower two-thirds of the left hemithorax."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005997/000005.png?itok=5FflYvJa",
            "caption": "Posteroanterior and lateral Chest radiograph showed homogeneous and well-circumscribed oppacification occupying the lower two-thirds of the left hemithorax."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005997/000006.png?itok=JRi-i7Lq",
            "caption": "Chest CT at different levels."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005997/000007.png?itok=ECAGiwLY",
            "caption": "Chest CT at different levels."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005997/000008.png?itok=XRNBSLFu",
            "caption": "Chest CT at different levels."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005997/000010.png?itok=v-qBpaBf",
            "caption": "Chest CT at different levels."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000005997/000013.png?itok=tx77iYat",
            "caption": "Chest CT (detail). Branching linear structures of enhancement within the lesion, consistent with intralesional blood vessels"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/5997",
    "time": "24.02.2008"
  },
  "6023": {
    "case_id": 6023,
    "title": "Pulmonary Alveolar Microlithiasis",
    "section": "Chest imaging",
    "age": "50",
    "gender": "female",
    "diagnosis": "Pulmonary alveolar microlithiasis",
    "history": "The authors present a clinical case of pulmonary alveolar microlithiasis, in a 50-year-old patient . The diagnosis was first suspected, following a chest x-ray, when she was 12 years old butasymptomatic. The patient\u2019s main clinical complaint was increasing shortness of breath.",
    "image_finding": "Family history reveals consanguinity (first-cousin parents). Two brothers had already died of pulmonary alveolar microlithiasis (Fig 1). Following the diagnostic confirmation , of one of the brothers, all the members of the family had to undergo chest-X rays. Doctors even then, suspected the disease could be present in two more members of the family (another brother and our patient, aged 12 at the time). This diagnosis was confirmed by pulmonary biopsy when she was a young adult. She was asymptomatic for several years, but then became gradually more dyspnoeic. She is now 50 years old and complains of dyspnoea following any minor effort and constant cyanosis. The latest chest X-ray shows bilateral, diffuse, micronodular, \u201csandstorm-like\u201d, confluent lesions, partially sparing the pulmonary apices (Fig 2). CT scans reveal extensive, bilateral, diffuse, minute alveolar calcifications. These scans show the same distribution as the chest X-ray but also the extent of the septal thickening. (Fig 3, 4, 5, 6 ). A heart and lung transplant was recently considered.",
    "discussion": "Pulmonary alveolar microlithiasis was first described by Harbitz in 1918 (1), and is a rare, (about 300 reported cases) (2;3) slowly progressive disease, characterized by the deposition of calcium phosphate microliths throughout the lungs (2;3). About one-third of the reported cases are found in close relatives (2). Other authors also believe that the illness is a recessive monogenic, full penetrance, inherited disease (2) in spite of a variety of environmental factors suggested as the aetiology (4). The SLC34A2 gene (type IIb sodium-phosphate cotransporter gene) which is involved inphosphate homeostasis, in several organs, has recently been considered responsible for the illness (4). The disease may not be confined to the alveoli since calcispherites have also been found in the bronchial walls, lumbar sympathetic chain and possibly the testicles (5). The hallmark of pulmonary alveolar microlithiasis is a dissociation between the radiological findings and the limited clinical symptoms and signs (1;6). The main clinical complaints include progressive dyspnoea, cough and expectoration. It can ultimately lead to respriatory and cardiac failure(1).Chest X-rays show typical \u201csandstorm\u201d like appearance \u2013 bilateral, diffuse, nodular calcification (7;2) that is more severe in the middle and pulmonary bases (6;1). CT scans show multiple, bilateral, diffuse, calcified micronodules, ground-glass opacities and a frequently reported sub-pleural lucent band, attributed to sub-pleural emphysema (6;1). The diagnosis is usually based on clinical and radiological findings. There is no effective treatment. In end stage disease heart and lung transplantation is performed(1).",
    "differential_diagnosis": "Pulmonary, alveolar, microlithiasis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006023/000002.jpg?itok=xluwhJgF",
            "caption": "overexposed X-ray shows typical widespread small nodules, diffusely involving both lungs, and commonly described as \"sand storm-like\"."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006023/000006.jpg?itok=_3IgDxlX",
            "caption": "axial CT-image at the level of the carina, lung window"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006023/000007.jpg?itok=epns8fpm",
            "caption": "axial CT-image at the level of the carina, mediastinal window"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006023/000008.jpg?itok=DBCH5jk5",
            "caption": "axial CT-image at the level of the lower lung areas. CT shows extensive, bilateral calcified micronodules in a miliary distribution, replacing almost completely the normal airspaces"
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006023/000010.jpg?itok=Wcp5OWXX",
            "caption": "axial CT-image at the level of the lower lung areas.\nCT shows extensive, bilateral calcified micronodules in a miliary distribution, replacing almost completely the normal airspaces"
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006023/000011.jpg?itok=99kkzhjC",
            "caption": "Fig. 1 \u2013 Recent family tree. See legend in the figure."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/6023",
    "time": "26.08.2008"
  },
  "6026": {
    "case_id": 6026,
    "title": "Costal Cartilage Fractures in Blunt chest wall traum",
    "section": "Chest imaging",
    "age": "19",
    "gender": "male",
    "diagnosis": "Fracture of the costal cartilages",
    "history": "19-year-old male with blunt trauma to the anterior chest wall presented with shortness of breath and hypoxia.",
    "image_finding": "A 19-year-old man presented acutely to the emergency department following blunt localised trauma to the anterior chest wall. Trauma was significant causing extensive bruising of the anterior chest\nwall extending into upper abdomen and severe pain. On examination, the patient found to have hypoxemia and shortness of breath with normal blood pressure. Lung contusion/pnuemothorax was suspected\nclinically and the patient was admitted to the high dependency unit. Plain radiograph of the chest was unremarkable with no evidence of fractures. In view of the significant injury and the patient's\ncondition, CT scan of the chest and abdomen were performed. The CT thorax showed fractures of 3 successive costal cartilages with overlapping fragments and minor atelectasis of the lung. No rib\nfractures or contusions of the lung seen. No other abnormalities in the remainder of chest or abdomen. The patient was managed with analgesics.",
    "discussion": "Fractures of the ribs are very common following trauma and they can be easily detected on plain radiography as well as cross sectional imaging. However, costal cartilage fractures are rare and under\nreported. Plain radiographs can not diagnose the cartilage fractures. In cases of persistent unexplained post traumatic chest pain and chronic painful swelling of the anterior chest wall, cross\nsectional imaging is indicated to detect acute and chronic costal cartilage fractures respectively. Sonography can also be used to detect the fractures accurately although less used (Ref.1). It is\noften important to diagnose the cause of the chest pain, not only to provide appropriate treatment, but also to avoid unnecessary further investigations and management. Biopsy of chronic painful\nswelling due to the unrecognized cartilage fractures may misdiagnose the condition as malignancy (Ref.2). The severe pain due to the acute fracture causes reduced movement of the chest wall and\natelectasis, thereby leading to SOB and hypoxia as in the above patient. This case is a reminder to look for the costal cartilage fractures as one of the causes of chest pain.",
    "differential_diagnosis": "Fracture, of, the, costal, cartilages",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006026/000004.jpg?itok=zAlZUkLd",
            "caption": "Fracture of the costal cartilage with overlapping fragments (white arrow) in the right anterior chest wall and minor atelectasis of the posterior aspect of the lung caused by the reduced chest movement due to the pain."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006026/000005.JPG?itok=2XLOshAB",
            "caption": "Fracture of the costal cartilage of one of the lower ribs on the right (arrow). Incidental simple cyst of the liver."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/6026",
    "time": "19.02.2008"
  },
  "6066": {
    "case_id": 6066,
    "title": "Tracheal squamous cell carcinom",
    "section": "Chest imaging",
    "age": "81",
    "gender": "male",
    "diagnosis": "Tracheal squamous cell carcinoma",
    "history": "Non-smoker patient suffering from acute onset of dysphonia with no other sympthoms. History of alcohol abuse.",
    "image_finding": "The patient was referred to our hospital in order to determine the cause of his dysphonia. A chest X-ray (not shown) revealed a peripheral middle lobe infiltrate. An enhanced thoracic CT scan was\nperformed and it showed, beyond a residual middle lobe infiltrate, an ill defined region of increased attenuation along the left side of the trachea with an associated tracheal small enhanced nodule.\nThese findings were consistent with a tracheal primary malignant neoplasm. Broncoscophy confirmed the presence of a tracheal wall infiltration 5 cm below vocal chords. Pathology revealed a tracheal\nsquamous cell carcinoma.",
    "discussion": "Tracheal diseases are frequently not apparent or overlooked on chest radiographs. CT is the imaging modality of choice for radiologic evaluation of the central airways. Primary malignant neoplasms of\nthe trachea are uncommon, accounting for less than 1% of all thoracic malignancy but malignant neoplasms account for 90% of adult primary tracheal tumors. The most common primary tracheal\nmalignancies are squamous cell carcinoma and adenoid cystic carcinoma. Squamous cell carcinoma typically occurs in older patients with risk factors of cigarette or alcohol abuse (as in the presented\ncase). These tumors manifest as large irregular tracheal masses and their prognosis is poor. In our case there was a blurring of the margin between the trachea and the esophagus and this finding has\nbeen described as a reliable sign of tracheal invasion by esophageal carcinoma; nevertheless, the enhacing nodule in the tracheal lumen strongly suggests tracheal origin. The second primary tracheal\ntumors in frequency are adenoid cystic carcinomas: they present as focal polypoid endoluminal masses involving the posterolateral wall of the middle to lower third of the trachea. CT findings\ncorrelate well with the pathologic findings.",
    "differential_diagnosis": "Tracheal, squamous, cell, carcinoma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006066/000001.JPG?itok=cxZLtAxj",
            "caption": "Axial image showing blurring of the space between trachea and esophagus."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006066/000002.JPG?itok=CqdLabjC",
            "caption": "Axial view of the trachea: note the anterolateral enhanced tracheal  nodule"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006066/000003.JPG?itok=D1RH9skM",
            "caption": "Same image with lung window setting"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006066/000004.JPG?itok=-BuHz68x",
            "caption": "Coronal reformated image showingcontrast- enhanced  nodule and left tracheal  wall thickening"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/6066",
    "time": "26.03.2008"
  },
  "6109": {
    "case_id": 6109,
    "title": "Unusual Complication of Heimlich&#039;s Manoeuver- Case Report and literature review",
    "section": "Chest imaging",
    "age": "52",
    "gender": "female",
    "diagnosis": "Partially calcified Intrathoracic haematoma following Haeimlich's Manoeuvre",
    "history": "Case report of a 52-year-old woman with asymptomatic calcified intrathoracic haematoma noted months after a Heimlich manoeuvre was carried out. Differential diagnosis was wide as history was not very\nforthcoming in view of learning difficulty of the patient.",
    "image_finding": "A 52-year-old woman with Down\u2019s syndrome was being investigated for an ischemic ulcer on her right gluteal region by Dermatology. Chest X-ray (Figure 1) organised as a part of the\ninvestigations revealed a calcified lesion in the right lateral wall of the chest. This lesion measured 14cm x 8cm. It had a large soft tissue component and was associated with a small right-sided\npleural effusion. On further examination, she had a slight asymmetry of the affected side of the chest and a large lipoma on her back. A CT Scan (Figure 2) of her chest revealed a large lesion in the\nright postero-lateral chest wall with heterogenous attenuation. The lesion had both soft tissue and calcified components, almost mimicking malignancy. The lung parenchyma was not involved. Findings\nwere suggestive of a partially calcified haematoma. Going back through her records, she had no such findings on her previous Chest X-ray from 2004. The answer lay in the history obtained from her\ncarers. She was resident in a care home and had an episode of choking while eating peanuts, a few months back, for which the staff present carried out the Heimlich\u2019s Manoeuvre, which seemed to\nrelieve her obstruction. On account of her learning difficulty she was not able to communicate the pain following the traumatic manoeuvre. Retrospective correlation with the history provided the\nright explanation for her asymptomatic clinical picture.",
    "discussion": "Heimlich Manoeuvre was first described by Henry Heimlich in June 1974.1 Following its widespread use, it was reported to have saved tens of lives within the first nine months. Fractured\nribs in two cases were the only major problems reported in the original article.1Currently, in the APLS guidelines, the words \u2018abdominal thrusts\u2019 are used instead of the phrase\n\u2018Heimlich Manoeuvre\u2019, primarily to define the indication and procedure more scientifically. \u2018Abdominal thrusts are indicated following witnessed aspiration of foreign body where the\nvictim is conscious but has a very weak and ineffective cough.2 There is recognition of the fact that abdominal thrusts can cause serious injury which has prompted an explanatory note\nstating that all victims receiving abdominal thrusts should be examined for injury by a doctor. Although the incidence of complications from the manoeuvre is low, serious complications can occur,\nsome of which may be fatal, if undetected. Most common complication reported is rib fracture3 followed by gastric rupture (1.7%).4-9 Gastric rupture has mostly been seen in\npeople over the age of 65 yrs or those neurologically impaired and in most cases multiple attempts were made. A variety of others have featured, mainly as case reports. A review of the literature\nrevealed a case of dislodgement of thrombus from an atherosclerotic non-aneurysmal aorta which resulted in thromboembolic occlusion of both lower extremities.10 In another case, repeated\nHeimlich\u2019s manoeuvre dislodged the foreign body further down in the trachea and may have contributed to rapid development of surgical emphysema, pneumomediastinum and\npneumopericardium.11 The following table (Table 1) collates the rare complications reported from Heimlich Manoeuvre over the years as published recently.12 Most of the reported\ncomplications have involved rupture of a hollow viscous. This article also described a case of hepatic rupture following Heimlich\u2019s Manoeuvre reported for the first time. Correct technique does\nnot preclude complications24,25. In most published cases of complications of Heimlich\u2019s manoeuvre, specific information regarding technique is not provided26,27,28,29,30.\nOur case of Calcified Haematoma, which was diagnosed months following the manoeuvre, is the first to be reported in medical literature and caused a distinctive diagnostic dilemma. Our case emphasizes\ntwo important points. First, the importance of seeking medical help immediately after this manoeuvre is carried out on a victim12,27,31 and second that the complications from this\nmanoeuvre can come to light weeks to months afterwards and can pose a diagnostic dilemma later on. Also finding of significant injuries in any institutionalised individuals should raise the suspicion\nof assault and specific questions regarding the technique used should always be asked.",
    "differential_diagnosis": "Partially, calcified, Intrathoracic, haematoma, following, Haeimlich's, Manoeuvre",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006109/000003.jpg?itok=hCWOXtNO",
            "caption": "Chest X-ray showing a calcified lesion in right lateral wall of chest"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006109/000004.jpg?itok=Uxb92lt9",
            "caption": "CT Scan Chest showing a large lesion in right postero-lateral chest wall with heterogenous attenuation and partial calcification"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006109/000005.GIF?itok=ZM2Xyrf2",
            "caption": "Complications reported following Heimlich Manoeuvre"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/6109",
    "time": "19.02.2008"
  },
  "6111": {
    "case_id": 6111,
    "title": "Amiodarone-induced pneumonitis",
    "section": "Chest imaging",
    "age": "53",
    "gender": "male",
    "diagnosis": "Amiodarone-induced pneumonitis.",
    "history": "A 53-year-old man under long-term amiodarone therapy was evaluated for the onset of non-productive cough and shortness of breath.",
    "image_finding": "The patient was referred to our hospital with non-productive cough and dyspnea. Some months earlier he had undergone cardiac surgery for valvular replacement due to severe mitralic insufficiency and\nthen he had started amiodarone therapy for treatment of atrial fibrillation. A chest X-ray examination showed patchy, ill-defined bilateral opacities, predominantly located at the middle and lower\npulmonary fields (fig. 1). Chest CT was then performed and confirmed the presence of diffuse, multiple areas of consolidation, a ground-glass appearance and a symmetric peripheral distribution with\nrelative sparing of the upper lobes. Moreover, we noticed that consolidation areas were associated with architectural distortion and dilation of air spaces with bronchial wall thickening (fig. 2), as\nwell as minimal bilateral pleural effusion, pleural thickening, and enlarged mediastinal lymph nodes (fig. 3). Broncho-alveolar lavage (BAL) was performed and demonstrated a high number of\nlymphocytes and foamy cells. Amiodarone was then discontinued and the patient began an anti-inflammatory treatment with methyl-prednisolone, leading to a gradual improving of symptoms. Three months\nlater the patient underwent a new chest CT that demonstrated a marked reduction of the consolidation areas and interstitial involvement (fig. 4).",
    "discussion": "Amiodarone is a benzofuran antiarrhythmic drug which may have several side effects involving the lung, liver, thyroid, cornea, skin, and the neuromuscular system. Amiodarone-induced pneumonitis (AIP) is a potentially fatal noncardiac side effect of prolonged amiodarone therapy, which is reported to develop with an overall frequency of 0.5-15% of patients, depending on the dose and the duration of treatment. The mechanism underlying AIP has not yet been elucidated clearly, but is supposed to imply direct cytotoxic damage through inhibition of phospholipase A (leading to accumulation of phospholipids within lysosomes), as well as an indirect immune reaction, with presence of foamy lipid-laden macrophages and type II pneumocytes containing whorled lamellar inclusion bodies. Clinical symptoms of AIP may occur within days or, more often, several months of therapy and include dyspnea, non-productive cough and, less commonly, fever, malaise, and pleuritic chest pain. The most frequent manifestation of AIP is non-specific interstitial pneumonia (NSIP), but it can also present as bronchiolitis obliterans organizing pneumonia (BOOP), acute respiratory distress syndrome (ARDS), or a solitary pulmonary mass (which has been termed amiodaronoma). The main hallmark of AIP on chest radiograph is represented by diffuse, patchy, or focal bilateral pulmonary opacities (62.5%), which are preferentially located in the middle and lower pulmonary fields. Other radiographic signs are bilateral or unilateral pleural effusion (37.5%), bibasilar atelectasis (37.5%), pleural thickening (12.5%), and localized fibrosis (12.5%). On computed tomography (CT) the most common abnormality is represented by areas of ground glass attenuation (80%), corresponding to the opacities seen on chest radiographs, which are usually bilateral and symmetric with a tendency to subpleural and basal dominance. Less frequently, and in our case, focal or diffuse consolidation areas with a peripheral and basal distribution may be associated with or replace ground glass areas, which is more typical of the BOOP-like variant of AIP. Consolidation areas tend to be hyperdense (usually >70HU), due to the relatively high iodine content (37.3%) of the amiodarone molecules incorporated into macrophages and type II pneumocytes. Their basal location can be partially explained by the higher perfusion gradient of the lower pulmonary fields compared with the upper ones; moreover, ground glass and consolidation areas in AIP have a gravity-independent distribution, which is important for differential diagnosis with heart failure and ARDS. On high resolution CT images (HRCT), interlobular septal thickening and intralobular lines can be detected, forming a 'crazy paving' pattern when ground glass areas are associated. Other HRCT findings are subpleural lines and bronchial abnormalities, such as traction bronchiectases and bronchiolectases secondary to interstitial fibrosis, as well as bronchial wall thickening. Differential diagnosis is required with other potentially concurrent conditions, such as heart failure, pulmonary embolism, or infective pneumonia. For this reason, and because of the lack of specificity of other diagnostic procedures (such as gallium scan, BAL, or lung biopsy), the diagnosis of AIP is often an exclusion one, for which radiologic techniques may have a supportive role.",
    "differential_diagnosis": "Amiodarone-induced, pneumonitis.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006111/000001.jpg?itok=q2-p8joE",
            "caption": "(a) Antero-posterior chest radiograph: the picture shows patchy, ill-defined bilateral opacities, predominantly located at the middle and lower pulmonary fields."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006111/000002.jpg?itok=OcEDL-AF",
            "caption": "(b) Latero-lateral chest radiograph: the picture shows patchy, ill-defined bilateral opacities, predominantly located at the middle and lower pulmonary fields."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006111/000003.jpg?itok=EgcR-QkB",
            "caption": "(a) Spiral CT scan at a level immediately below the carina showing diffuse, multiple areas of consolidation and ground glass attenuation with a symmetric peripheral distribution. Most consolidation areas have a peribronchovascular location, suggesting an overlapping BOOP pattern."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006111/000004.jpg?itok=NrejN8B3",
            "caption": "(b) HRCT scan at approximately the same level as in (a), showing coexistent pseudonodular consolidation foci and ground glass attenuation areas associated with architectural distortion, dilation of air spaces and bronchial wall thickening. Note the \\'crazy paving\\' pattern in the anterior segment of the right upper lobe."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006111/000005.jpg?itok=HOCT_34T",
            "caption": "(c) Spiral CT scan of the lower pulmonary fields showing diffuse, multiple areas of consolidation and ground glass attenuation with a symmetric peripheral distribution. Most consolidation areas have a peribronchovascular location, suggesting an overlapping BOOP pattern."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006111/000006.jpg?itok=ybVUTVto",
            "caption": "(d) HRCT scan of the lower pulmonary fields showing coexistent pseudonodular consolidation foci and ground glass attenuation areas associated with architectural distortion, dilation of air spaces and bronchial wall thickening."
          },
          {
            "number": "Figure 2e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006111/000007.jpg?itok=czbELArC",
            "caption": "(e) Pathologic involvement of upper pulmonary fields is sensibly milder than that of mid and lower ones."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006111/000008.jpg?itok=1M3nylbM",
            "caption": "(a) Chest CT with mediastinum window showing minimal bilateral effusion."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006111/000009.jpg?itok=AjaAhJ2E",
            "caption": "(b) Chest CT with mediastinum window showing enlarged mediastinal lymph nodes."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006111/000010.jpg?itok=K6bh7PWl",
            "caption": "(a) CT scan at a level below the carina shows reduction of ground glass and consolidation areas."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006111/000011.jpg?itok=iT0TLD6p",
            "caption": "(b) HRCT scan at a level below the carina shows reduction of ground glass and consolidation areas, as well as of interstitial involvement."
          },
          {
            "number": "Figure 4c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006111/000012.jpg?itok=CNjhbiag",
            "caption": "(c) CT scan of the lower pulmonary fields shows reduction of ground glass and consolidation areas."
          },
          {
            "number": "Figure 4d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006111/000013.jpg?itok=VQMXDXpo",
            "caption": "(d) HRCT scan of the lower pulmonary fields shows reduction of ground glass and consolidation areas, as well as of interstitial involvement."
          },
          {
            "number": "Figure 4e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006111/000014.jpg?itok=GGrE4V5T",
            "caption": "(e) Chest CT with mediastinum window shows size reduction of mediastinal lymph nodes."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/6111",
    "time": "27.05.2008"
  },
  "6173": {
    "case_id": 6173,
    "title": "Malignant Teratoid Tum",
    "section": "Chest imaging",
    "age": "2",
    "gender": "male",
    "diagnosis": "malignant tertoid tumor",
    "history": "A 2-year-old male patient presented with shortness of breath, cough and signs of SVC obstruction.",
    "image_finding": "A 2-year-old male patient presented with shortness of breath, cough and signs of SVC obstruction. A CT scan of the chest with IV contrast showed a huge lobulated markedly necrotic and heterogeneously enhancing anterior mediastinal mass compressing and shifting the mediastinal structures towards the left side. The SVC was markedly compressed and slit-like explaining multiple mediastinal and chest wallcollaterals (SVC syndrome). Multiple small satellite lymph nodes were noted around the mass and in the supraclavicular and axillary regions. Bilateral pleural effusion was marked on the right side.The case was diagnosed by CT-scan guided biopsy.",
    "discussion": "MALIGNANT TERATOID TUMOR:Teratocarcinoma/ malignant teratoma. 1. Seminoma or germinoma:most common mediastinal germ cell tumor. Most common primary malignant germ cell tumor of mediastinum! Incidence: 2-6% of all mediastinal tumors; 5-13% of all malignant mediastinal tumors. Age: 3rd-4th decade; Male> Female. Metastases: To regional lymph nodes, lung, bone, liver. Radiological appearance: large bulky well-marginated lobulated mass. Usually no calcification. Homogeneous soft\u2013tissue density with slight enhancement. 2. Nonseminomatous Malignant germ cell tumor: Age: During 2nd-4th decade. Male : Female = 9:1; in children Male=Female. Associated with: Klinefelter syndrome (in 20%), hematologic malignancy. Clinical presentation: Chest pain, dyspnea,cough, weight loss, fever SVC syndrome. Metastases to: lung, liver. Radiological appearance: Large tumor of heterogeneous texture with central hemorrhage / necrosis. Well circumscribed / with irregular margins and enhancement of tumor periphery. Lobulation suggests malignancy. Invasion of mediastinal structures (SVC obstruction is ominous).  Pleural/pericardiacl effusion (from local invasion). Complication: (1) Hemorrhage (2) Pneumothorax (from bronchial obstruction with air trapping and alveolar rupture) (3) Respiratory distress (rapid increase in size from fluid production) with compression of traches/ SVC (SVC syndrome). (4) Fistula formation to aorta, SVC, esophagus (5) Rupture into bronchus (expectoration of oily substance /trichopytysis in 5-14%lipoid pneumonia). (6) Rupture into pericardium (pericardial effusion) or pleural cavity (pleural effusion). Differential diagnosis: thymoma, lymphoma.",
    "differential_diagnosis": "malignant, tertoid, tumor",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006173/000002.jpg?itok=2lI7StKO",
            "caption": "showed huge lobulated markedly necrotic and heterogeneously enhancing anterior mediastinal mass compressing and shifting the mediastinal structures towards the left side. The SVC is markedly compressed and slit like hence the multiple mediastinal and chest wall collaterals (SVC syndrome). Multiple small satellite lymph nodes are noted around the mass and in the supraclavicualr and axillary regions .Bilateral pleural effusion which is marked on the right side."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006173/000003.jpg?itok=Vj1uakg3",
            "caption": "showed huge lobulated markedly necrotic and heterogeneously enhancing anterior mediastinal mass compressing and shifting the mediastinal structures towards the left side. The SVC is markedly compressed and slit like hence the multiple mediastinal and chest wall collaterals (SVC syndrome). Multiple small satellite lymph nodes are noted around the mass and in the supraclavicualr and axillary regions .Bilateral pleural effusion which is marked on the right side."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006173/000004.jpg?itok=UFfNH57F",
            "caption": "showed huge lobulated markedly necrotic and heterogeneously enhancing anterior mediastinal mass compressing and shifting the mediastinal structures towards the left side. The SVC is markedly compressed and slit like hence the multiple mediastinal and chest wall collaterals (SVC syndrome). Multiple small satellite lymph nodes are noted around the mass and in the supraclavicualr and axillary regions .Bilateral pleural effusion which is marked on the right side."
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006173/000005.jpg?itok=r44gpJWi",
            "caption": "showed huge lobulated markedly necrotic and heterogeneously enhancing anterior mediastinal mass compressing and shifting the mediastinal structures towards the left side. The SVC is markedly compressed and slit like hence the multiple mediastinal and chest wall collaterals (SVC syndrome). Multiple small satellite lymph nodes are noted around the mass and in the supraclavicualr and axillary regions .Bilateral pleural effusion which is marked on the right side."
          },
          {
            "number": "Figure 1e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006173/000006.jpg?itok=39qA8fwk",
            "caption": "showed huge lobulated markedly necrotic and heterogeneously enhancing anterior mediastinal mass compressing and shifting the mediastinal structures towards the left side. The SVC is markedly compressed and slit like hence the multiple mediastinal and chest wall collaterals (SVC syndrome). Multiple small satellite lymph nodes are noted around the mass and in the supraclavicualr and axillary regions .Bilateral pleural effusion which is marked on the right side."
          },
          {
            "number": "Figure 1f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006173/000007.jpg?itok=Iozj2qma",
            "caption": "showed huge lobulated markedly necrotic and heterogeneously enhancing anterior mediastinal mass compressing and shifting the mediastinal structures towards the left side. The SVC is markedly compressed and slit like hence the multiple mediastinal and chest wall collaterals (SVC syndrome). Multiple small satellite lymph nodes are noted around the mass and in the supraclavicualr and axillary regions .Bilateral pleural effusion which is marked on the right side."
          },
          {
            "number": "Figure 1g",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006173/000008.jpg?itok=Lhp-f-mh",
            "caption": "showed huge lobulated markedly necrotic and heterogeneously enhancing anterior mediastinal mass compressing and shifting the mediastinal structures towards the left side. The SVC is markedly compressed and slit like hence the multiple mediastinal and chest wall collaterals (SVC syndrome). Multiple small satellite lymph nodes are noted around the mass and in the supraclavicualr and axillary regions .Bilateral pleural effusion which is marked on the right side."
          },
          {
            "number": "Figure 1h",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006173/000009.jpg?itok=m8IhWb59",
            "caption": "showed huge lobulated markedly necrotic and heterogeneously enhancing anterior mediastinal mass compressing and shifting the mediastinal structures towards the left side. The SVC is markedly compressed and slit like hence the multiple mediastinal and chest wall collaterals (SVC syndrome). Multiple small satellite lymph nodes are noted around the mass and in the supraclavicualr and axillary regions .Bilateral pleural effusion which is marked on the right side."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/6173",
    "time": "06.06.2008"
  },
  "6261": {
    "case_id": 6261,
    "title": "Cystic fibrosis",
    "section": "Chest imaging",
    "age": "22",
    "gender": "male",
    "diagnosis": "Cystic fibrosis.",
    "history": "22-year-old male with recurrent chest infections.",
    "image_finding": "22-year-old male with recurrent chest infections. CT scan of the chest showed diffuse peribronchial wall thickening and cuffing with multifocal variable size cystic bronchiectatic changes mainly involving the perihilar regions and the upper lobes. Superadded irregular subsegmental areas of pneumonitis and scarring are seen also scattered in both lungs. Background of faint pachy ground glassopacification due to the concommitant bronchiolitis. Multiple small and medium size mediastinal and hilar lymphadenopathy.",
    "discussion": "Autosomal recessive multisystem disease characterized by mucous plugging of exocrine glands secondary to (a) dysfunction of exocrine glands forming a thick tenacious material obstructing the conducting system (b) reduced mucociliary transport. Location: Predilection for apical + posterior segments of upper lobes. \u201cFingerlike\u201d mucus plugging (mucoid impaction in dilated bronchi) withinfirst month of life subsegmental/segmental/lobar atelectasis with right upper lobe predominance (10%) progressive cylindrical/cystic bronchiectasis. Parahilar linear densities + peribronchial cuffing, hilar adenopathy large pulmonary arteries (pulmonary arterial hypertension) recurrent local pneumonitis. Allergic bronchopulmonary aspergillosis. Interstitial cysts in 32%.",
    "differential_diagnosis": "Cystic, fibrosis.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006261/000001.jpg?itok=GIQW1yyg",
            "caption": "CT scan of the chest showed diffuse peribronchial wall thickening and cuffing with multifocal variable size cystic bronchiectatic changes mainly involving the perihilar regions and the upper lobes. Superadded irregular subsegmental areas of pneumonitis and scarring are seen also scattered in both lungs. Background of faint patchy ground glass opacification due to the concommitant bronchiolitis. Multiple small and medium size mediastinal and hilar  lymphadenopathy"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006261/000002.jpg?itok=Nq2AoIhQ",
            "caption": "CT scan of the chest showed diffuse peribronchial wall thickening and cuffing with multifocal variable size cystic bronchiectatic changes mainly involving the perihilar regions and the upper lobes. Superadded irregular subsegmental areas of pneumonitis and scarring are seen also scattered in both lungs. Background of faint patchy ground glass opacification due to the concommitant bronchiolitis. Multiple small and medium size mediastinal and hilar  lymphadenopathy"
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006261/000003.jpg?itok=FkuWMMrs",
            "caption": "CT scan of the chest showed diffuse peribronchial wall thickening and cuffing with multifocal variable size cystic bronchiectatic changes mainly involving the perihilar regions and the upper lobes. Superadded irregular subsegmental areas of pneumonitis and scarring are seen also scattered in both lungs. Background of faint patchy ground glass opacification due to the concommitant bronchiolitis. Multiple small and medium size mediastinal and hilar  lymphadenopathy"
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006261/000004.jpg?itok=2l3FiaBM",
            "caption": "CT scan of the chest showed diffuse peribronchial wall thickening and cuffing with multifocal variable size cystic bronchiectatic changes mainly involving the perihilar regions and the upper lobes. Superadded irregular subsegmental areas of pneumonitis and scarring are seen also scattered in both lungs. Background of faint patchy ground glass opacification due to the concommitant bronchiolitis. Multiple small and medium size mediastinal and hilar  lymphadenopathy"
          },
          {
            "number": "Figure 1e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006261/000005.jpg?itok=sDtB9hEZ",
            "caption": "CT scan of the chest showed diffuse peribronchial wall thickening and cuffing with multifocal variable size cystic bronchiectatic changes mainly involving the perihilar regions and the upper lobes. Superadded irregular subsegmental areas of pneumonitis and scarring are seen also scattered in both lungs. Background of faint patchy ground glass opacification due to the concommitant bronchiolitis. Multiple small and medium size mediastinal and hilar  lymphadenopathy"
          },
          {
            "number": "Figure 1f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006261/000006.jpg?itok=Lzvtr4bY",
            "caption": "CT scan of the chest showed diffuse peribronchial wall thickening and cuffing with multifocal variable size cystic bronchiectatic changes mainly involving the perihilar regions and the upper lobes. Superadded irregular subsegmental areas of pneumonitis and scarring are seen also scattered in both lungs. Background of faint patchy ground glass opacification due to the concommitant bronchiolitis. Multiple small and medium size mediastinal and hilar  lymphadenopathy"
          },
          {
            "number": "Figure 1g",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006261/000007.jpg?itok=MUKwds3d",
            "caption": "CT scan of the chest showed diffuse peribronchial wall thickening and cuffing with multifocal variable size cystic bronchiectatic changes mainly involving the perihilar regions and the upper lobes. Superadded irregular subsegmental areas of pneumonitis and scarring are seen also scattered in both lungs. Background of faint patchy ground glass opacification due to the concommitant bronchiolitis. Multiple small and medium size mediastinal and hilar  lymphadenopathy"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/6261",
    "time": "26.03.2008"
  },
  "6286": {
    "case_id": 6286,
    "title": "Pulmonary alveolar microlithiasis",
    "section": "Chest imaging",
    "age": "29",
    "gender": "male",
    "diagnosis": "Pulmonary alveolar microlithiasis.",
    "history": "A 29-year-old young man, without complaints, was submitted to a routine chest radiogram.",
    "image_finding": "A 29-year-old young man, without complaints, was submitted to a routine chest radiogram, which showed multiple calcific micronodules scattered throughout the lungs, more numerous in the lower lobes, with obliteration of the heart borders. High resolution computed tomography demonstrated innumerable, very small calcifications, diffusely distributed throughout both lung fields, especially in thelower lobes, with a subpleural and peribronchovascular predominance. Interlobular septal thickening was also present. Ground glass opacification was visible in the middle lobe and lingula. Small areas of emphysema in the peripheral lung account for the black pleural line. The diagnosis of pulmonary alveolar microlithiasis was established and confirmed by transthoracic lung biopsy.",
    "discussion": "Pulmonary alveolar microlithiasis is a rare condition of unknown pathogenesis characterized by widespread intraalveolar calcifications of both lungs. These calcifications represents 0.01-3mm tiny stones or calcipherites [3, 4]. Patients generally present between the ages of 30 to 50 years, although pediatric cases have been reported. There is a strong family history. Most patients are asymptomaticat the time of diagnosis, with the disease incidentally detected on chest radiographs obtained for other reasons. However, the disease is slowly progressive and there is a tendency for pulmonary fibrosis and cor pulmonale. Patients have normal serum calcium and phosphorus levels. There is no treatment. Chest radiogram shows characteristic findings. Alveolar microlithiasis typically appears as fine, sandlike calcific micronodules (<1mm) scattered throughout the lungs. There is a predominantly symmetric middle and lower lobe involvement. If the micronodules are limited in number they predominate in a subpleural location. When myriad, they become confluent, very dense, obliterating the heart borders and the diaphragm. The heart may appear relatively lucent, when the lungs are very dense. A stripe of relative lucency at the pleural surface, the so-called black pleural line, can also be present. It represents small subpleural areas of emphysema. Overpenetrated films may be necessary to demonstrate the calcifications. High resolution computed tomography demonstrates diffuse, ground-glass increased opacification throughout the lungs. The calcifications are more numerous and dense along the bronchovascular bundles and in the subpleural regions. They can be seen in a perilobular and centrilobular distribution or associated with interlobular septa. The disease may be associated with intraparenchymal cyst or paraseptal emphysema (the black pleural line).",
    "differential_diagnosis": "Pulmonary, alveolar, microlithiasis.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006286/000001.JPG?itok=Ce1mmxjg",
            "caption": "PA chest radiogram: Multiple calcific micronodules scattered throughout the lungs, more numerous in the lower lobes, with obliteration of the heart borders."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006286/000002.jpg?itok=g2S9ExCd",
            "caption": "High resolution CT of the lung (soft tissues window): Innumerable, very small calcifications, diffusely distributed throughout both lung fields, specially in the lower lobes, with a subpleural and peribronchovascular predominance."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006286/000003.jpg?itok=Qz0rStMp",
            "caption": "High resolution CT of the lung (soft tissues window): Innumerable, very small calcifications, diffusely distributed throughout both lung fields, specially in the lower lobes, with a subpleural and peribronchovascular predominance."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006286/000004.jpg?itok=s7tMbAYw",
            "caption": "High resolution CT of the lung (lung window): Innumerable, very small calcifications, diffusely distributed throughout both lung fields, specially in the lower lobes, with a subpleural and peribronchovascular predominance."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006286/000005.jpg?itok=rYAztmnj",
            "caption": "High resolution CT of the lung (lung window): Innumerable, very small calcifications, diffusely distributed throughout both lung fields, specially in the lower lobes, with a subpleural and peribronchovascular predominance."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/6286",
    "time": "24.09.2008"
  },
  "6303": {
    "case_id": 6303,
    "title": "Incidental detection of mediastinal tumour in an elderly patient",
    "section": "Chest imaging",
    "age": "95",
    "gender": "female",
    "diagnosis": "Asymptomatic mediastinal lipoma in an Elderly woman.",
    "history": "A 95-year-old woman presented with intermittent diarrhoea of 4 months duration. A chest x ray was ordered as a part of routine investigation which showed a widened mediastinum. CT scan of the chest\ndemonstrated a mediastinal lipoma. She was totally asymptomatic from it. .",
    "image_finding": "An otherwise healthy 95-year-old woman presented with intermittent diarrhoea of 4 months duration. A chest x ray was performed as part of her routine investigation on the acute admissions unit. This\nshowed a widened mediastinum although the patient denied any thoracic symptoms. A CT scan of the chest was requested to characterize the abnormality. CT chest showed large fatty superior mediastinal\nmass lesion extending from the thoracic inlet down to the level of the carina containing one or two fibrous septa with appearances consistent with a mediastinal lipoma. The aorta was markedly\natheromatous and ectatic, particularly in its descending thoracic portion. No focal active lung lesion was evident. No finding of any relevance was noted in the upper abdomen. As the patient was\nasymptomatic nothing was done about the mediastinal lipoma. The patient\u2019s diarrhoea improved during her stay in hospital and stool examination results did not show anything significant. She was\ndischarged after 10 days.",
    "discussion": "Mediastinal lipomas are rare. They comprise less than 1% of all mediastinal tumours [1]. They arise from the fetal embryonal white fat. The tumour can cause recurrent chest infection, dyspnoea,\n  respiratory distress, or even asphyxia, due to compression on trachea or bronchi [2]. On the contrary it may be totally asymptomatic and incidentally detected as in our patient. Initial diagnosis\n  may be by chest x ray showing an enlarged mediastinum as in this patient. X ray might also occasionally show a clear peripheral zone present around the tumour which is called Huer' sign [3]. X ray\n  chest is not generally adequate to make the diagnosis. A CT scan of the chest gives further information with regards to the size, extension and character of the mass and is almost always required\n  following a suspicion of mediastinal tumour. Mediastinal lipoma on CT scan appears as homogenous mass with a tissue density consistent with fat. The differential diagnosis of mediastinal fatty\n  turnours includes lipoma, liposarcoma, thymolipoma, and herniated peritoneal fat (hiatus or diaphragmatic hernia) [1]. Lipoma is a well circumscribed and well encapsulated tumour on gross\n  pathology. Needle biopsy might aid the diagnosis but it is often difficult to differentiate lipoma from liposarcoma. The two most common appearances of lipoma are a well defined fatty mass and\n  circumscribed soft tissue lesions embedded within large masses of fatty tissues. Variable proportions of mature adipocytes within lobules and immature peripherally situated lipoblasts, fibrous\n  septa and myxoid tissues are consistent findings on histology [2]. Even if, as above, findings are very suggestive of lipoma, the definitive diagnosis is established at surgery, which is curative\n  [4]. Surgery is only required in symptomatic cases. In our patient, the lipoma was asymptomatic, therefore it was left alone. Although the lesion is considered as biologically benign, it can grow\n  locally to an impressive proportion and lead to a significant mass effect. Death may result if expedient surgical removal is not undertaken. Under these circumstances, complete surgical excision is\n  the treatment of choice [3]. Local recurrences are reported in 14% to 25% of the lipoblastoma and lipoblastomatosis cases and these have been attributed to an incomplete excision [2].",
    "differential_diagnosis": "Asymptomatic, mediastinal, lipoma, in, an, Elderly, woman.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006303/000001.jpg?itok=UwydRTCl",
            "caption": ""
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006303/000002.jpg?itok=mtW-FJ6k",
            "caption": ""
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006303/000003.jpg?itok=EDKKZmcz",
            "caption": ""
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006303/000005.jpg?itok=cVOb2E2J",
            "caption": ""
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006303/000006.jpg?itok=nSLg3R5k",
            "caption": ""
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006303/000007.jpg?itok=h3wu7wn1",
            "caption": ""
          }
        ]
      },
      {
        "number": "Figure 7",
        "subfigures": [
          {
            "number": "Figure 7",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006303/000008.jpg?itok=OjjGLqy4",
            "caption": ""
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/6303",
    "time": "26.08.2008"
  },
  "6306": {
    "case_id": 6306,
    "title": "Paroxysmal nocturnal haemoglobinuria presenting with pulmonary haemorrhage",
    "section": "Chest imaging",
    "age": "59",
    "gender": "male",
    "diagnosis": "Laboratory proven PAROXYSMAL NOCTURNAL HAEMOGLOBINURIA presenting with pulmonary hemorrhage.",
    "history": "59-year-old male presented with generalized weakness, dyspnea and palor with recent onset of haemoptysis in addition to signs of renal failure.",
    "image_finding": "A 59-year-old male presented with generalized weakness, dyspnea and palor with recent onset of haemoptysis in addition to signs of renal failure. Radiological findings: HRCT Findings :- Fluffy patchy\n& confluent faint ill-defined ground glass opacification is seen involving both lungs more towards the central portions & lung bases with relative sparing of lung periphery. Most of these\nopacities are peribronchovascular in distribution, features suggestive of pulmonary haemorrhage. - Background of diffuse hyperinflation with diffuse peribronchial wall thickening and patchy\nemphysematous changes indicative of signs of COPD. - A localized area of scarring is noted in the LUL, otherwise no focal mass or consolidation. - No pleural effusion. - Tiny reactive mediastinal\nadenopathy. - U/S showed small kidneys with increased parenchymal echogenicity & poor cortico-sinus diffentiation.",
    "discussion": "Paroxymal Noctunal Haemoglobinuria is a rare acquired disorder of nonmalignant hematopoietic stem cells. Causes: infection, transfusion, radiographic contrast material, exercise, drugs, immunization,\nsurgery. Pathophysiology: destruction of abnormally sensitive RBCs, granulocytes and platelets by activated complement; complement activation of abnormal platelets and release of thrombogenic\nmaterial from lysed RBCs. Clinical and radiological features: Hemoglobinuria: In most patients with PNH, hemoglobinuria occurs irregularly. Bouts of hemolysis may be initiated by infections, surgery\nand possibly even strenuous excercise. The injection of contrast media may precipitate hemolysis by activating complement. Chronic Haemolysis: Patients with PNH manifest all clinical and laboratory\nsigns of chronic haemolytic anemia. Weakness, dyspnea and palor are common. Splenomegaly is present in some patients, but enlargement of the spleen is usually quite modest. Iron Deficiency: Iron\ndeficiency is a common manifestation of PNH because of iron loss in the urine. Bleeding: Thrombocytopenia may be very severe and extensive haemorrhagic complications may be part of the clinical\npresentation and we tried to highlight this association of PNH and pulmonary haemorrhage in our case. Thrombosis: The reason for this is not entirely clear, but it may be related to activation of\nplatelets by complement or to the intravascular release of ADP from red cells, leading to platelet aggregation. The Budd Chiari syndrome has been observed repeatedly. Pulmonary hypertension has been\nattributed to widespread thromboses in the pulmonary microvasculature. Both arterial and venous thromboses have been reported. Renal manifestations: abnormal tubular and declining creatinine\nclearance are common features. Acute and chronic renal failure may occur. Neurologic Manifestations:Severe headaches or pains in the eyes occur in patients with PNH. These complications may be due to\nsmall venous occlusions. MR: low signal intensity of renal cortex on T1W1 and T2W1 due to hemosiderin deposition in proximal convoluted tubules (secondary to intravascular hemolysis). Usually\ndecreased iron concentration in liver and spleen unless transfusions are given (Differential diagnosis to other hemolytic anaemias). Diagnosis rests on the clinical picture and clinical laboratory\nmeasurement of a population of circulating cells with unusual sensitivity to complement mediated lysis. This may be demonstrated in the sugar water test; the patient's serum is mixed with 5% dextrose\nin water and incubated with the patient's cells. In PNH, haemolysis ensues. In Ham\u2019s test, patient's cells are incubated in acidified serum. Under these condition the alternative complement\npathway is triggered, and lysis of PNH, but not normal, cells follows. Prognosis: venous thrombosis is a major cause of death.Ross L.Titton et al,2002 ,have discussed the occurence of pulmonary\nembolism with PNH with no much stress regarding it's association with pulmonary haemorrhage,a point which we tried to clarify in our current article.",
    "differential_diagnosis": "Laboratory, proven, PAROXYSMAL, NOCTURNAL, HAEMOGLOBINURIA, presenting, with, pulmonary, hemorrhage.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006306/000001.jpg?itok=pPTofzwT",
            "caption": "Fluffy patchy &amp; confluent faint ill-defined ground glass \nopacification is seen involving both lungs  .  Most of these opacities are peribronchovascular in distribution, features suggestive of pulmonary haemorrhage."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006306/000002.jpg?itok=ZDDfr8Zs",
            "caption": "-\tFluffy patchy &amp; confluent faint ill-defined ground glass \nopacification is seen involving both lungs more towards the central portions &amp; lung bases with relative sparring of lung periphery .  Most of these opacities are peribronchovascular in distribution, features suggestive of pulmonary haemorrhage. \n-\tBackground of diffuse hyperinflation with diffuse peribronchial wall thickening and patchy emphysematous changes indicative of signs of COPD."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006306/000003.jpg?itok=UESfH5HY",
            "caption": "-\tFluffy patchy &amp; confluent faint ill-defined ground glass \nopacification is seen involving both lungs more towards the central portions &amp; lung bases with relative sparring of lung periphery .  Most of these opacities are peribronchovascular in distribution, features suggestive of pulmonary haemorrhage. \n-\tBackground of diffuse hyperinflation with diffuse peribronchial wall thickening and patchy emphysematous changes indicative of signs of COPD.\n-\tA localized area of scar is noted in the LUL, otherwise no focal mass or consolidation."
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006306/000004.jpg?itok=lsuNGTYS",
            "caption": "-\tFluffy patchy &amp; confluent faint ill-defined ground glass \nopacification is seen involving both lungs more towards the central portions &amp; lung bases with relative sparring of lung periphery .  Most of these opacities are peribronchovascular in distribution, features suggestive of pulmonary haemorrhage. \n-\tBackground of diffuse hyperinflation with diffuse peribronchial wall thickening and patchy emphysematous changes indicative of signs of COPD."
          },
          {
            "number": "Figure 1e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006306/000005.jpg?itok=yu38SCNl",
            "caption": "-\tFluffy patchy &amp; confluent faint ill-defined ground glass \nopacification is seen involving both lungs more towards the central portions &amp; lung bases with relative sparring of lung periphery .  Most of these opacities are peribronchovascular in distribution, features suggestive of pulmonary haemorrhage. \n-\tBackground of diffuse hyperinflation with diffuse peribronchial wall thickening and patchy emphysematous changes indicative of signs of COPD."
          },
          {
            "number": "Figure 1f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006306/000006.jpg?itok=e_AfVZT_",
            "caption": "-\tFluffy patchy &amp; confluent faint ill-defined ground glass \nopacification is seen involving both lungs more towards the central portions &amp; lung bases with relative sparring of lung periphery .  Most of these opacities are peribronchovascular in distribution, features suggestive of pulmonary haemorrhage. \n-\tBackground of diffuse hyperinflation with diffuse peribronchial wall thickening and patchy emphysematous changes indicative of signs of COPD."
          },
          {
            "number": "Figure 1g",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006306/000007.jpg?itok=OpV03ml7",
            "caption": "-\tFluffy patchy &amp; confluent faint ill-defined ground glass \nopacification is seen involving both lungs more towards the central portions &amp; lung bases with relative sparring of lung periphery .  Most of these opacities are peribronchovascular in distribution, features suggestive of pulmonary haemorrhage. \n-\tBackground of diffuse hyperinflation with diffuse peribronchial wall thickening and patchy emphysematous changes indicative of signs of COPD."
          },
          {
            "number": "Figure 1h",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006306/000008.jpg?itok=-5NwnMNM",
            "caption": "Tiny reactive mediastinal adenopathy."
          },
          {
            "number": "Figure 1i",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006306/000011.jpg?itok=ZTzyaY-J",
            "caption": "Fluffy patchy &amp; confluent faint ill-defined ground glass \nopacification is seen involving both lungs more towards the central portions &amp; lung bases with relative sparring of lung periphery .  Most of these opacities are peribronchovascular in distribution, features suggestive of pulmonary haemorrhage. \n-\tBackground of diffuse hyperinflation with diffuse peribronchial wall thickening and patchy emphysematous changes indicative of signs of COPD."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/6306",
    "time": "26.02.2008"
  },
  "6311": {
    "case_id": 6311,
    "title": "Recurrent solitary fibrous tumour of the ple",
    "section": "Chest imaging",
    "age": "66",
    "gender": "female",
    "diagnosis": "Recurrence of solitary fibrous tumour of the pleura",
    "history": "A 66-year-old patient was found to have a mass on CXR which was further investigated by CT and MRI. The histological diagnosis of solitary fibrous tumour was confirmed after surgical resection. Follow-up chest radiograph and CT indicated recurrence of the tumour. Long term follow up is indicated in all patients.",
    "image_finding": "A 66-year-old female presented with a chest infection in March 2005. She had a past history of carcinoma of the colon for which she had bowel resection in 1998. At the time of current admission the tumour marker CEA was not elevated. On CXR she was found to have a large mass in the right hemithorax (Fig 1). On CT scan, a heterogeneous mass was seen, which measured 16 cm in maximal dimension (Fig 2). There was no evidence of chest wall invasion. No evidence of lymph node or liver metastases was seen. MR of the chest was performed to assess the chest wall invasion (Fig 3) which showed a 17cm x 6.6cm x12 cm solid lesion in the right pleural space, with no evidence of invasion of chest wall. A CT guided biopsy of the mass showed a possible sarcoma. But surgical resection of the tumour in August 2005 confirmed a solitary fibrous tumour of the pleura. On histology there was considerable pleomorphism with frequent mitoses and necrosis. The features were suggestive of aggressive behaviour of the tumour with increased risk of recurrence. On follow up CXR (Fig 4) in 2006 a 4 cm nodule projecting over the right hilum was shown . On CT scan of the thorax (Fig 5), there was a 4.2 cm mass in theright lung upper lobe. This was associated with marked anterior mediastinal lymphadenopathy. There were four further lung nodules seen in the left upper lobe. CEA was within normal range. She is currently considered for chemotherapy.",
    "discussion": "Solitary fibrous tumours (SFT) are rare tumours frequently diagnosed as an incidental finding on a routine CXR or for evaluation of an unrelated disease. These tumours usually arise from the visceral pleura with a lesser percentage (20-40%) arise from the parietal pleura. SFT has also been described in other sites such as upper and lower respiratory tract, orbit, salivary glands, liver, breast,soft tissues, peritoneal cavity, retroperitoneum, thyroid, meninges and heart. SFT tends to affect mainly adults during the sixth and seventh decades of life. Respiratory symptoms like cough, dyspnoea, pleuritic pain and hemoptysis can present in one third of patients. Extrathoracic manifestations are more often associated with large tumours, include osteoarthropathy, clubbing and infrequently hypoglycaemia. Hypoglycemia occurs due to tumour secretion of an insulin-like growth factor. The main differentials to consider include malignant mesothelioma and metastatic pulmonary carcinoma. Histopathologically malignant peripheral nerve sheath tumour, mesothelioma, sarcomatoid carcinoma, synovial sarcoma, hemangiopericytoma and fibrosarcoma are important considerations.Solitary fibrous tumour of the pleura is usually a benign neoplasm and surgical resection is curative and remains the treatment of choice. However on histology features of malignancy should be looked for including high cellularity (> 4 mitotic figures per 10 HPF), pleomorphism, haemorrhage and necrosis. Clinical and radiological follow up is recommended in all cases as recurrence can occur.",
    "differential_diagnosis": "Recurrence, of, solitary, fibrous, tumour, of, the, pleura",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006311/000001.jpg?itok=PCzwBTvf",
            "caption": "Large right lower zone mass"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006311/000002.jpg?itok=8gHZh5xR",
            "caption": "Heterogenous mass in the right hemithorax"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006311/000003.jpg?itok=jJrXb9SW",
            "caption": "Coronal T1W MR image of the thorax showing a large mass with heterogenous signal in the right hemi thorax"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006311/000004.jpg?itok=CD-mGLzG",
            "caption": "Follow up chest radiograph shows a mass projected over the right hilum"
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006311/000005.jpg?itok=9IhjM9PN",
            "caption": "Recurrence of tumour in right hemi thorax"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/6311",
    "time": "26.03.2008"
  },
  "6312": {
    "case_id": 6312,
    "title": "The management of Streptococcus pneumonia and multiple pulmonary emboli in a pregnant woman",
    "section": "Chest imaging",
    "age": "35",
    "gender": "female",
    "diagnosis": "Streptococcus pneumonia and multiple pulmonary emboli",
    "history": "This 35-year-old pregnant woman developed streptococcus pneumonia on a background of multiple pulmonary emboli and required high dependency care with specialist obstetric input throughout.",
    "image_finding": "This 35-year-old lady in the 24th week of gestation presented with a 2 day history of pleuritic chest pain and dyspnoea. Her past medical history included two previous pulmonary emboli for which she\nwas receiving dalteparin throughout her pregnancy. On clinical examination she was apyrexial but tachypnoeic with no crackles on auscultation. The initial chest x-ray was normal. A\nventilation/perfusion scan showed segmental and subsegmental filling defects consistent with a pulmonary embolism. Thus she was commenced on appropriate therapeutic dalterparin. The following day she\nbecame acutely unwell, pyrexial and on chest auscultation right sided crackles were elicited. After much discussion a repeat chest x-ray was requested and showed a severe right upper lobe pneumonia,\nwhich was later identified as Streptococcus pneumoniae on blood cultures. Consequently she was commenced on intravenous ceftriazone and was managed on the high dependency unit with noradrenaline\nsupport for septic shock. After one day she was transferred back to the respiratory ward with joint obstetric support for foetal monitoring throughout her acute illness. She recovered quickly and was\ndischarged three days later with ongoing obstetric input for the rest of her pregnancy.",
    "discussion": "In a pregnant patient pneumonia is the most common fatal non-obstetric infection [i]. Due to the physiological demands placed on the mother and foetus during illness a severe community acquired\ninfection can be detrimental. An approximate incidence has been reported as 1.2-1.7 per 1000 deliveries in UK [ii]. PHYSIOLOGICAL CHANGES IN PREGNANCY: An enlarging uterus causes elevation of the\ndiaphragm and splaying of the thoracic cage. These changes combined with an increased oxygen consumption can significantly affect the mother\u2019s ability to clear respiratory infections. In\naddition, gastro-oesophageal sphincter relaxation and delayed gastric emptying increases the risk of aspiration. On an immunological level, pregnancy is associated with a decrease in NK cells and T\ncells which in turn compromise the maternal immune system [iii]. Cell-mediated immune function is also impaired by progesterone, human chorionic gonadotrophin, and alpha fetoprotein [iv]. FOETAL\nOUTCOME: There is well documented evidence that mothers with pneumonia deliver before 34 weeks gestation [v]. In addition the birth weight of babies born to mothers with pneumonia can be\nsignificantly less. One study identified a difference of 150g in babies born compared with the control group [vi]. RISK FACTORS: Maternal smoking is a recognised risk factor, which has a dose\ndependent relationship in terms of occurrence and severity of pneumonia. One study highlighted that approximately 30% of maternal pneumonia patients are in fact smokers [vii]. Mothers with asthma,\nanaemia or recurrent pulmonary emboli are also at an increased risk of developing infective complications and should therefore be more closely monitored. CLINICAL PRESENTATION: Patients usually\npresent with fever, cough productive of purulent sputum, dyspnoea, and pleuritic chest pain. However difficulties in achieving an initial diagnosis is often found as clinicians may find it difficult\nto separate physiological changes of pregnancy and underlying disease processes as highlighted by this case. Chest x-ray is a mandatory investigation when pneumonia is queried, however concerns can\nbe raised regarding radiation dosage. One single (PA) chest x-ray gives a low radiation dose of 0.02 mSv. However, a typical Computed Tomography (CT) scan of the chest is equivalent to 400 chest\nx-rays and therefore a Computed Tomography-Pulmonary Angiography (CTPA) scan would not be advised during pregnancy[viii]. PATHOLOGY: Streptococcus pneumoniae is the most common organism identified,\nfollowed by Haemophilus influenzae and Legionella pneumobilia. Pneumocystis carinii pneumonia (PCP) in HIV patients has been associated with significant maternal mortality. Failure to treat HIV with\nantiretroviral agents may impact on maternal PCP rates and further research is clearly needed [ix]. TREATMENT: It is essential to balance the risks of antibiotics in pregnancy against the risks of\nnot adequately treating pneumonia, however no antibiotic is actually licensed for use in pregnancy [x]. Penicillins, macrolides and cephalosporins are the commonest used antibiotics in the treatment\nof community-acquired pneumonia in pregnancy and these have been associated with the least number of side effects. In summary, where there is coexisting respiratory compromise, such as pulmonary\nembolism in this case, specialist obstetric care is critical in order to reduce mortality from maternal community-acquired pneumonia.",
    "differential_diagnosis": "Streptococcus, pneumonia, and, multiple, pulmonary, emboli",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006312/000004.png?itok=bME3_ZsW",
            "caption": "right upper zone consolidation"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/6312",
    "time": "09.06.2008"
  },
  "6314": {
    "case_id": 6314,
    "title": "FB Bronchus",
    "section": "Chest imaging",
    "age": "66",
    "gender": "male",
    "diagnosis": "Occult foreign body aspiration.",
    "history": "66-year-old man presented with a foreign body (Blom-Singer Valve) in the right lower lobe bronchus which went undetected for 4 years.",
    "image_finding": "This 66-year-old man presented with weight loss and cholestatic jaundice. He had previously undergone a laryngectomy in May 2003 for a squamous cell carcinoma of his larynx. A CT Chest was performed\nin 2003 (Figure 1). In view of this history and the suspicion that he may have a recurrence of his malignancy he underwent a repeat CT scan of chest abdomen and pelvis in June 2007. No evidence of\nmalignancy was seen, however a high attenuation structure was seen in the right lower lobe bronchus. This looked like a foreign body (Figures 2, 3, 4 & 5). Review of his chest radiograph on\nadmission to hospital confirmed that a foreign body was visible at the right hilum (Figure 6). Upon reviewing the history the patient had a tracheostomy since his surgery and initially had a\nBlom-Singer valve inserted to help with phonation. According to the patient the valve fell out at home some weeks after its insertion and he did not wish for it to be replaced. During the intervening\nfour years he did not report any chest symptoms. In view of the findings on his CT chest a fibre optic bronchoscopy was performed and a white valve-like object was visualized in the right lower lobe\nbronchus (Figure 7 & 8). This was removed quite easily using forceps (Figure 9). The bronchial tree appeared normal distal to the foreign body.",
    "discussion": "Inhaled foreign bodies are a common phenomenon. The overall tendency is for the foreign body to enter the more vertically orientated right main bronchus (1). A large variety of aspirated foreign\nbodies have been described including pins, needles, jewellery, thermometers, pencils and metallic and plastic toys (2). Radiographic appearances of foreign body in the acute setting include secondary\nfindings of air trapping and or atelectasis (3). Bronchiectasis and Bronchial stenoses are well-recognised late complications (4). However, this particular case was quite atypical. The patient did\nnot suffer any clinical symptoms following aspiration and none of the typical radiological appearances are seen on chest X-ray (though the foreign body is seen on close inspection). We would\nhypothesise that the design of the valve with a patent lumen and the longitudinal alignment within the right lower lobe bronchus led to a clinically occult foreign body aspiration. It was only\nthrough discussion with the patient's Physician and careful history taking that the findings on CT could be explained. Bronchoscopy confirmed the nature of the foreign body.",
    "differential_diagnosis": "Occult, foreign, body, aspiration.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006314/000006.JPG?itok=uiOihK9v",
            "caption": "View on fibre optic bronchoscopy. Note the patent lumen."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006314/000008.jpg?itok=qgQI_PeF",
            "caption": "CT chest 2003. Correlation with axial image 2007 reveals no foreign body at this time."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006314/000009.JPG?itok=axF9GShn",
            "caption": "Magnified chest xray showing foreign body at the right hilum."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006314/000010.jpg?itok=Md3wDJib",
            "caption": "Axial CT Chest demonstrating foreign body right lower lobe bronchus."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006314/000011.jpg?itok=nFN7d4oe",
            "caption": "Coronal CT Chest depicts the anatomical location of the foreign body."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006314/000012.JPG?itok=wuJ4SZVE",
            "caption": "View on fibre optic bronchoscopy."
          }
        ]
      },
      {
        "number": "Figure 7",
        "subfigures": [
          {
            "number": "Figure 7",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006314/000015.jpg?itok=UheJ5_dE",
            "caption": "Axial CT on lung windows demonstrates normal appearing lung parenchyma distal to the foreign body."
          }
        ]
      },
      {
        "number": "Figure 8",
        "subfigures": [
          {
            "number": "Figure 8",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006314/000016.jpg?itok=w2PZBmLC",
            "caption": "Coronal CT on lung windows demonstrates normal lung parenchyma distal to the foreign body."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/6314",
    "time": "26.03.2008"
  },
  "6346": {
    "case_id": 6346,
    "title": "MAC-induced granulomatous pneumonitis or \u201cHot tub lung\u201d",
    "section": "Chest imaging",
    "age": "45",
    "gender": "male",
    "diagnosis": "MAC-induced granulomatous pneumonitis or \u201cHot tub lung\u201d.",
    "history": "A 45-year-old male engineer presented symptoms of cough, fever and dyspnoea within hours after exposure to hot tub water. He had no history of pre-existing pulmonary disorder, no cigarette smoking\nand minimal alcohol use.",
    "image_finding": "A 45-year-old immunocompetent man developed symptoms of cough, fever and dyspnoea within hours after using his Jacuzzi. Before the onset of these complaints he was completely healthy and had no\nhistory of pre-existing pulmonary disorder. Inspiratory thin section HRCT scans of 1mm, cellular analyses of the bronchoalveolar lavage fluid (BALF), histological scans and water specimens were\nobtained. HRCT showed areas of bilateral ground-glass opacities with diffuse micronodular appearance, mosaic perfusion, hilar and mediastinal adenopathy.",
    "discussion": "Atypical mycobacteria offer a variety of clinicopathological presentations in the chest. Mycobacterium avium complex (MAC), which is a combination of Mycobacterium avium and Mycobacterium\nintracellularae, is the most common of the pathogens and commonly found in natural and tub water. Warm temperatures promote the growth of MAC. The classic MAC infection typically occurs in patients\nwith acquired immunodeficiency syndrome or older patients with underlying chronic lung disease (eg. bronchiectasis). The non-classic MAC infection typically occurs in elderly women without any\npredisposing factors. Several recent articles report granulomatous pneumonitis with hypersensitivity reactions after exposure to MAC contaminated water. This granulomatous pneumonitis is called\n\u201cHot tub lung\u201d. The pathogenesis of \u201cHot tub lung\u201d is poorly understood. Maybe MAC is processed by pulmonary macrophages to T lymphocytes, because of their clonal\nproliferation and expansion, the result of the immunological response is the formation of granulomas. The gold standard for diagnosis of \u201cHot tub lung\u201d is the presence of bronchoalveolar\nlavage fluid (BALF) with lymphocyte predominance and typical HRCT findings like ground glass opacities and nodules. In the current case HRCT showed areas of bilateral ground-glass opacities with\ndiffuse micronodular appearance, mosaic perfusion and hilar and mediastinal adenopathy. Cellular analysis of the bronchoalveolar lavage fluid (BALF) revealed a lymphocytic alveolitis with an elevated\nCD4/CD8 ratio of 2.9. Transbronchial biopsy showed multiple well-formed non necrotizing granulomas and hypersensitivity testing was weakly positive for Aspergillus fumigatus, but PCRs for MAC were\nnegative. The patient was diagnosed as hypersensitivity pneumonitis towards Aspergillus fumigatus and treated with systemic corticosteroids for 3 months, with pulmonary function test (PFT) and\nCT-scan improving markedly. He was advised to check his home for aspergillus and reported there was none. Six months later he suffered a relapse after using his Jacuzzi. Specimens now taken from the\nhot tub were positive for MAC. At this point, it was thought that the patient had hypersensitivity-like pneumonitis, possibly related to MAC from the hot tub spa. The patient was instructed to avoid\nhis hot tub. Thereafter he showed complete resolution of the radiographic and pulmonary function abnormalities, and is currently symptom free. Evidence favouring a hypersensitivity-like reaction\nincludes rapid onset of symptoms (4-6h) after exposure to the hot tub and improvement after discontinuation of hot tub use. The elevated CD4/CD8 ratio seen in the BALF in \u201cHot tub lung\u201d\nis not typical for hypersensitivity-like pneumonitis. Histological and radiological features might suggest a diagnosis of hypersensitivity-like pneumonitis but radiologists should not ignore the\npossibility of MAC-induced granulomatous pneumonitis or \u201cHot tub Lung\u201d.",
    "differential_diagnosis": "MAC-induced, granulomatous, pneumonitis, or, \u201cHot, tub, lung\u201d.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006346/000001.jpg?itok=cB6Yef2P",
            "caption": "This axial HRCT image shows areas of diffuse bilateral ground glass opacities and mediastinal adenopathy at the time of acute exacerbation."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006346/000002.jpg?itok=JAZSEbHs",
            "caption": "This axial HRCT image demonstrates micronodular appearance."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006346/000003.jpg?itok=JO5vqFMl",
            "caption": "Axial HRCT image showing ground glass opacities with mosaic perfusion."
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006346/000004.jpg?itok=sKJnLed6",
            "caption": "This image at the aortic arch illustrates mediastinal adenopathy."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/6346",
    "time": "25.02.2008"
  },
  "6347": {
    "case_id": 6347,
    "title": "High innominate artery bifurcation",
    "section": "Chest imaging",
    "age": "61",
    "gender": "female",
    "diagnosis": "High innominate artery bifurcation.",
    "history": "A 61-year-old patient with a 45-mm wide ascending aorta measured by cardiac echocardiography underwent a chest computed tomography (CT) examination.",
    "image_finding": "The patient was referred to our centre for assessment of the thoracic aorta after cardiac echocardiography had revealed a mild aortic dilatation (45 mm) at the ascending level. Her clinical history\nwas unremarkable except for hypertension and persistent superficial pulsation anteriorly at the neck base. Chest CT angiography (CTA) showed the presence of a long innominate artery (IA) travelling\nanteriorly to the trachea for 52 mm from its aortic origin and then crossing rightward and posteriorly with an aberrant high bifurcation located about 1 cm below the right thyroid lobe (fig. 1). In\naddition, the left vertebral artery arose autonomously from the aortic arch (fig. 2).",
    "discussion": "A high bifurcation of the IA is an extremely rare occurrence, with as few as five cases of IA bifurcation located up to the thyroid gland level having been reported in the literature so far. The\ndevelopmental abnormalities underlying this condition are unknown. Embryologically the great supra-aortic vessels evolve from the aortic sac and six pairs of aortic arches corresponding to the six\nbranchial arches, most of which obliterate partially or completely within the eighth week of development. A possible explanation for a high IA bifurcation might be the persistence of a longer portion\nof the proximal segment of the right fourth arch (from which the IA derives), resulting in elongation of the IA and superior displacement of the origin of the right subclavian artery. A high IA\nbifurcation can also be associated to variation in the course of the recurrent portion of the right inferior laryngeal nerve, which loops around the right subclavian artery in proximity to its\norigin. Diagnosis of a high IA bifurcation is imperative before performing neck surgery or other invasive neck interventions (such as tracheostomy) in order to avoid massive hemorrhage or recurrent\nnerve damage. Other conditions that may cause neck pulsation include a tortuous carotid artery, cervical aortic arch, a cervical origin of the right subclavian artery, as well as tumour masses\ntightly attached to or arising from neck vessels. Cross-sectional imaging techniques, such as CT and magnetic resonance imaging (MRI), have replaced conventional angiography for the assessment of\nneck vessel abnormalities, owing to their relative non-invasiveness and their ability to provide additional information about extravascular structures. Doppler ultrasonography can be advantageous in\nemergency cases, as it allows saving time and can be performed at patient's bedside.",
    "differential_diagnosis": "High, innominate, artery, bifurcation.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006347/000001.jpg?itok=Fzt7GW3U",
            "caption": "Fig. 1a. Coronal CPR showing long IA with high bifurcation."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006347/000002.jpg?itok=rKC1Kg2D",
            "caption": "Fig. 1b. Sagittal MIP image showing anterior course of the IA relative to the trachea."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006347/000003.jpg?itok=VaCQ9MIM",
            "caption": "Fig. 1c. Axial MIP image showing right posterolateral course of the distal IA prior to bifurcation. The left vertebral artery is visible on this thick section MIP image between the common left carotid artery and the left subclavian artery."
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006347/000004.jpg?itok=_7cgAkUK",
            "caption": "Fig. 1d. VR image on the coronal plane depicts the course of the IA and its anatomical relationship with the surrounding structures."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006347/000005.jpg?itok=x79ElIbp",
            "caption": "Fig. 2a. Sagittal CPR image showing aortic origin of the left vertebral artery."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006347/000006.jpg?itok=B-p7bsja",
            "caption": "Fig. 2b. Coronal CPR image showing aortic origin of the left vertebral artery."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006347/000007.jpg?itok=SWaYPl88",
            "caption": "Fig. 2c. VR image showing the course of the left vertebral artery."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/6347",
    "time": "23.05.2008"
  },
  "6374": {
    "case_id": 6374,
    "title": "Malignant Mesothelioma of the Ple",
    "section": "Chest imaging",
    "age": "63",
    "gender": "female",
    "diagnosis": "Malignant Mesothelioma of the Pleura",
    "history": "A 63-year-old woman with pleuritic chest pain.",
    "image_finding": "A 63-year-old-woman presented with right sided pleuritic chest pain. She had no history of concurrent productive cough, haemoptesis and fever. Occupational and habitual history revealed neither cigarette smoking nor asbestos exposure. At physical examination decreased breathing sound over the base of the right lung was picked up. Laboratory findings showed anaemia, but the rest of the results was normal. On chest radiographs, a homogenous well-circumscribed opacity located on the posterior aspect of the right hemithorax without any air bronchogram was identified. It had an obtuse angle especially in the inferior margin of the mass with the chest wall that was highly suggestive of an extrapulmonary mass (Fig. 1). Computed tumography (CT) imaging showed a well-demarcated soft-tissue density mass in the right hemithorax. Calcification, pleural thickening and pleural nodules were not seen. A tiny amount of pleural effusion was also identified in the same side (Fig. 2 & 3). After obtaining the informed consent she underwent biopsy for diagnosis of the mass. Histologic examination revealed pleural mesothelioma.",
    "discussion": "Malignant mesothelioma is a rare and aggressive pleural neoplasm [1-3]. The association between asbestos exposure and development of malignant mesothelioma has been strongly established however this contribution is not completely defined and some patients, like our case, have no history of exposure to asbestos. Malignant mesothelioma may be suspected on chest radiographs demonstrating irregular, nodular, peripheral pleural opacities with associated ipsilateral pleural effusion [4]. On fewer than 25% of presenting chest radiographs, a focal pleural mass without a pleural effusion is demonstrated [1]. Malignant mesothelioma on CT imaging shows widespread nodular pleural thickening with mediastinal surface involvement, encasement of the lung, and extension into the interlobar fissures [5-11]. At CT, the soft tissue density of tumor tissue can be readily distinguished from the adjacent pleural effusion, but the nodules may on occasion be so tiny that they are unrecognizable and the only CT feature is, therefore, a pleural effusion [2, 5, 8]. Calcification of the tumor is extremely rare, though reported [2, 7, 8]. The differential diagnosis includes pleural involvement by other malignant tumors, notably bronchial adenocarcinoma, breast carcinoma, malignant thymoma and lymphoma, as well as benign conditions such as asbestos-related benign pleural plaques [2]. Unless there are other features to indicate the primary tumor, the distinction between adenocarcinoma of the lung and malignant mesothelioma cannot be made radiographically from the appearance of the pleural involvement alone, which is hardly surprising in view of the difficulty that pathologists experience when trying to distinguish between these two entities [7, 8, 12, 13].Although pleural involvement by breast carcinoma can also appear identical, there is usually no diagnostic difficulty because the primary tumor will have been diagnosed previously or will be clinically obvious [2, 7, 8]. Pleural deposits of lymphoma and thymoma usually appear as more discrete localized masses than malignant mesothelioma, and the primary thymoma or other foci of lymphoma are visible or previously been documented. The distinction from benign pleural thickening due to condition such as previous tuberculosis or old hemothorax is usually readily made by noting the smoothness of the pleural shadowing in these disorders [2]. Mediastinal pleural involvement, circumferential pleural thickening, nodularity, irregularity of pleural contour, and infiltration of the chest wall and/or diaphragm are most suggestive of a malignant cause both on CT and MRI [2, 12-14]. On the other hand, pleural calcification on CT is suggestive of a benign cause. The interesting point about this patient is that this well-demarcated soft-tissue density mass in the right hemithorax, without pleural thickening and pleural nodule is a less typical feature of the malignant mesothelioma of pleura however histological examination revealed the definite diagnosis.",
    "differential_diagnosis": "Malignant, Mesothelioma, of, the, Pleura",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006374/000001.jpg?itok=i---9Aan",
            "caption": "shows the opacity as a homogenous mass in the posterior aspect of the right hemithorax that has an obtuse angle with the chest wall."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006374/000002.JPG?itok=6d3OHAR0",
            "caption": "reveals a soft-tissue density mass on the right hemithorax without calcification, pleural thickening, and nodularity."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006374/000003.JPG?itok=FOvRFcJl",
            "caption": "Demonstrates tiny amount of pleural effusion on the right side."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006374/000004.jpg?itok=_8YMHPHh",
            "caption": "shows the glands lined by malignant cells with pleomorphic and large nuclei and prominent nucleoli."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/6374",
    "time": "23.05.2008"
  },
  "6399": {
    "case_id": 6399,
    "title": "Pneumocytis jiroveci in an HIV infected patient: a review",
    "section": "Chest imaging",
    "age": "30",
    "gender": "male",
    "diagnosis": "Pneumocytis jiroveci pneumonia",
    "history": "A 30-year old man with AIDS was admitted to hospital with a subacute insidious onset of nonproductive cough, fever and increasing shortness of breath.",
    "image_finding": "A 30-year old man, HIV+ with known AIDS, was admitted to hospital with a history of nonproductive cough, fever and increasing shortness of breath. The blood tests revealed a CD4 cell count of 6 cells/mm3 and an increased LDH. The routine plain film showed diffuse ground glass infiltrates in both lungs (figure 1). Since the patient had a previous history of cutaneousKaposi\u2019s sarcoma, a CT scan was also performed in order to exclude pulmonary involvement of this disease. The CT chest scan (figure 2a, 2b), including thin-section acquisition (figure 2c), confirmed the clinical-radiographic suspicion of Pneumocytis jiroveci pneumonia, showing the classic diffuse ground-glass infiltrates withbilateral distribution, along with apical air cysts. No pleural effusion or lymphadenopathies were seen. On the other hand, pulmonary involvement of Kaposi Sarcoma was excluded (even tough Kaposi Sarcoma may present as focal or diffuse airspace opacities, this neoplasm  has a preferential distribution along the interstitium, producing small to medium poorly marginated nodular (flamed-shaped) and course linear opacities that extend from the hilum into mid and lower lung, which were not present in this patient; besides, usually there's no fever or pulmonary symptoms despite extensive parenchymal disease).",
    "discussion": "More than 40 million people worldwide are infected with HIV, the cause of AIDS, with the majority of these patients encountering a pulmonary complication during the course of their illness [1]. Since the introduction of HAART therapy and the use of prophylactic antibiotics, the pattern and epidemiology of the disease is changing [2]. Still, Pneumocytis jiroveci pneumonia (formerly known as Pneumocytis carinii pneumonia) is one of the commonest lung infections, particularly once CD4 cells count falls below 200cells/mm3.  Shortness of breath, dry cough, high fever, hypoxia, elevated lactate dehydrogenase level are most common non-imaging findings [3]. The radiographic appearances of Pneumocytis jiroveci pneumonia demonstrate considerable variation. The chest film may be normal in the early phase (up to 18% of cases) [4] but most commonly,  it demonstrates bilateral, perihilar or diffuse, symmetric, poorly defined groundglass opacities or reticular infiltrates (figure 1) that can be exclusively interstitial or associated with airspace consolidation. CT findings, just like radiographic findings, encompass a spectrum of features: frequently there's a bilateral, diffuse or patchy, extensive ground glass opacities (figure 2a, 2c), sometimes associated with a smooth septal thickening and intralobular linear opacities, causing a \u00abcrazy paving\u00bb pattern. Foci of confluent consolidation are often encountered later in the disease [3]. Up to 38% of patients may develop the cystic form of this infection, which etiology remains unclear (perhaps by a \u00abcheck-valve\u00bb bronchiolar obstruction or a cavitary infarction due to necrotizing vasculitis). These cyst are frequently thin-walled with smooth inner and outer margins (pneumatoceles), mainly in the upper lobes or subpleural in location (figure 2b) and may predispose to spontaneous pneumotorax or pneumomediastinum, with a worse prognosis [4]. However, cysts may be multiple, thicker-walled, distributed throughout the parenchyma, and the differential diagnosis of this cystic form of pneumocystis includes bullous emphysema, cystic lesions of intravenous drug abusers, post-infectious pneumatoceles (Staphylococcus), post-traumatic pneumatoceles, coccidiodomycosis, necrotizing metastasis and less frequently lymphangioleiomyomatosis or histiocytosis X . One or more small lung nodules showing a limited granulomatous response of the host to the infection can be seen, in addition to the groundglass opacities. Predominantly upper lobe Pneumocytis jiroveci pneumonia occurs in patients receiving prophylaxis with inhaled aerosolized pentamidine, simulating postprimary tuberculosis [5]. Patients receiving systemic prophylaxis with cotrimoxazole are also at risk for extrapulmonary Pneumocytis jiroveci pneumonia (rare, only 1% of the patients) spreading via the lymphatics or bloodstream, with involvement of the liver, spleen, kidney or lymph nodes, appearing on CT as microabcesses or punctuate/rim-like calcifications [6]. Pleural effusions and lymphadenopathy are uncommon imaging findings in uncomplicated infection (only in 5%) and should suggest an alternative or additional diagnosis [5], namely, mycobacterial and bacterial infections, lymphoma and Kaposi\u2019s sarcoma. Occasionally, evidence of interstitial fibrosis (mild or severe) may be seen in patients who have recovered from Pneumocytis jiroveci infection, with irregular linear opacities, traction bronchiectasis and architectural distortion [3]. Rare cases of miliary Pneumocytis jiroveci pneumonia have been reported [2]. Diagnosis is established by methenamine silver staining of induced sptutum or bronchoalveolar lavage fluid specimens.",
    "differential_diagnosis": "Pneumocytis, jiroveci, pneumonia",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006399/000001.jpg?itok=Kxo9US2y",
            "caption": "Chest film: \nBilateral perihilar symmetric fine reticular infiltrates"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006399/000002.jpg?itok=BZaIHE1f",
            "caption": "CT: Diffuse ground-glass opacities typical of Pneumocytis jiroveci pneumonia"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006399/000003.jpg?itok=oLeFfTMh",
            "caption": "CT: diffuse ground-glass opacities with bilateral distribution along with apical air cysts"
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006399/000005.jpg?itok=HdImgwCL",
            "caption": "HRTC (thin-acquisition scan): diffuse ground-glass infiltrates"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/6399",
    "time": "08.06.2008"
  },
  "6457": {
    "case_id": 6457,
    "title": "Laryngeal tuberculosis: an uncommon disease",
    "section": "Chest imaging",
    "age": "25",
    "gender": "female",
    "diagnosis": "Laryngeal tuberculosis.",
    "history": "A 25-year-old female patient presented with weakness, anorexia, productive cough and hoarseness during the last month. The patient reported a previous infection from syphilis but she reported to have\nbeen cured. She is a non-EU resident.",
    "image_finding": "A 25-year-old female patient presented with weakness, anorexia and hoarseness during the last month. The patient reported a previous infection of syphilis but subsequent cure. Routine blood\nparameters were normal except the sedimentation rate and the reactive C-protein which were increased. The patient underwent laryngeal inspection that showed an uncommon picture: the true vocal cords\nwere thickened and edematous with hypomobility of the right vocal cord. Before a new inspection and biopsy the patient underwent a chest radiography that showed the presence of two pulmonary nodules\nwith cavitation. In addition, the chest radiography showed bronchial wall thickening, retraction area of the apical lobes, multiple micronodules and a reticular pattern in both pulmonary fields.\nThese features were strongly suggestive of pulmonary tuberculosis. The microbiologic analysis of the sputum confirmed tuberculosis caused by typical mycobacteria. She was treated with\nanti-tuberculosis therapy with resolution of the disease.",
    "discussion": "Laryngeal tuberculosis is an uncommon disease in developed countries and is usually a complication of pulmonary tuberculosis by contact of the surface with tubercular bacillus present in the\nbronchial secretions. The prominent presenting symptoms are hoarseness, weak voice and sometimes dyspnea. The laryngeal sites affected are, in order of frequency: true vocal cords, epiglottis, false\ncords, laryngeal ventricles, arytenoids, interarytenoid and subglottic area. The main laryngeal features observed with laryngoscopic examination are soft-tissue thickening, infiltration of the\npreepiglottic and paraglottic spaces, focal ulcerovegetative lesions, granulomatous lesions and irregularity, immobility and edema of the vocal cords. Biopsy and rapid response to anti-tuberculosis\ntreatment are the most important methods in the diagnosis of laryngeal tuberculosis but the biopsy is crucial for definitive diagnosis. The differential diagnosis includes others inflammatory\nlaryngeal conditions and laryngeal carcinoma. The patients are usually treated with isoniazid, rifampicin, ethambutol for 6-12 months and the results of chemotherapy are good; in some cases the\nexcision of laryngeal lesions is necessary.",
    "differential_diagnosis": "Laryngeal, tuberculosis.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006457/000001.JPG?itok=nDxqijKO",
            "caption": "Hypomobility of the right vocal cord."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006457/000002.JPG?itok=e9tSica1",
            "caption": "The true vocal cords were thickened and edematous."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006457/000003.JPG?itok=1ixkhKLH",
            "caption": "The chest radiograph shows two nodules with cavitation; one in the left sub-claviculararea (5cm diameter) and the second ( 2 cm) in the right sub-clavicular area. In addition, the chest radiograph shows a retraction area of the apical lobes, multiple micronodules and a reticular pattern in both pulmonary fields."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006457/000004.JPG?itok=vzRqJcab",
            "caption": "Not pleural effusion was found."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/6457",
    "time": "25.02.2008"
  },
  "6508": {
    "case_id": 6508,
    "title": "Tracheal Obstruction Secondary to Lymphom",
    "section": "Chest imaging",
    "age": "18",
    "gender": "male",
    "diagnosis": "T-cell Lymphoblastic Lymphoma",
    "history": "This is an interesting case both diagnostically and radiographically of an 18-year-old male presenting with symptoms of increasing upper airway obstruction secondary to mediastinal lymphoma.",
    "image_finding": "This is an interesting case of an 18-year-old male with mediastinal lymphoma. His only presenting symptom was of increasing upper airway obstruction over the course of one month. At initial presentation,a provisional diagnosis of asthma was made following unremarkable flexible laryngoscopy. Despite escalation of medical treatment, including a course of oral corticosteroids, his symptoms increased.He re-presented to the emergency department one month later. Chest radiography was performed (figure 1) and showed tracheal compression. Further assessment with Computed Tomography (CT) demonstrateda large mediastinal mass compressing the trachea (figure 2). CT guided biopsy was attempted but due proximity to the mediastinal vasculature insufficient tissue was obtained. Mediastinoscopy andbiopsy were therefore performed and provided a diagnosis of T-cell lymphoblastic lymphoma. He responded well to a course of chemotherapy and a repeat chest radiograph showed significant reduction inthe tracheal compression (figure 3).",
    "discussion": "T-cell lymphoblastic lymphoma (T-LBL) is a malignancy of pre-cursor T cells and accounts for 2% of all Non-Hodgkins Lymphomas (1). It is an aggressive malignancy which involves both nodal and\nextranodal structures particularly bone marrow and the CNS (1). T-LBL presents most commonly in children and adolescents with a male to female ratio of 2.5:1 (1). Mediastinal disease is a presenting\nfeature in 45-75% (1,2) and is three times more common in males (2). Disease in the mediastinum may also cause superior vena cava syndrome, pleural and pericardial effusions (3). Fine needle\naspiration cytology (FNAC) is an effective and safe method of making a diagnosis providing there is sufficient tissue for immunochemistry (3). In this case CT guided FNAC was unsuccessful and formal\nsurgical biopsy was required. Differential diagnoses include other subtypes of lymphoma and thymoma. Combination chemotherapy has been proven to be effective in the treatment of T-LBL although there\nis still a significant relapse rate. Of interest, there is current debate as to the differentiation between T-LBL and Acute Lymphoblastic Leukaemia (ALL) (1). When treated synonymously with ALL\nchemotherapy regimes, 5-year survival rates in children are between 60-90% (1,4).",
    "differential_diagnosis": "T-cell, Lymphoblastic, Lymphoma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006508/000001.jpg?itok=89KQZofD",
            "caption": ""
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006508/000002.jpg?itok=W5FTWQ3U",
            "caption": ""
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006508/000004.jpg?itok=Oh-BtRmL",
            "caption": ""
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006508/000005.jpg?itok=_f710di5",
            "caption": ""
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/6508",
    "time": "15.10.2008"
  },
  "6519": {
    "case_id": 6519,
    "title": "Abnormal articulation of the first rib mimicking Pancoast tum",
    "section": "Chest imaging",
    "age": "80",
    "gender": "male",
    "diagnosis": "Abnormal appearance of first rib",
    "history": "A case of the first rib mimicking a mass or tumour is presented. The significance of identifying the structure as a rib is stressed to avoid subjecting patients to unnecessary procedures.",
    "image_finding": "An 80-year-old man with a known history of asthma and chronic bronchitis was brought into Accident and Emergency after having been found on the floor of his home. He was thought to have been there\nfor two days. A chest x-ray was requested to rule out a chest infection. The chest x-ray demonstrated a large mass in the right upper zone, which was initially thought to be a Pancoast Tumour. On\ncloser inspection however, this was not the case.",
    "discussion": "In the study by Ichinohe K et al., it was shown that Pancoast tumour can be easily missed and care must be taken when considering this as a possible diagnosis. Treatment delay for Pancoast tumours\nwas relatively long, and approximately two-thirds of the delay was due to doctors, mainly because of errors in radiology. However, in a new study from the National Cancer Institute (NCI), part of the\nNational Institutes of Health, it was shown that chest X-rays can detect early lung cancer but also can produce many false-positive test results, causing needless extra tests. Radiographic\ninterpretation is a systematic search for disease patterns, regardless of the image display or noise in the image. In this case, even though the initial thought was that of a tumour, a second look\nwith careful comparison of the opposite side revealed the true diagnosis. The significance of this finding is that the patient was not exposed to any unnecessary tests.",
    "differential_diagnosis": "Abnormal, appearance, of, first, rib",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006519/000003.JPG?itok=y-IwrlIB",
            "caption": "At first glance, there appears to be a large mass in the right lung that could possibly be a Pancoast tumour; but on closer inspection of the other side, it can be seen that the articulation point of both the first ribs is rotated and similar in character. It is more radio-opaque on the right side."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/6519",
    "time": "03.06.2008"
  },
  "6529": {
    "case_id": 6529,
    "title": "sophageal Perforation in a young woman \u2013 Investigation with CT esophagography",
    "section": "Chest imaging",
    "age": "28",
    "gender": "female",
    "diagnosis": "Iatrogenic esophageal perforation.",
    "history": "A 28-year-old female was transported to the emergency room with pain in the lower anterior chest and vomiting. She reported esophagogastroduodenoscopy 4 hours ago for diagnosis of peptic ulcer. Her\nmedical history was free. The patient underwent a CT before and after oral administration of contrast medium.",
    "image_finding": "The patient was referred to the emergency department 4 hours after esophagogastroduodenoscopy with a recent history of chest pain and vomiting. She had no symptoms of nausea, was not on any\nmedication and had no allergies. Plain radiography of the chest revealed a right pneumothorax and a chest tube was placed in the right pleural cavity for drainage (Fig 1). A CT scan was performed and\ndemonstrated a small right pleural effusion and thickening of the lower esophagus (Fig 2). Because of the background of the esophagogastroduodenoscopy there was a strong suspicion of esophageal\nrupture. A CT scan after oral admission of contrast medium (Gastrografin) followed and revealed communication of the esophagus with the right pleural cavity (Fig 3). There was no evidence of\npneumomediastinum and the CT scan of the neck was normal. The patient was treated with conservative therapy.",
    "discussion": "Esophageal perforation is a life-threatening condition usually occurring due to penetrating trauma, blunt trauma, iatrogenic causes, foreign body ingestion and spontaneous rupture. Morbidity and\nmortality depend on prompt recognition and proper clinical management. As clinical signs of esophageal perforation are unreliable, diagnosis requires imaging or endoscopic evaluation. Iatrogenic\nesophageal perforation usually results from endoscopy or intubation and the most common sites for perforations are hypopharynx and cervical esophagus. It occurs in around 0.1% of patients undergoing\nendoscopy with modern fibre-optic instruments. There are other causes of esophageal perforation due to instrumentation, such as endotracheal and nasogastric intubation, especially in neonates.\nTransesophageal echo is associated with a perforation rate of 0.1% to 0.3%. In the standard plain radiography of the chest the first signs to be seen are widening of the mediastinum and\npneumomediastinum. It was also observed that the chest radiograph may be negative when the perforation is intraluminal and contained within the esophageal wall. Fluoroscopic esophagography performed\nwith water-soluble contrast agents is the study of choice for suspected esophageal perforation. Sometimes the first gastrographin swallow study may not clearly show the contrast leakage which can\ninstead be detected in the subsequent barium studies. However, fluoroscopic esophagography can be difficult to perform in seriously ill patients, requires patient transport to the fluoroscopy suite\nand false-negative results may occur. Because esophageal perforation is one of several diagnostic considerations for patients with chest pain, many patients with esophageal perforation may first\nundergo thoracic CT, requiring fluoroscopic esophagography to be performed as a separate examination. A method for evaluating patients with chest pain that provides evaluation of both esophageal\nperforation and more common causes of acute chest pain is desirable. This can be done with a CT technique with the use of oral contrast agent, expanding the evaluation of patients presenting with\nchest pain. CT is able to identify even minimal collections of air or contrast in the mediastinal spaces, as well as any complications (acute mediastinitis, intrathoracic abscess). Other CT findings\nare periaortic air, mediastinal fluid, esophageal wall thickening, esophago-pleural fistulae, hydropneumothorax and pneumopericardium. Helical CT offers several advantages over fluoroscopic\nesophagography examinations: it can be performed after the initial thoracic CT scan is obtained to exclude other causes of chest pain; it can readily detect the small periesophageal air collections;\nfinally, it is easy to perform and CT technicians and nurses can readily be trained in its use. Controversy exists regarding indications for surgery for esophageal rupture. However, operative therapy\ndepends on a number of factors, including etiology, location of the perforation, and the time interval between injury and diagnosis. Other considerations include the extension of the perforation into\nan adjacent body cavity and the general medical condition of the patient.",
    "differential_diagnosis": "Iatrogenic, esophageal, perforation.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006529/000001.jpg?itok=rDUtS1hU",
            "caption": "Right pneumothorax and chest tube in the right pleural cavity"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006529/000002.jpg?itok=cnuFod0V",
            "caption": "Esophageal wall thickening and right pleural effusion"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006529/000003.jpg?itok=4ppyUZfp",
            "caption": "Right pneumothorax"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006529/000004.jpg?itok=vl1-tA7d",
            "caption": "Extraluminal extravasation of oral contrast material in the right pleural cavity"
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006529/000005.jpg?itok=uOX5zief",
            "caption": "Extraluminal extravasation of oral contrast material in the right pleural cavity"
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006529/000006.jpg?itok=1TjKKikw",
            "caption": "Esophageal rupture with extravasation of oral contrast material"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/6529",
    "time": "01.03.2008"
  },
  "6551": {
    "case_id": 6551,
    "title": "Scimitar syndrome: a case report",
    "section": "Chest imaging",
    "age": "21",
    "gender": "female",
    "diagnosis": "Scimitar syndrome.",
    "history": "Patient, who presented with symptoms of upper respiratory infection, was submitted to PA chest radiograph.",
    "image_finding": "A female, 21-year-old patient with a history of nasal congestion, slight fever, fatigue, headache and loss of appetite with one week of evolution was submitted to a PA chest radiograph, in whitch the\nexistence of an anomalous pulmonary vein was detected. The radiographic appearance of the Scimitar syndrome is generally characteristic and diagnostic, appearing in the PA chest radiograph as arcuate\nvascular shadow in the right hemithorax parallel to the right heart border and extending to right diaphragmatic cupula, as in the case presented (Fig. 1). This typical radiographic appearance of the\nanomalous pulmonary vein led to the comparison with the scimitar, a curved blade of a sword traditionally used by the Turks and Persians warriors. Subsequently the patient was submitted to\ncomplementary CT scan, showing that the anomalous pulmonary vein drained only part of the right lower lobe to the suprahepatic veins without concomitant significant pulmonary hypoplasia.",
    "discussion": "The scimitar syndrome is a rare type of pulmonary venous drainage, usually occurring in the right lobe, in whitch an anomalous pulmonary vein drain parte of or the entire right pulmonary lobe in to\nthe inferior vena cava. Occasionally, the anomalous pulmonary vein drains to the suprahepatic veins, portal vein, right atrium or coronary sinus. This syndrome is frequently associated with various\ndegrees of right pulmonary hypoplasia. Congenital heart lesions are associated in 25% of the patients, most commonly septal defects and patent ductus arteriosus. This syndrome is usually diagnosed in\npatients less than 30 years, and more than half are symptomatic. The most frequent symptoms are recurrent chest infections, asthenia and dyspnoea, especially with the effort. The clinical\nsignificance and prognosis of the syndrome of scimitar depends mainly of the severity of the left-to-right-shunt. In patients with mild symptoms, as in our case, management is conservative, with\nsurgery reserved for patients with severe symptoms.",
    "differential_diagnosis": "Scimitar, syndrome.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006551/000007.jpg?itok=Z1zk_Sqs",
            "caption": "PA chest radiograph: anomalous pulmonary vein parelleling the right heart border (arrows)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006551/000002.jpg?itok=dDpgAitR",
            "caption": "CT scan: scimitar vein in axial planes (arrow)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006551/000003.jpg?itok=dRJYlqsG",
            "caption": "CT scan: scimitar vein in axial planes (arrow)."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006551/000004.jpg?itok=eDz6lapT",
            "caption": "CT scan: scimitar vein in axial planes (arrow)."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006551/000005.jpg?itok=wwYo8bfi",
            "caption": "CT scan: scimitar vein in axial planes (arrow)."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/6551",
    "time": "19.02.2008"
  },
  "6577": {
    "case_id": 6577,
    "title": "Localized fibrous tumor of the pleura mimicking a pleural effusion",
    "section": "Chest imaging",
    "age": "70",
    "gender": "female",
    "diagnosis": "Localized fibrous tumor of the pleura",
    "history": "A 70-year-old woman presented to the Emergency Room with left sided chest pain exacerbating during inspiration, dyspnea and palpitations. She reported dry cough for three weeks, without fever.",
    "image_finding": "Past History: Three years ago, the patient had undergone mechanical mitral valve replacement and she was under anticoagulation therapy. Physical examination: dullness to percussion, with absent breath sounds over the left hemithorax. A posteroanterior and lateral Chest radiograph (figure 1) on admission to the hospital showed homogeneous and well-circumscribed opacification occupying the lower two-thirds of the left hemithorax. The initial diagnosis of pleural effusion was made, and a difficult pleurocentesis yielded a little amount (20 ml) of bloody fluid. Then, a chest CT (figure 2) was performed and the initial diagnosis was changed at that moment, due to the CT  findings. The interest of this case is the presentation of this Solitary Fibrous Tumour. In the emergency room the patient was diagnosed as pleural effusion according to the symptoms, physical  examination, chest x-ray and CT. The diagnosis of a septated pleural effusion was suggested by a non-experienced radiology resident on guard. During the next day several experienced radiologists found clues  for a different diagnosis: CT showed branching linear structures of enhancement within the lesion \u2013 consistent with intralesional blood vessels (figure 3) - and the CT density values were similar to  those of soft-tissue attenuation. Then, the possibility of a pleural tumour was taken into account. After a diagnostic pleuroscopy, the patient underwent a thoracotomy, and a large lobulated gray-white mass with firm consistency occupying a great portion of the left hemithorax was detected. The histologic diagnosis was a localized fibrous tumor of the pleura.",
    "discussion": "Localized fibrous tumors are rare mesenchymal neoplasms that most commonly affect the pleura but have also been described in a number of other locations including the mediastinum and the lung.Extrathoracic localized fibrous tumors have been reported in the abdomen, the head and neck, and the central nervous system. Localized fibrous tumors of the pleura (LFTP), also known as benign mesotheliomas, localized fibrous mesotheliomas, and pleural fibromas, are rare tumors, accounting for less than 5% of all neoplasms involving the pleura. These tumors originate from submesoepithelial mesenchymal cells, and approximately 80% arise from the visceral pleura. They are not related to asbestos exposure. Although the most common primary pleural neoplasm is malignant mesothelioma, radiologists should also be able to identify the much rarer LFTP, as these two neoplasms have radically different prognoses. These tumors, commonly found in the dependent portions of the thorax, may range from 1 to 39 cm in diameter. Large tumors usually displace rather than invade adjacent structures. Because of the presence of a vascular pedicle in 30-50% of patients, these tumors may show a change in shape and location with changes in respiration or position. Benign and malignant subtypes of LFTP are recognized. On unenhanced CT scans, localized fibrous tumors show soft-tissue attenuation. MR imaging typically demonstrates intrathoracic lobular masses of heterogeneous signal intensity with both T1- and T2-weighted sequences. Internal low-signal-intensity septa on T2-weighted images are common. On CT and MR images, marked enhancement caused by the rich vascularization is usually seen with the administration of IV contrast material. CT and MR images may show associated regions of hemorrhage and necrosis, tumoral calcifications and pleural effusions. Rib erosion is rare. Although approximately half the patients with localized fibrous tumors of the pleura are asymptomatic, cough, chest pain, and dyspnea may be presenting symptoms, especially in patients with large tumors. Hypertrophic osteoarthropathy was seen in 4-35% of patients, and hypoglycemia was noted in up to 5%. Atelectasis of the adjacent lung and mass effect on the mediastinum are common associated findings. The fibrous acellular nature of localized fibrous tumors makes diagnosis by transthoracic needle biopsy difficult. Although there are no imaging features that definitively distinguish benign from malignant subtypes of LFTP, heterogeneity on cross-sectional images, mass effect, and pleural effusion may be slightly more common in malignant lesions.",
    "differential_diagnosis": "Localized, fibrous, tumor, of, the, pleura",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006577/000001.png?itok=JAArOiQU",
            "caption": "Posteroanterior and lateral Chest radiograph showed homogeneous and well-circumscribed opacification occupying the lower two-thirds of the left hemithorax."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006577/000002.png?itok=G_9FKNfq",
            "caption": "Posteroanterior and lateral Chest radiograph showed homogeneous and well-circumscribed opacification occupying the lower two-thirds of the left hemithorax."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006577/000003.png?itok=SbIiZW-d",
            "caption": "Chest CT at different levels."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006577/000004.png?itok=dchXlWul",
            "caption": "Chest CT at different levels."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006577/000005.png?itok=LZcguPYB",
            "caption": "Chest CT at different levels."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006577/000006.png?itok=wsmJaZDb",
            "caption": "Chest CT at different levels."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006577/000007.png?itok=JQpIJWtQ",
            "caption": "Chest CT (detail). Branching linear structures of enhancement within the lesion, consistent with intralesional blood vessels."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/6577",
    "time": "26.05.2008"
  },
  "6586": {
    "case_id": 6586,
    "title": "Pulmonary  Kaposi  sarcoma and brain lymphoma in AIDS",
    "section": "Chest imaging",
    "age": "45",
    "gender": "male",
    "diagnosis": "Pulmonary Kaposi sarcoma and brain lymphoma in an AIDS patient",
    "history": "A HIV-positive, 45-year-old male presented with a one month history of dyspnea, cachexia, dysphagia and constipation. He also had a plaque-like cutaneous lesion.",
    "image_finding": "A HIV-positive patient (1,04 X 106 cop/ml) and heavy smoker (30 pack/yrs) presented with a one month history of dyspnea, cachexia, dysphagia and constipation. Clinical examination revealed\na plaque-like cutaneous lesion of the left hand and similar \u2013 less extensive \u2013 lesions in the thoracoabdominal area, consistent with Kaposi sarcoma. He had been on antiretroviral therapy\nfor 8 years and had stopped it on his own for the last 4 years. Blood tests showed a CD4 count of 6 cells/ml. Gastroscopy revealed fungal infection of the oral cavity and lower third of the\noesophagus. Neurological examination disclosed left paraparesis. Chest radiograph revealed bilateral peribronchovascular patchy consolidations (Fig 1). HRCT of the chest disclosed ill-defined nodular\nopacities, some of which were surrounded by a halo of ground glass opacity (Fig 2a). There were characteristic peribronchovascular nodular-like consolidations (Fig 2b) and thickening of the\ninterlobular septa especially in the lung bases (Fig 2c). Mild upper lobe centrilobular emphysema was noted (Fig 2d). HRCT findings were attributed to Kaposi sarcoma associated with smoking related\nchanges. Bronchoscopy revealed patchy inflammatory infiltrates and BAL cytology was positive for Pneumocystis jirovecii. A CT-guided lung biopsy of a nodule was performed and histology disclosed\npulmonary Kaposi sarcoma (Fig 3). Brain MRI revealed abnormal high T2 signal intensity and enhancement in basal ganglia \u2013 predominantly at the right (Fig 4). Most probable diagnoses were\ntoxoplasmosis and lymphoma. Follow-up MRI after completion of therapy for toxoplasmosis showed deterioration (Fig 5) and, therefore, lymphoma was considered the most likely diagnosis.",
    "discussion": "Kaposi sarcoma (KS) is a low-grade mesenchymal tumor affecting primarily the skin and causing disseminated disease in a variety of organs. The prevalence may reach 50% among homosexual male AIDS\npatients. AIDS-related KS usually develops in the setting of a low CD4 lymphocyte count (<200 cells/mm3) (1). Thoracic disease is found in about 45% of patients with cutaneous KS and is\nassociated with a low CD4 lymphocyte count (<100 cells/mm3). Common clinical symptoms include chronic cough, dyspnea, fever, and hemoptysis. The typical purplish endoscopic appearance\nof tracheobronchial KS is helpful in reaching the diagnosis (1). At radiography, AIDS-related KS may demonstrate middle to lower lung zone reticular opacities and parenchymal nodules with a\nperibronchovascular distribution that may progress to consolidation, peribronchial cuffing, Kerley B lines, pleural collections, and hilar or mediastinal adenopathy. On the other hand, when\nAIDS-related KS is associated with an opportunistic infection (e.g., Pneumocystis jirovecii infection), radiography demonstrates granular opacities with a more diffuse or apical distribution and, in\nsome cases, upper lobe predominant lung cysts (1). CT and especially HRCT are more sensitive in detecting thoracic complications of AIDS (2). AIDS-related KS is characterized by the presence of\nperibronchovascular bilateral and symmetric ill-defined nodules (flame-shaped lesions), usually exceeding 1 cm in diameter (3). Ground-glass opacities may surround the nodules (\u201chalo\nsign\u201d) representing hemorrhage in the surrounding lung parenchyma (2). Other findings include interlobular septal thickening, fissural nodularity, and pleural abnormalities (4). Lymphadenopathy\n(30-35% of patients), is usually less extensive in the thorax than elsewhere, and may show enhancement (4). The differential diagnosis of peribronchovascular nodular opacities includes lymphoma,\nbronchogenic carcinoma, infection, and bacillary angiomatosis. Mycobacterial or bacterial infection is favored by the presence of a tree-in-bud pattern or nodules less than 1 cm in diameter with\ncentrilobular distribution. Pneumocystis jirovecii pneumonia does not usually manifest with hilar adenopathy or pleural effusion but may exhibit cavitation. Nodule size is not helpful in\ndifferentiating KS from lymphoma or bronchogenic carcinoma, and biopsy may be necessary (1). Bacillary angiomatosis may mimic KS, with solitary or multiple pulmonary nodules, and mediastinal\nlymphadenopathy demonstrating intense enhancement (5). Apart from KS, non-Hodgkin\u2019s lymphoma is the second most common malignancy seen in the AIDS population. Primary CNS lymphoma develops in\n2%-6% of AIDS patients. However Toxoplasma encephalitis still remains the most common cause of brain lesions \u2013 although administration of highly active antiretroviral therapy has resulted in\nsignificant decline of toxoplasmosis (6). At CT and MRI, lymphomas may be indistinguishable from toxoplasmosis. Toxoplasmosis and brain lymphoma may manifest as solitary or multicentric lesions that\nare hypointense on T1-weighted images (WI), iso- to hypenintense on T2-WI, show surrounding oedema and ring enhancement (7). Primary brain lymphoma occurs in basal ganglia, frontal and parietal\nlobes. It rapidly becomes multicentric and can more than double in size within weeks (7). Indisputable diagnosis of CNS toxoplasmosis is established with clinical and radiographic response to\nantitoxoplasmosis therapy. SPECT, 18F-fluoro-2-deoxyglucose PET and diffusion-weighted MRI have been reported to help in distinguishing between toxoplasmosis and lymphoma, but diagnostic inaccuracy\npersists (6).",
    "differential_diagnosis": "Pulmonary, Kaposi, sarcoma, and, brain, lymphoma, in, an, AIDS, patient",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006586/000001.jpg?itok=JPHNiwyb",
            "caption": "Chest radiograph shows bilateral peribronchovascular consolidation predominantly at the right and in the mid and lower lung zones"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006586/000002.jpg?itok=7-Ryow93",
            "caption": "HRCT of the chest shows ill-defined nodular opacities (flame-shaped), some of which are surrounded by a halo of ground glass opacity."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006586/000003.jpg?itok=u45Lv1fV",
            "caption": "HRCT of the chest discloses nodular-like consolidations with the characteristic characteristic peribronchovascular distribution."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006586/000004.jpg?itok=iXgqiUQb",
            "caption": "HRCT of the chest at the lung bases shows peribronchonascular ill-defined nodular opacities and thickening of the interlobular septae."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006586/000005.jpg?itok=2tPPkrTy",
            "caption": "HRCT pf the chest at the level of the upper lobes shows mild centrilobular emphysema secondary to smoking history and small ill-defined nodules especially at the left."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006586/000006.jpg?itok=RQz2_4zh",
            "caption": "CT of the chest shows a CT-guided transthoracic insertion of the needle in an anteriorly located nodule of the right middle lobe."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006586/000007.jpg?itok=Z05ZTvNo",
            "caption": "Gadolinium enhanced T1-WI axial image shows an lesion with ring enhancement in the right basal ganglia with mass effect on the anterior horn of the right ventricle. A small nodular enhancing lesion is seen in the left lentiform nucleus."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006586/000008.jpg?itok=gxCxyNEw",
            "caption": "FLAIR axial image shows extensive area of increased signal intensity in the right basal ganglia causing mass effect on the anterior horn of the right ventricle. Note a smaller area of increased signal intensity in the left lentiform nucleus."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006586/000009.jpg?itok=184sPzRq",
            "caption": "Gadolinium enhanced T1-WI axial image after completion of therapy for toxoplasmosis shows progression of abnormal enhancement in the left lentiform nucleus."
          },
          {
            "number": "Figure 5b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006586/000010.jpg?itok=SvW2Pcaz",
            "caption": "FLAIR axial image after completion of therapy for toxoplasmosis shows progression of increased signal intensity occupying the entire left lentiform nucleus."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/6586",
    "time": "01.03.2008"
  },
  "6632": {
    "case_id": 6632,
    "title": "Pleural thickening in a patient with known sarcoidosis",
    "section": "Chest imaging",
    "age": "48",
    "gender": "female",
    "diagnosis": "Mycetoma development in a patinet with sarcoidosis",
    "history": "Pleural thickening detected on the routine follow-up chest radiograph of a patient with known sarcoidosis.",
    "image_finding": "A 48 year old woman with known sarcoidosis attended a follow up out patient chest clinic appointment.  She was not taking any medication for her illness.  She was found to have facial dermatological appearances of active sarcoidosis. To monitor her disease activity, routine bloods and a serum ACE were requested.  It had been almost four years since her previous chest radiograph, and this too was requested.The old chest radiograph from July 2003 (Figure 1) demonstrates bilateral upper zone fibrosis with volume loss consistent with chronic sarcoidosis.  The newly requested chest radiograph from January 2007 (Figure 2) demonstrates a marked increase in the degree of pleural thickening in the left upper zone. On the basis of this, a CT scan of the chest was arranged for further evaluation.Figure 3 clearly demonstrates a thick-walled cavity in the left upper zone, within which lies a ball of high attenuation material.  This is the classic appearance of an mycetoma.  Extensive pleural thickening is seen related to this.",
    "discussion": "A mycetoma is a saprophytic growth of fungus, most commonly aspergillus fumigatus, which proliferates in pre-existing fibrotic cavities within the lungs. Such cavities are a feature of many chronic lung diseases. The occurrence of aspergillus superinfection in lungs with persistent cavitary or cystic disease represents a serious complication due to the risk of massive haemoptysis. The morbidity and mortality associated with mycetoma formation are high with an overall mortality reported to be as high as 31% at 5 years (1). In addition, suppurative lung disease can further compromise already diseased lungs. Early detection of mycetoma formation within the fibrotic lung is therefore desirable.In the earliest stage of development a mycetoma consists of small fronds arising from the cavity wall. However, this stage of mycetoma formation is radiographically occult. Potential early signs of mycetoma formation include generalised pleural thickening of the cavity wall and adjacent pleural thickening (2,3,4). Pleural thickening is a very frequent manifestation of aspergillus superinfection in patients with cavitary or cystic pulmonary disease. The presence of pleural thickening in pulmonary disease not usually associated with it, or an increase in its extent in disease in which pleural thickening is commonly seen, both suggest aspergillus superinfection.Chronic lung diseases often associated with mycetoma formation include emphysema, and particularly, fibrocavitary lung diseases including tuberculosis and sarcoidosis (4). Diagnosis may become more difficult in a patient with a fibrotic lung disease which affects the upper zones, since previous radiographs may already demonstrate extensive upper zone abnormality.  Ankylosing spondylitis is one such example, in which a small number of cases have been reported (5).Other than previous radiographic abnormality masking the mycetoma, diagnosis may also be made difficult by conditions mimicking mycetoma appearances.  One such reported case is adenocarcinoma of the lung, which can, albeit rarely, produce an upper lobe cavitary mass with an air-crescent sign typical of mycetoma.  In order to demonstrate the difference, prone and supine CT scans can be performed.  A mobile mass would indicate a mycetoma, whereas a fixed mass would be in keeping with adenocarcinoma.  In addition, a PET scan can aid differentiation. Malignancy shows central uptake within the tumour inside the cavity, whereas mycetoma does not have a blood supply and therefore only the wall of the cavity demonstrates uptake, with a central defect (6).In summary, diagnosis of mycetoma can be difficult, either due to marked underlying abnormality on plain chest radiographs, or due to other conditions mimicking mycetoma, and further imaging techniques may be needed to make the diagnosis. Attention to pleural changes in patients with cystic or cavitary disease is important. A plain chest radiograph showing the presence of lateral wall thickening immediately adjacent to a fibrotic cavity on chest radiography is suggestive of the development of a mycetoma. Recognition of this feature should prompt further investigation with CT to identify a radiographically occult mycetoma.",
    "differential_diagnosis": "Mycetoma, development, in, a, patinet, with, sarcoidosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006632/000001.jpg?itok=Dk0Z__sw",
            "caption": "Chest Radiograph in 2003 demonstrates bilateral upper zone fibrosis in keeping with chronic sarcoidosis."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006632/000002.jpg?itok=xioTGvVt",
            "caption": "Chest radiograph in 2007 demonstrates additional pleural thickening in the left upper zone when compared with the previous examination"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006632/000003.jpg?itok=K5JN6qBU",
            "caption": "CT in 2007 demonstrates typical appearances of mycetoma formation within the left upper lobe cavity, with associated pleural thickening."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/6632",
    "time": "08.05.2008"
  },
  "6670": {
    "case_id": 6670,
    "title": "Intralobar Pulmonary Sequestration",
    "section": "Chest imaging",
    "age": "58",
    "gender": "female",
    "diagnosis": "Intralobar Pulmonary Sequestration",
    "history": "A 58-year-old lady was referred to A&E with a sudden onset of severe chest pain radiating to the back.",
    "image_finding": "The pain was described as tearing in nature by the patient. The patient, who had no previous history of hypertension, was found to have a blood pressure of 180/105. No significant difference was recorded between right and left arm blood pressure measurements. The patient described a chronic cough, but otherwise she had no family or medical history of note. Physical examination was unremarkable.Initial evaluation showed an ECG within normal limits and a non elevated CKMB. Other parameters including temperature, full blood count, urea & electrolytes, APTT/INR, ESR and CRP were all found to be within the normal range. A PA chest radiograph was reported as normal.The patient was completely unrelieved by NSAIDs, and the pain was of a severe, constant nature. The suspicion of a dissecting aortic aneurysm was raised, and an urgent CT Angiogram of the aorta was performed.CTA excluded a dissecting aneurysm as being the cause of her pain. It however showed a dilated aortic bulb, which was however probably asymptomatic. An incidental anomalous finding was also detected. Both lower lung lobes were supplied directly by branches from the thoracic aorta.",
    "discussion": "Classically a triad is used to describe bronchopulmonary sequestration: (1) a non functioning lung segment, (2) with no communication with the tracheobronchial tree, (3) and having a systemic arterial supply. The lesion is usually a round/ oval smooth, well defined homogenous mass near the diaphragm. Characteristically, there is enhancement of sequestration at the same time as the thoracic aorta on rapid sequential CT scans. Sometimes the sequestration may communicate with the gastrointestinal tract, when it is termed bronchopulmonary foregut malformation.In intralobar sequestration, though the affected lobe is separated from the bronchial tree (as described by the triad), it is enclosed by visceral pleura. Aetiology is still controversial \u2013 however it is probably acquired in the majority of patients. Intralobar sequestration as opposed to the extralobar variety, usually presents in adulthood, and there is an equal incidence in males and females.About 10% of cases are associated with congenital anomalies: cardiac (including Tetralogy of Fallot), renal (failure of ascent and rotation), cerebral anomalies and skeletal deformities.15% of patients remain completely asymptomatic. Symptoms may include: pain, repeated chest infections in the same location, high output congestive heart failure, cough and sputum production and haemoptysis. The condition most commonly affects the posterobasal segments, and is slightly more common on the Left.Several imaging modalities can be used to make/confirm a diagnosis of sequestration. Chest radiography is not very specific, though it might show recurrent pneumonias localized to the lower lobe. Sometimes cavitation and cysts can be also present. Bronchography will show the absence of communication of the rudimentary bronchial system. The arterial supply can be demonstrated using angiography. Usually a single large artery ( though multiple smaller arteries can be found in about 16% of cases) arises from the distal thoracic aorta, or the proximal abdominal aorta. Rarer  origins might be from the celiac trunk, the splenic artery, intercostals or coronary arteries. The venous supply is usually via normal pulmonary veins to the left atrium. In contrast to the extralobar type of sequestration, only 5 % of cases drain into the systemic veins (azygos, hemiazygos, intercostals, and the superior vena cava). CT may show single or multiple thin walled cysts, and mucus impacted ectatic bronchi in the sequestered lung. Emphysema commonly borders the normal lung, and is due to postobstructive hyperinflation of the sequestered lung. Mucoid impaction of the involved bronchus is characteristic.Complications of sequestration include massive spontaneous nontraumatic pleural haemmorrhage, chronic inflammation, and fibrosis of the affected lung.",
    "differential_diagnosis": "Intralobar, Pulmonary, Sequestration",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006670/000001.jpg?itok=4McUxftj",
            "caption": "3D reconstruction: arrows point to the anomalous arterial supply"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006670/000002.jpg?itok=iKJYHfzO",
            "caption": "Axial CT image showing the origin of the anomalous arteries from the ventral part of the aorta"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006670/000003.jpg?itok=zizpPsne",
            "caption": "Sagittal CT reconstruction showing the origin of the Right anomalous artery, which is seen turning dorsally to the affected lobe"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006670/000004.jpg?itok=MQ4NcBLG",
            "caption": "Image showing the emphesematous changes of the affected lobe"
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006670/000007.jpg?itok=UViN_Tb6",
            "caption": "Axial CT image showing the course of the Left anomalous artery, and also the emphysematous changes of the affected lobe"
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006670/000008.jpg?itok=b7l-xSY3",
            "caption": "Mucus plugging of the affected bronchus"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/6670",
    "time": "08.05.2008"
  },
  "6672": {
    "case_id": 6672,
    "title": "Saprophytic Aspergillosis",
    "section": "Chest imaging",
    "age": "25",
    "gender": "male",
    "diagnosis": "Saprophytic Aspergillosis (Aspergilloma)",
    "history": "25-year-old migrant, with a past history of pulmonary tuberculosis, presented with a one month history of haemoptysis.",
    "image_finding": "25-year-old man referred to A&E department with a one month history of blood stained sputum. History revealed that the patient had similar symptoms in the past, but he was never properly investigated. At the time the patient was institutionalized in a facility for migrants without necessary visas.A thorough physical examination was carried out and this was unremarkable. Baseline investigations showed a mildly elevated lymphocytic count, but all other tests were normal. The chest radiograph revealed a cavitatory lesion in the left upper lobe. A provisional diagnosis of tuberculosis was made, and the patient was admitted to the Infectious Disease Unit. Mantoux test was positive, with induration of the skin after 48 hrs. Aspergillosis was however raised as a possible differential diagnosis especially after that an 'air crescent' sign was noted on the patient's radiograph. The PA film in fact showed a cavitatory lesion affecting the left upper lobe, within which a radio opaque fungus ball was seen,and which was separated from its walls by an air space, resulting in the 'air crescent' sign.This sign is highly suggestive of invasive pulmonary aspergillosis when seen in the appropriate clinical setting.Chest CT was carried out to better characterise the lesion. CT confirmed multiple cavitatory lesions in the both upper lobes, associated with marked pleural thickening. A supine and a prone CT scan was performed, in order to demonstate the gravity dependent aspergilloma within one of such cavities. This sign which is known as Monad sign is pathognomic of Saprophitic Asperillosis.",
    "discussion": "Aspergillosis is a mycotic disease caused by Aspergillus species, usually A fumigatus. This organism is an intensely antigenic ubiquitous fungus found in soil, water and decaying organic matter. It exists as either conidiophores or hyphae. It commonly occurs in the sputum of normal persons. Both preexisting lung diseases (tuberculosis, bronchiectasis) and immunocompromisation (malnutrition, diabetes, AIDS, malignancy) predispose to infection. It has the ability to invade blood vessels, therefore facilitating hematogenous dissemination. The histologic, clinical and radiologic manifestations of pulmonary aspergillosis are determined by the number and virulence of the organisms, and the patient's immune response. Pulmonary aspergillosis can be subdivided into five categories: (1) Saprophytic aspergillosis [aspergilloma], (2) Hypersensitivity reaction [allergic bronchopulmonary aspergillosis], (3) semi-invasive [chronic necrotizing] aspergillosis, (4) airway invasive aspergillosis and (5) angioinvasive aspergillosis. Saprophtic aspergillosis is a non invasive colonization of a preexisting cavity/cyst, and typically leads to a formation of a fungus ball [mycetoma] within such cavity. The ball is composed of fungal hyphae admixed with mucus and cellular debris. Other infectious agents that might cause a fungus ball include Candida albicans, Pseudallescheria boydii, Cocciodes immitis, Nocardia, and Actinomyces. The infection typically affects the upper lobes, and might be bilateral. In the majority of cases an underlying cause is identified; most commonly tuberculosis, sarcoidosis, and acquired immuno deficiency syndrome (AIDS). Other conditions that might occasionally be associated with aspergilloma include bronchogenic cysts and pulmonary sequestration. Thought the condition may remain completely asymptomatic patients may present with haemoptysis, which may be life threatening. At radiography, mycetomas present as round soft tissue opacity within a lung cavity typically separated from the wall of the cavity by an air space of variable size and shape, resulting in the 'air crescent' sign. The fungus ball may also calcify in a scattered or rimlike fashion. Pleural thickening is often seen adjacent to the cyast/cavity, and this is commonly the earliest radiographic sign (before visualising mycetoma).",
    "differential_diagnosis": "Saprophytic, Aspergillosis, (Aspergilloma)",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006672/000002.jpg?itok=puN5s_68",
            "caption": "Mobile Aspergilloma (gravity-dependent = Monad sign) within a pulmonary cystic cavity. Chest CT scans obtained with the patient supine (a) and prone (b) show a change in position of the aspergilloma.\nCaution\nis advised not to mistake the Monad sign of aspergilloma with\nthe air crescent sign of invasive aspergillosis. The former develops\nin immunologically competent patients with structural\nlung disease."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006672/000006.jpg?itok=Ii_Uv3Oc",
            "caption": "Mobile Aspergilloma (gravity-dependent = Monad sign) within a pulmonary cystic cavity. Chest CT scans obtained with the patient supine (a) and prone (b) show a change in position of the aspergilloma."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006672/000003.jpg?itok=op5Tt-96",
            "caption": "Marked pleural thickening surrounding the cavity containing the aspergilloma."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006672/000007.jpg?itok=k9L3dCvr",
            "caption": "PA chest radiograph, showing a cavitatory lesion affecting the left upper lobe. Within this cavity, a fungus ball is seen, which is separated from its walls by an air space, resulting in the 'air crescent' sign."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006672/000008.jpg?itok=7XfEtuce",
            "caption": "Magnified view, showing more clearly the 'air crescent sign'"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/6672",
    "time": "05.09.2008"
  },
  "6678": {
    "case_id": 6678,
    "title": "Thoracic Schwannoma:  Radiologic-Pathologic Correlation",
    "section": "Chest imaging",
    "age": "50",
    "gender": "female",
    "diagnosis": "Intercostal nerve schwannoma (neurilemoma).",
    "history": "Incidental pulmonary nodule detected in a routine PA chest radiograph.",
    "image_finding": "An asymptomatic, non-smoker, 50-year-old woman has been referred to the Department of Radiology of our institution by her primary care physician for study of a pulmonary nodule detected in a routine PA chest radiograph. Physical examination was unremarkable. The PA chest radiograph revealed a well-defined peripheral nodular area of increase opacity on the base of the right hemit\u00f3rax. Computer Tomography (CT) scan of the chest demonstrated the presence of a well-defined, low density round mass originated from intercostal soft tissue that measured 5 x 3 cm in the axial plane, with discrete heterogeneous contrast enhancement (Figure 1). Subsequent transthoracic needle biopsy (TNB) was performed, pathologic examination revealed aspects suggestive of solitary fibrous tumor of the pleura (SFTP). Results of bronchoscopy and transbronchial washings and biopsies were negative for the presence of malignant cells. Surgical excision was performed for definitive diagnosis and treatment.The patient underwent surgical excision of the thoracic mass performed with a right posterolateral mini-thoracotomy. The mass was located in the dependence of the parietal pleura. Gross pathologic evaluation demonstrated an oval well-circumscribed mass, measured 5 x 4 x 3 cm and weighed 32 g. The outer tumor surface revealed a fine encapsulation.  Microscopic evaluation of the tumor, demonstrated alternated areas of densely cellular with nuclear palisading and interlacing fascicles (Antoni A areas) and areas that were less cellular with variable myxoid component  (Antoni B areas). Immunohistochemically, the tumor was S-100 positive. The definitive diagnosis was neurilemoma.",
    "discussion": "The Schwann cells (also referred to as neurolemmocytes) were discovered by a German physiologist named Theodor Schwann. They are part of the glial cell and there function is to synthesise the insulating and protective lipoprotein myelin. The most part of benign tumors of the peripheral nervous tissue is of Schwann cell origin and have been divided into two major groups: schwannoma (neurilemoma) and neurofibroma (1,3). Schwannomas, also known as neurilemomas, are usually solitary, benign, slow growth and true encapsulated neoplasms that may occur nearly anywhere in the body but have a predilection for the head, the neck and the major nerve trunks (1,5,9). Malignant transformation is very uncommon (1,6,7,8). Only 20% of the chest wall tumors are benign being schwannoma the most common (7). Chest wall schwannomas commonly arise from the spinal nerve roots and in only 5% from an intercostal nerve of de lateral chest wall (5,7). In this location they are commonly asymptomatic and consequently discovered incidentally, nevertheless if the tumor becomes large symptoms like dyspnea and/ or thoracic pain radiating along the course of a peripheral nerve can be present (1,5). The tumors typically occur in patients between the 2nd and 5th decades of life, affecting twice more women than men (5, 9). The CT appearance of schwannomas has been described as a well-circumscribed, homogeneous mass, with attenuation slightly less than or equal to that of surrounding chest wall muscles with variable homogeneous or heterogeneous enhancement (5,8,9, 10,11). However, the imaging findings of schwannomas are similar to those of neurofibromas and cannot be distinguished in many cases (9). A tumor eccentrically positioned in relation to the parent nerve suggest schwannoma, while centrally located suggests a neurofibroma (1,9). The presence of cystic degeneration areas due to vascular thrombosis and subsequent necrosis in the mass appear nonenhance and are usually found in schwannomas and are uncommon in neurofibroma (5,9,11).Schwannomas microscopically consist of two different components, designated by the Swedish neurologist Nils Antoni as A and B. The areas densely cellular with nuclear palisading and interlacing fascicles are nominated Antoni type A and the areas sparsely cellular organized with more myxoid component are named Antoni type B (1,5,8). Immunohistochemically, the tumor is usually S-100 positive (1,4). Our case, like those described in the literature revealed both Antoni type A and type B areas within the tumor. The treatment of choice is surgical excision, which is generally curative with recurrences being rare (6,7). In conclusion, schwannomas arising from an intercostal nerve is a rare commonly benign condition, that may, as in the case we experience, simulate a pulmonary nodule. Although the difficulty in establishing the diagnosis certain imaging characteristics, like association with a peripheral nerve, tumor position in relation to the parent nerve and typical CT appearance (well-circumscribed, hypodense relative to muscle with heterogeneous enhancement) may help the radiologist to suspect the correct diagnosis, however the definitive diagnosis is made by histological evaluation.",
    "differential_diagnosis": "Intercostal, nerve, schwannoma, (neurilemoma).",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006678/000001.jpg?itok=QY2NaMFk",
            "caption": "Topogram: well-defined peripheral nodular area of increase opacity on the base of the right hemit\u00f3rax (arrow)."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006678/000002.jpg?itok=sbh1p9lh",
            "caption": "CT scan axial planes: well-defined, low density round mass originated from intercostal soft tissue, with discrete heterogeneous contrast enhancement (arrow)."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006678/000003.jpg?itok=T_CJ_PNl",
            "caption": "CT coronal and sagital reformations showing the same lesion (arrow)."
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006678/000004.jpg?itok=3xfjee62",
            "caption": "VRT reformations of the same lesions (arrow)."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/6678",
    "time": "08.05.2008"
  },
  "6695": {
    "case_id": 6695,
    "title": "A case of scimitar syndrome in adult",
    "section": "Chest imaging",
    "age": "82",
    "gender": "female",
    "diagnosis": "Scimitar syndrome",
    "history": "An 82 year old female with increasing dyspnoea was admitted to the Emergency Department. A Posterior-Anterior (PA) chest radiograph was obtained, followed by chest computed tomography (CT).",
    "image_finding": "A previously healthy 82 year old woman developed respiratory symptoms with dyspnoea and weakness. She presented to the emergency department because of the worsening of clinical conditions. The patient's history was not relevant. A PA chest radiograph was taken and a right pleural effusion, associated with lung atelectasis, as well as left second arc protrusion and enlarged heart shadow, were evident. A CT scan with contrast media administration was acquired for further evaluation. At CT imaging, a curvilinear, soft tissue density was revealed, describing a left-convex curve in the right lung parenchyma reaching the diaphragm in its medial part. In the axial images following contrast media administration a right atrial and ventricular enlargement was confirmed (Fig 1). In addition, the calibre of the common pulmonary artery and its bifurcations increased, as in pulmonary hypertension. The vascular nature of the curvilinear image was evident after contrast media administration (Fig 2a-d). Multiplanar reconstructions were performed and clearly demonstrated the course of this anomalous vein, which descends into the lung adjacent to the right atrium and curved posteriorly to enter the inferior vena cava below the diaphragm (Fig 3). The right inferior pulmonary vein had a normal course to the left atrium. A volume rendering reconstruction of the right atrium revealed that the right superior pulmonary vein was missing (Fig 4). No other associated anatomical anomalies were present.",
    "discussion": "The scimitar syndrome, also known as hypogenetic lung syndrome, is a rare congenital disorder with partial anomalous pulmonary venous return, consisting in an anomalous pulmonary vein that drains below the diaphragm in the inferior vena cava, hepatic veins, portal vein or azygos vein [1]. More frequently in the scimitar syndrome an anomalous course and drainage of the right inferior pulmonary vein is present; in our case it is appreciable the rare situation of an anomalous right superior pulmonary vein, with a right inferior pulmonary vein draining normally in the left atrium. In rare cases, the anomalous vein may curve upwards and drain othotopically into the left atrium, and this condition is named \u201cmeandering vein\u201d [2]. An incidence of 1-3 out of 100,000 live births is described [3], but the true incidence is unknown because the syndrome can be asymptomatic [4]. The name of scimitar syndrome derives from the scimitar sign, a chest postero-anterior radiograph finding consisting in a curved vascular shadow located to the right of the heart that descends towards the diaphragm [5]. The name, first introduced by Halasz et al. in 1956, is due to its similarity with the Turkish sword produced by the curved vascular shadow of the anomalous vein. In addition to the pulmonary vein, associated anomalies include hypoplasia of the right lung and right pulmonary artery, dextroposition of the heart due to dextrorotation, cardiac malformations, systemic arterial supply to the right lung base and bronchial anomalies [2]. Three types of the syndrome have been described: an adult form characterized by a small shunt and excellent prognosis; an infantile form, characterized by a large shunt, prominent systemic arteries supplying the right lung base, pulmonary hypertension, right heart failure, and overall poor prognosis; and a third form characterizing multiple cardiac ad extracardiac malformations [3, 5]. When isolated, the scimitar syndrome is compatible with normal life, and the development of clinical symptoms is related to the degree of the left-to-right shunt that the anomalous venous drainage causes. This is the reason why the syndrome can remain asymptomatic and be evidenced in the adult age, as in the case that we observed. In such cases, it is usually detected incidentally and needs no therapeutic intervention. In cases of associated abnormalities and severe clinical problems, operative repair is considered mandatory. The major clinical complications are right cardiac failure, related to abnormal venous draining into the inferior vena cava; pulmonary infection, related to the architectural distortion of the maldeveloped lung; and haemoptysis, related to the anomalous systemic arterial supply of bronchopulmonary sequestration [7].",
    "differential_diagnosis": "Scimitar, syndrome",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006695/000005.jpg?itok=5aRSEPMH",
            "caption": "a"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006695/000006.jpg?itok=fABbC9Zq",
            "caption": "b"
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006695/000007.jpg?itok=HwLPBO7g",
            "caption": "c"
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006695/000008.jpg?itok=UNU8i3aC",
            "caption": ""
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006695/000009.jpg?itok=iWgDzcAG",
            "caption": "With MPR the course of the vein is evident: it descends into the lung adjacent to the right atrium and curves posteriorly to enter the inferior vena cava below the diaphragm"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006695/000010.jpg?itok=T5GQnae0",
            "caption": ""
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006695/000011.jpg?itok=HPM-g-ir",
            "caption": ""
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006695/000012.jpg?itok=7XeYBxr4",
            "caption": "The volume rendering reconstruction of the right atrium shows that the right superior pulmonary vein is missing"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006695/000013.jpg?itok=tu1BzIRN",
            "caption": "Looking at the scout of the CT examination, a curvilinear soft tissue is evident, describing a left-convex curve in the right lung parenchyma reaching the diaphragm in its medial part"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/6695",
    "time": "29.08.2009"
  },
  "6696": {
    "case_id": 6696,
    "title": "Turner sydrome diagnosed firstly at 55 years of age",
    "section": "Chest imaging",
    "age": "55",
    "gender": "female",
    "diagnosis": "Turner syndrome",
    "history": "A 55 year old female evaluated for hypertension underwent chest and abdominal CT, CT and substraction angiography and plain Xray of the wrist.",
    "image_finding": "At chest CT examination, an axial view at the level of aortic arch revealed an interruption of the aorta, a part of the arch is missing.  Abdominal CT examination demonstrated a horse-shoe shaped kidney (Figure 2a) and at lower scans renal cysts (Figure 2b) and a hypoplastic uterus (Figure 2c). CT angiography demostrated a defect of the peripheral part of the aortic arch and connection with the descending aorta through an aberrant vessel (Figures 3a,b).  Substraction angiography (Figure 4) confirmed CT findings of interruoted aortic arch.  Plain X-ray of the hand showed short metacarpals and lateral and dorsal bowing of the radius - a \"bayonet deformity\" of the wrists.",
    "discussion": "Turner Syndrome (TS) was first described in 1768. TS affects approximately 1 in 2,500 live female births and characterized cytogenetically by X chromosome monosomy.The diagnosis of TS may be delayed until adulthood in up to 10% of women. The diagnosis is made on the basis of a chromosomal analysis. There is a wide variation of clinical features seen in females with TS, ranging from the severe phenotype with short stature, gonadal dysgenesis, lymphedema, and characteristic dysmorphic features, to women with only a mild reduction in final height, or premature ovarian failure. Cardiovascular disease is the most common cause of death in adults with TS Short stature is an almost invariable finding in women with TS. The mean final adult height is between 143 and 147 cm. Bone abnormalities are typical, and presented with disproportionately short legs and an abnormal upper-to-lower segment ratio. This results in the appearance of a squarely shaped chest and widely spaced nipples. Cervical vertebral hypoplasia contributes to the short stature and also causes the short neck often seen in females with TS. Scoliosis may be present in approximately 10% of females, and it may or may not be associated with vertebral abnormalities. Just under half of females with TS have cubitus valgus, or a wide carrying angle. Similar abnormalities of the medial tibial and femoral condyles may also be present, resulting in a genu valgum. Short metacarpals and metatarsals are found in a proportion of women with TS, and a \"bayonet deformity\" (also known as Madelung deformity) of the wrists may be present as a result of lateral and dorsal bowing of the radius and subluxation of the distal ulna. In addition to crowding of the carpal bones and an osteoporotic appearance. Micrognathia, outer corner of the eyes and epicanthic folds, a high arched palate, and low-set ears. Propensity also has been reported. These features may also be seen radiologically.Ultrasonic assessment of the pelvis in females with TS reveal the majority to have streak ovaries and, ovaries are too small to be identified and a hypoplastic uterus. Left-sided congenital cardiac abnormalities are more prevalent in women with TS with increased risk of aortic dissection and ischemic heart disease.  Bicuspid aortic valve is the most common congenital malformation affecting the heart and occurs  isolated or in combination with other anomalies, particularly aortic coarctation. Coarctation of the aorta affects approximately 10% TS patients.Congenital renal anomalies are approximately 9 times more common in females with TS compared with the general population. The prevalence of structural renal abnormalities in TS iw between 25% and 43% and involve a double collecting system or absent kidney, and an abnormality in migration of the kidney from the pelvis may result in a pelvic or a horseshoe kidney. Inflammatory bowel disease calculated a 2-fold increase in risk of developing IBD in women with TS. Recent evidence suggests that women with TS have an increased risk of developing chronic liver disease and  cirrhosis in TS.",
    "differential_diagnosis": "Turner, syndrome",
    "figures": [],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/6696",
    "time": "23.06.2008"
  },
  "6703": {
    "case_id": 6703,
    "title": "Mediastinal and Spinal Epidural Lipomatosis",
    "section": "Chest imaging",
    "age": "66",
    "gender": "male",
    "diagnosis": "Mediastinal and Spinal Epidural Lipomatosis secondary a steroid treatment.",
    "history": "A 66-year-old man with a history of steroid therapy for 4 months for treatment of back pain, presented in the emergency room with subacute onset of dyspnea, progressive and rapid increasing lumbar spine pain and weakness of both limbs.",
    "image_finding": "A 66-year-old man presented in the emergency room with subacute onset of dyspnea and rapidly progressive lumbar back pain and weakness of both limbs.He had a long history of mild lumbar back pain treated sporadically with anti-inflammatory medication. Four months ago, the patient had taken corticosteroids (prednisolone 150mg/day IV) by self-medication due to insufficient relief of the back pain with anti-inflammatory medication.The chest film showed an enlarged cardiac silhouette with a retrocardiac shadow of increased lucency resulting in a \"double contour\" effect (Fig. 1). The axial T1w chest MR revealed extensive mediastinal lipomatosis. There was no tracheal deviation or compression and no definable mass (Fig. 2). In the sagittal and axial T1w MR images of the thoracic and lumbar spine high intensity fat was visible within the spine epidural canal (Fig. 3) compressing the thecal sac, which has been referred to as the \"Y sign\" (Fig. 4).",
    "discussion": "Mediastinal lipomatosis is a benign condition characterized by abnormal accumulation of  non circumscribed fat within the mediastinum.  It is associated with the Cushing syndrome as a result of both chronic endogenous and exogenous steroid excess, as well as ectopic adrenocorticotropic hormone secretion and obesity.Clinically, patients could be cushingoid and obese; most of them are asymptomatic, but if symptomatic, the most frequent symptom is dyspnea. On chest X-ray, the diagnosis is suggested by symmetrical widening of the mediastinum and absence of a circumscribed mass; deviation of the trachea is uncommon which helps to differentiate it from mediastinal masses. However, occasionally tracheal compression can occur and cause dyspnea. Symptomatic spinal epidural lipomatosis (SEL) is considered a rare condition that is characterized by a pathologic accumulation of epidural fatty tissue within the epidural canal. This excessive fat can provoke slowly progressive medulla and nerve root compression. The thickness of fatty tissue greater than 7mm is a diagnostic criterion. Most of the cases are related with long-term steroid treatment but other causes have been reported in the literature, such as obesity, rheumatoid arthritis, chronic obstructive pulmonary disease and the association between steroids and protease inhibitor treatment for HIV. Only a few cases of SEL have been described in the absence of these pre-existing conditions, and referred to as \"idiopathic\" SEL. Thoracic involvement of SEL is most common followed, by lumbar involvement; cervical location has never been described.  The diagnosis of SEL relies on clinical symptoms and imaging studies with MRI being the modality of choice for the detection of the fatty tissue.",
    "differential_diagnosis": "Mediastinal, and, Spinal, Epidural, Lipomatosis, secondary, a, steroid, treatment.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006703/000002.jpg?itok=hT1bn9Mp",
            "caption": "Sagittal T1w MR lumbar spine"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006703/000003.jpg?itok=MRpzxXhZ",
            "caption": "Axial T1w MR chest"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006703/000007.jpg?itok=6WcFjWqM",
            "caption": "Chest film"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006703/000005.jpg?itok=ngvQp0JF",
            "caption": "Axial T1w MR lumbar spine"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/6703",
    "time": "12.09.2008"
  },
  "6721": {
    "case_id": 6721,
    "title": "Large pleural masses - a radiological challenge?",
    "section": "Chest imaging",
    "age": "54",
    "gender": "female",
    "diagnosis": "Solitary fibrous pleura tumour of the RIGHT lower lobe.",
    "history": "A large pleural mass was detected in a 54 year old non smoker. Clinical findings did not suggest bronchogenic carcinoma. A core needle biopsy revealed a benign mass that was subsequently surgically removed.",
    "image_finding": "A 54 year old female had a ten year history of periodical cough and little amounts of clear sputum. She had no dyspnea or weight loss. She was a non smoker and suffered from mild arterial hypertension. Laboratory findings were inconspicious. Computed tomography with a 16 slice CT and an i.v. contrast agent was performed and revealed a large pleural mass in direct and extensive contact with the right diaphragmatic pleura (Fig 1, 2). Axial images  further showeda vascular pedicle arising from an artery of the lower lobe (Figure 3) and a well delineated and lobular pleural mass (Figure 4 , 5) indicating benignity.A CT guided core biopsy of the mass was performed and histologic examination showed a localized fibrous tissue tumour with no signs of malignancy.A wedge resection of the right lower lobe around the vascular pedicle of the lower lobe artery with partial diaphragmatic resection of the pars tendinosa was necessary to remove the tumour completely. The appearance of the surgical situs and mass confirmed the radiological findings (Figure 6, 7). Final histological diagnosis was described as solitary fibrous pleura tumour (SFPT) with a tubular pedicle to the lower lobe.",
    "discussion": "Solitary fibrous pleura tumours (SFPT) are a rare tumour entity [1] with a good prognosis if surgically completely removed [2]. The former term benign pleural mesothelioma (BPM) is obsolete nowadays because SFPT are malignant in 12% to 30% [3, 4]. Numerous cases of pleural masses exist and the number of cases with SFPT reported in the literature exceeds 1000. Radiological criteria for distinguishing this tumours from pleural invasive bronchogenic carcinoma were reported by Metintas et al. 2002 [5]. SFTP are usually solitary pleural lesions. 70% arise fom the visceral pleura and 50% have a vascular pedicle. The majority of lesions are lobular with well defined borders and are located in the lung periphery. More than 25% of all lesions have contact to the ipsilateral diaphragm or cover parts of it, some are found in the fissures.CT typically shows a homogenous mass with smooth margins but large and malignant tumours can be heterogenous with areas of low attenuation. Contrast enhancement has been described in 40% of lesions. Obtuse or right angles to the pleura can be found only in 30% indicating a pleural origin. Visualization of the pedicle by CT scan is a rare finding though a pedicle \"connecting the lesion to the pleura\" was described in 50% during surgery. Improved scanner technology might improve this. MRI imaging reveals a low or intermediate signal in T1 and T2 weighted images but cases with bright T2 intensity have been reported as well. Tumour extent and infiltration into diaphragm and chest wall may be better determined by MRI [6]. Detection of SFPT with chest X-ray and computed tomography is easy. Because of missing or moderate symptoms  tumours are often quite large at presentation. Diagnosis instead can remain difficult in certain cases by radiological features. Core biopsy is beneficial then (though just in a quarter of cases a reliable histological diagnosis can be made [6]) and leads to complete surgical resection [7] as a curable procedure. In cases of incomplete resection and malignant lesions recurrences are possible.",
    "differential_diagnosis": "Solitary, fibrous, pleura, tumour, of, the, RIGHT, lower, lobe.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006721/000001.jpg?itok=jWjmadzp",
            "caption": "A large right sided pleural mass is visible."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006721/000002.jpg?itok=q_HH0ZLi",
            "caption": "The lesion has broad contact to the diaphragma."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006721/000003.jpg?itok=GVZ7gdTL",
            "caption": "A central vascular pedicle is visible."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006721/000004.jpg?itok=gOHqlA0c",
            "caption": "The mass is homogenous and has a lobular border."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006721/000005.jpg?itok=YKC9H7dM",
            "caption": "There is a broad pleural contact of the mass."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006721/000006.jpg?itok=Aziee8nO",
            "caption": "The central vascular pedicle is shown."
          }
        ]
      },
      {
        "number": "Figure 7",
        "subfigures": [
          {
            "number": "Figure 7",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006721/000007.jpg?itok=RRvCXG3c",
            "caption": "The tumour is lobular and has a central vascular pedicle."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/6721",
    "time": "27.07.2008"
  },
  "6759": {
    "case_id": 6759,
    "title": "Intrathoracic Metastatic Low Grade Fibromyxoid Sarcom",
    "section": "Chest imaging",
    "age": "64",
    "gender": "male",
    "diagnosis": "metastatic low grade fibromyxoid sarcoma",
    "history": "64 year old man who presented with a progressive shortness of breath over a couple of years. His GP ordered a chest x-ray which showed multiple large round opacities. He also had a long standing enlarged left testicle.",
    "image_finding": "This 64 year old retired aircraft parts engineer presented to his GP with increasing shortness of breath. He is a current smoker of 40 cigarettes a day. His GP ordered a chest x-ray which showed multiple large well circumscribed opacities in both lungs. He also has had a large swollen left testicle for the past eight years. Initially it was thought that the lung lesions could represent a metastatic teratoma, however ultrasound examination and urological review of his testicles did not show any evidence of malignancy. A CT scan confimed the presence of multiple oval well defined solid nodular lesions within both side of the lung panenchyma and mediastinum with calcifications.The patient underwent bronchoscopy which unfortunately did not give a tissue diagnosis. He then had an ultrasound guided biopsy of the lung nodules which was also unsuccessful. He was then referred for a mediastinoscopy. The biopsyof the lesions was successful and material was sent for histology.Ultrasound of the testicles revealed a large anechoic structure within the left scrotum.",
    "discussion": "Fibromyxoid sarcomas are very rare tumours often found on the distal extremities. They tend to affect younger patients i.e. <50 years old , the youngest patient reported on was a 4 year old child. They were first desrcibed by Evans in 1987 [1]. They often recur after primary surgical excision and frequently metastasise as was the case for this patient. Interestingly no primary sarcomatous lesion was identified for this patient although it may be possible that the original lesion was in the chest wall and at presentation was indestinguishable from the metastases.A publication in 2000 discussed 11 cases of fibromyxoid sarcoma at a large London teaching hospital. Of these 11 cases the primary lesion was in the lower extremities in four cases, chest wall in three cases, groin in one case, buttock in one case, axilla in one case and retroperitoneum in one case [2]. Of the 11 cases only one patient developed pulmonary metastases.In this case the histopathology report showed a mixture of patterns with cellular spindle areas, collagenous areas and areas of acellular hyalinisation. These features are likely to represent a fibromyxoid sarcoma. Immunohistochemistry staining shows nuclear positivity for S100 and cytoplasmic staining with bcl-2. Vimetin is also strongly positive. An article published in 2007 looked at differnt histopathological features of 48 low grade fibromyxoid sarcomas. They found that hypercellular areas (16/48), foci of epitheloid cells (13/48), and giant rosettes (6/48) were the most common histological findings. Common immunohistochemical markers present included EMA (41/45), at least focally, CD99 (38/41) and bcl-2 (36/41) while markers were essentially negative for CD34 (2/45), mdm2 (1/41), smooth muscle actin (1/45) and S100 protein (0/46) [3].Treatment for these patients is centered on surgical resection. The tumours are very unlikely to respond to traditional chemotherapy. Even when successful surgical resection takes place the tumours may recur or metastasise years or even decades later.In conclusion in a patient with large widespread lesions in the lungs the differential diagnosis shoud begin with common tumours causing cannon ball metastases but must extend to include soft tissue tumours such as fibromyxoid sarcoma. For this reason a tissue diagnosis is of utmost importance even if the patient has signs of a primary lesion elsewhere.",
    "differential_diagnosis": "metastatic, low, grade, fibromyxoid, sarcoma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006759/000001.jpg?itok=UxA-tj_k",
            "caption": "The chest x-ray ordered by the patients GP showing multiple oval well defined lesions. The lesions were initially thought to represent cannon ball metastases from either a renal, testicular or prostate primary."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006759/000002.jpg?itok=WIF7Matw",
            "caption": "CT slice showing three well circumscribed semi calcified lesions in both lungs."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006759/000003.jpg?itok=H1QEpR5V",
            "caption": "CT slice upper chest - four well defined solid nodular lesions with calcifications"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006759/000004.jpg?itok=cakbptHW",
            "caption": "CT slice (lung window) showing 3 large well circumscribed lesions"
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006759/000005.jpg?itok=w1UVF4r2",
            "caption": "Ultrasound left testicle - no evidence of focal lesion"
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006759/000006.jpg?itok=tqVRN8su",
            "caption": "Ultrasound scrotum - evidence of hydroceole"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/6759",
    "time": "08.06.2008"
  },
  "6762": {
    "case_id": 6762,
    "title": "Solitary Intrapulmonary Lymph Node",
    "section": "Chest imaging",
    "age": "65",
    "gender": "male",
    "diagnosis": "Solitary intrapulmonary lymph node with known sigmoid colonic cancer.",
    "history": "Initial presentation of rectal bleeding. Flexible sigmoidoscopy demonstrated a sigmoid neoplastic polyp. Staging CT of chest and abdomen and pelvis demonstrated a solitary right middle lobe lung nodule measuring 8mm. The nodule showed benign histology after video assisted thorascopic surgery.",
    "image_finding": "A middle aged man presented with rectal bleeding and underwent a flexible sigmoidoscopy. A sigmoid neoplastic polyp was discovered and the patient underwent further staging investigations for colonic malignancy. A CT chest, abdomen and pelvis was arranged. The sigmoid lesion was not clearly demonstrated, with no other synchronous lesion present. A solitary 11mm pre-caval lymph node was the only other feature of note in the abdomen. The liver was normal.A single 8mm nodule was demonstrated in the right lung middle lobe. No mediastinal lymphadenopathy or other feature was present.The patient underwent video assisted thoracic surgery after a sigmoid colectomy. Subsequent histology showed the nodule to an intrapulmonary lymph node and not a pulmonary metastasis.",
    "discussion": "Colonic cancer is very common in the UK and is staged well with CT imaging. The most common sites for metastases are the lungs and liver. After initial colonic surgery, some patients have reasonable survival after resection of isolated metastases in the liver or lungs. This patient was thought to have an isolated right middle lobe metastasis which later proved to be a solitary intrapulmonary lymph node, demonstrated well on CT.Solitary nodules detected on CT demonstrate diagnostic challenges with treatment options often based on known statistical information. Even with CT-PET imaging, knowledge of certain statistics is often required. In patients with a known malignancy, nodules smaller than 5mm are likely to be benign, whereas nodules larger than 5mm and smaller than 10mm are more likely to be malignant. Nodules greater than 10mm are nearly always malignant. In one study, 254 patients with a solitary lung nodule underwent video assisted thorascopic surgery (VATS). 182/254 had a known malignancy and 74/182(41%) had benign nodules. 11/182(6%) were intrapulmonary lymph nodes. 14/182(8%) had a known colorectal primary. The chances of having a solitary intrapulmonary lymph node in a patient with known colorectal cancer is quite rare. Other examples of benign nodules in the lungs to consider in the differential diagnosis of benign nodules are hamartomas, granulomas, fibrosis and focal scars. (1)Metastases always need to be excluded and the radiologist should known about what benign conditions can mimic metastases in the lungs.",
    "differential_diagnosis": "Solitary, intrapulmonary, lymph, node, with, known, sigmoid, colonic, cancer.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006762/000001.jpg?itok=wBu_aNF7",
            "caption": "Minor stranding around mid sigmoid colon. No obvious mass"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006762/000002.jpg?itok=e0pxmZmF",
            "caption": "Sigmoid colon. No obvious mass."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006762/000003.jpg?itok=svVDS4j-",
            "caption": "Sigmoid Colon"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006762/000004.jpg?itok=A422uGVr",
            "caption": "Right Middle Lobe 8mm subpleural nodule."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/6762",
    "time": "03.06.2008"
  },
  "6822": {
    "case_id": 6822,
    "title": "Infant with bronchopulmonary dysplasia (BPD)",
    "section": "Chest imaging",
    "age": "20",
    "gender": "male",
    "diagnosis": "Bronchopulmonary dysplasia in a 20-days infant.",
    "history": "A 20-days old male infant who was born preterm and had been treated with oxygen and positive pressure for 20 days shows tachypnea, tachycardia, increased work of  breathing (with retractions, nasal flaring, and grunting) and frequent desaturations.",
    "image_finding": "Chest radiography showed opacity in left upper superior pulmonary lobe.CT confirmed the presence of an apical hyperdense area which is compatible with bronchopulmonary dysplasia (BPD).",
    "discussion": "Bronchopulmonary dysplasia (BPD) is a form of chronic lung disease that develops in preterm new borns treated with oxygen and positive-pressure ventilation (PPV).It was first described by Northway and collegues in 1967. The pathogenesis of BPD remains complex and poorly understood. It results from a variety of toxic factors injuring small airways and that can interfere with alveolarization (septation), leading to alveolar simplification with a reduction in the overall surface area for gas exchange. The developing pulmonary microvasculature can also be injured. Oxygen alone can arrest septation of lungs in a saccular stage of development. Infants with BPD who were exposed to higher levels of supplemental oxygen to achieve higher levels of oxygen saturation developed a more persistent lung disease. An imbalance in releasing of pro- and anti-inflammatory cytokines, occurring as a result of volu/baro trauma, hyperoxia, pulmonary edema, and/or sepsis, damages the immature lung.Infants with BPD have abnormal findings on physical examination, chest radiography, pulmonary function testing, and histopathologic examination. Physical examination may reveal tachypnea, tachycardia, increased work of breathing (with retractions, nasal flaring, and grunting), frequent desaturations, and significant weight loss during the first 10 days of life. Chest radiography is helpful in determining the severity of BPD and in differentiating BPD from atelectasis, pneumonia, and air leak syndrome. Chest radiographs may demonstrate decreased lung volumes, areas of atelectasis and hyperinflation, pulmonary edema, and pulmonary interstial emphysema. Most recently, CT and MRI studies on infants with BPD have provided detailed images of the lung. High- resolution CT may detect radiographic abnormalities not readily identified with routine chest radiography.Therapy in this little patient consisted in making prevention for the respiratory infections. It means making some respiratory-physiotherapy and nasal irrigation, give some ascorbic acid and if necessary antibiotics. Some authors also suggest to somministrate Ab RSV as a prevention .",
    "differential_diagnosis": "Bronchopulmonary, dysplasia, in, a, 20-days, infant.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006822/000006.jpg?itok=dJuZTSyT",
            "caption": "The CT images are acquired without sedation and the quality of images is disturbed by the presence of movement-artifacts. Opacities are seen throughout the pulmonary parenchyma."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006822/000007.jpg?itok=3X1bEvz6",
            "caption": "The CT images are acquired without sedation and the quality of images is disturbed by the presence of movement-artifacts. Opacities are seen throughout the pulmonary parenchyma."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006822/000004.jpg?itok=VHnFqwaF",
            "caption": "On the right pulmonary apex a crescent shaped opacity is clearly visible. Additional opacities are seen on the left superior lobe."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/6822",
    "time": "27.06.2008"
  },
  "6860": {
    "case_id": 6860,
    "title": "Pulmonary Sequestration",
    "section": "Chest imaging",
    "age": "35",
    "gender": "female",
    "diagnosis": "Pulmonary Sequestration",
    "history": "A 40 year old female patient with left thoracic pain, after curettage for an unaccepted gestation, underwent a CT examination.",
    "image_finding": "A 40 year old woman with   left thoracic pain, after curettage for an unaccepted gestation, underwent a chest radiograph and CT examination.  No smoking history and no other relevant medical  background.A retrocardiac lesion depicted at the chest radiograph and a further CT examination was conducted. No other symptoms were present and the laboratory exams were within the normal limits. At CT examination an air-fluid level was present within this consolidation (Figure 1), with compensatory emphysema (Figure 2). Also a dilated azygos vein (Figure 3) was observed.Further imaging investigation with chest CT Multiplanar Imaging Reconstruction, confirmed the presence anomalous arterial supply of the left lower lobe mass (Figure 4). Findings were compatible with pulmonary sequestration, in accordance with the typical morphology and location.",
    "discussion": "Pulmonary sequestration (PS) is a mass of non-functioning pulmonary tissue, disconnected or abnormally communicating to the tracheobronchial tree with a normal or anomalous arterial supply and venous drainage. PS occurs in two forms of which the more frequent type is intralobar (ILS, 75-85%), located within normal pulmonary parenchyma, pleura and pulmonary venous drainage. The extralobar form is less frequent (ELS, 15-25%) which usually drains via the systemic venous system. The most frequent location of PS is in the lower left lobe. ELS may also be subdiaphragmatic or even intraperitoneal.\tEspecially the intralobar form remains often clinically latent. The major clinical manifestations are recurrent pulmonary infections, associated with fever, cough and hemoptysis.  In rare cases heart failure due to the massive blood supply of the anomalous artery and hemothorax due to hemorrhage have been described. It may also be discovered incidentally. ELS have earlier manifestations, usually during the neonatal period such as respiratory distress and recurrent infections. During the fetal period pulmonary sequestration can be complicated with fetal hydrops and hydrothorax. \tThe plain radiograph typically shows a consolidation usually in the left lower  lobe. The most usual presentation is a single homogeneous opacity but recurrent infections may lead to the formation of cystic areas within it and focal bronchiectatic changes.Identifying the anomalous arterial blood supply of a suspected pulmonary mass is the cardinal aspect of the radiographic diagnosis. Angiography is consequently considered the most suitable method to make the definitive diagnosis. The classic findings are the abnormal blood supply, directly from the lower thoracic or upper abdominal aorta in most cases. Anomalous venous drainage to the systemic venous system can also be identified with this method. CT shows the abnormal lung parenchyma and aberrant vessels supplying and draining the sequestred tissue. Within the parenchymal abnormalities cavities or cystic elements have been described, ocassionally with air-fluid levels. In some cases the alveoli are hyperinflated, forming areas of low attenuation, indicating air trapping in the sequestred mass. Calcifications can be also identified better with CT rather than with any other imaging method. Three dimensional reconstruction can depict the location and the relationship of these pathological elements.MR imaging may have advantages over CT in identifying blood vessels. Nevertheless, it cannot accuratelly evaluate the lung parenchyma with the disadvantage of considerably slower imaging.Sonography shows a mass homogeneously echogenic but may have cystic or complex character. Aberrant arterial and venous drainage can also be seen. The diagnosis can be made in utero or in infants. In these cases it can show the lung mass in fetus, particullary if hydramnios is present. Duplex Doppler is also useful in identifying the anomalous vessels.\tDifferential diagnosis includes mainly bronchiectasis, lung abscess, arterio-venous shunt, Bochdalek hernia, pulmonary infarction, cystic adenomatoid malformation, bronchogenic cyst, congenital lobar emphysema, bronchial atresia, Swyer-James syndrome, pneumonia, systemic arterial supply to normal lung and mediastinal tumors such as teratomas and neuroblastomas.\tTreatment strategy depends on the form and presence of symptoms.",
    "differential_diagnosis": "Pulmonary, Sequestration",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006860/000001.jpg?itok=6rqJlMQG",
            "caption": "Axial view, at the left lower lobe (posterior basal segment),  a solid lesion with an air fluid level is observed."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006860/000002.jpg?itok=W5i-Tc4w",
            "caption": "Air trapping"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006860/000003.jpg?itok=pLB9aPzS",
            "caption": "Dilated azygos vein due to systemic drainage."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006860/000004.jpg?itok=34tlCFYF",
            "caption": "Systemic  arterial blood  supply of the lesion."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006860/000005.jpg?itok=rl6udM_M",
            "caption": "Systemic  arterial blood  supply of the lesion."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/6860",
    "time": "28.07.2008"
  },
  "6883": {
    "case_id": 6883,
    "title": "Pleural desmoplastic small round cell tum",
    "section": "Chest imaging",
    "age": "71",
    "gender": "male",
    "diagnosis": "Pleural desmoplastic small round cell tumour.",
    "history": "A 71-year-old man with intense left chest pain and marked weight loss.",
    "image_finding": "A 71-year-old man with progressive effort dyspnoea and easy fatigue with several years of duration, with worsening in the last 7 months. Associated findings included marked weight loss and intense left chest pain with one month of evolution.In the emergency room he was submitted to a routine chest radiogram, which showed a nodular pleural thickening and a left pleural effusion with contralateral mediastinal shift. The effusion consisted of a sero-hematic fluid on thoracocentesis.During the hospital stay, he was submitted to a thoracic computed tomography (CT), which revealed a widespread nodular thickening of both visceral and parietal pleural leaflets, extending into the interlobular fissure and encasing the entire lung surface. Pleural effusion and left rib destruction with a soft-tissue component were also disclosed, as well as multiple nodular lesions in the contralateral lung and several hypoattenuating nodular liver lesions.He was then submitted to a transthoracic biopsy. Immunohistochemical studies revealed large ammounts of citoplasmatic vimentin, suggesting the diagnosis of a sarcomatous lesion, namely a desmoplastic small round cell tumour.",
    "discussion": "Desmoplastic small round cell tumour is an extremely rare and highly aggressive neoplasm, usually affecting young males and presenting as single or multiple abdominal soft-tissue masses, growing along serosal membranes with multiple nodules attached to the peritoneal surface. Because of their dissemination along serous surfaces, the development of serous effusions is a common clinical finding. At CT, areas of low attenuation within the tumour, suggestive of haemorrhage or necrosis, are frequent. In contrast-enhanced studies, the degree of uptake by the tumour is modest, approximately equal in attenuation to that of the abdominal wall musculature. The most common symptoms include abdominal pain and symptoms of gastrointestinal obstruction. Although rare, other primary sites have been reported, such as pleura, paratesticular region, bone, soft tissues and ovary. They commonly spread to the liver, lung and bone. The cell of origin for this tumour is unclear. This neoplasm shows features of epithelial, mesenchymal and neural differentiation. A characteristic translocation between chromosome 11 and 22 has been associated with it. Effective treatment must rely upon chemotherapy and radiation therapy, since due to the diffuse involvement of the abdomen at the time of diagnosis, complete resection is rarely possible. Overall survival rates for desmoplastic small round cell tumour is poor, less than 20 percent at 5 years.",
    "differential_diagnosis": "Pleural, desmoplastic, small, round, cell, tumour.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006883/000001.jpg?itok=6Bgtqw9r",
            "caption": "Nodular pleural thickening and left pleural effusion with contralateral mediastinal shift."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006883/000002.jpg?itok=EmXP4hVe",
            "caption": "Widespread nodular thickening of both visceral and parietal pleural leaflets, with extension into the interlobular fissure and encasing the entire lung surface."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006883/000003.jpg?itok=2TGTbh1n",
            "caption": "Widespread nodular thickening of both visceral and parietal pleural leaflets, with extension into the interlobular fissure and encasing the entire lung surface."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006883/000004.jpg?itok=huwAVKVo",
            "caption": "Widespread nodular thickening of both visceral and parietal pleural leaflets, with extension into the interlobular fissure and encasing the entire lung surface."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006883/000005.jpg?itok=pgQMY7uA",
            "caption": "Widespread nodular pleural thickening and pleural effusion."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006883/000006.jpg?itok=jrVoGiUq",
            "caption": "Widespread nodular pleural thickening and pleural effusion."
          }
        ]
      },
      {
        "number": "Figure 7",
        "subfigures": [
          {
            "number": "Figure 7",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006883/000007.jpg?itok=B6cQHHr0",
            "caption": "Diffuse pleural thickening associated with pleural effusion, left rib destruction with a soft-tissue component and several hypodense nodular lesions of the liver."
          }
        ]
      },
      {
        "number": "Figure 8",
        "subfigures": [
          {
            "number": "Figure 8",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006883/000008.jpg?itok=DET3R5Yh",
            "caption": "Several nodular lesions in the contralateral lung."
          }
        ]
      },
      {
        "number": "Figure 9",
        "subfigures": [
          {
            "number": "Figure 9",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006883/000009.jpg?itok=w4m3zSP9",
            "caption": "Several nodular lesions in the contralateral lung."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/6883",
    "time": "26.08.2008"
  },
  "6939": {
    "case_id": 6939,
    "title": "Aortic Transection",
    "section": "Chest imaging",
    "age": "39",
    "gender": "male",
    "diagnosis": "Traumatic Aortic Transection",
    "history": "A 39 year old motorcyclist was involved in a road traffic accident. CT chest revealed traumatic aortic transection. The patient did not survive. The CT images are presented as this is a rarely encountered finding in the radiology department owing to the high mortality rate prior to hospital admission.",
    "image_finding": "A 39 year old male motorcyclist was involved in a road traffic accident. At the scene he was intubated and put on a spinal board. The patient was airlifted to the nearest trauma centre. On arrival chest and pelvic radiographs were obtained (Fig. 1, 2). CT was intended but the patient became haemodynamically unstable and was brought to theatre. At laparotomy, haemoperitoneum was present secondary to liver lacerations and ruptured spleen. Intraabdominal bleeding was brought under control following splenectomy and surgical packing of liver lacerations.Cardiothoracic surgeons requested CT before proceeding to sternotomy.Spiral CT of the chest (arterial phase), abdomen and pelvis (portal venous phase) was performed following intravenous contrast with the arms down on a Toshiba 16 slice machine. CT brain and cervical spine followed.CT revealed aortic transection at the level of the aortic isthmus with extravasation of contrast into the mediastinum (Fig. 3). Other findings included posterior fracture-dislocation of the left hip and basal skull fracture.Sadly the patient did not survive his injuries.",
    "discussion": "The arch of the aorta passes posteriorly and from right to left. It passes anterior to the trachea and arches over the left mainstem bronchus and pulmonary artery to come to lie to the left of the body of T4. Its inferior aspect is connected to the ligamentum arteriosum, the fibrous remnant of the ductus arteriosus. Superiorly are the three branches of the arch: the brachiocephalic, the left common carotid and the left subclavian arteries. The aortic isthmus is the junction of the arch of the aorta and the descending aorta. This area is relatively fixed and prone to injury with the shearing forces of blunt trauma (1).Traumatic transection of the aorta is a common cause of death in high-speed accidents such as air crashes and road traffic accidents. Shearing stress and bending stress are forces that involve the aortic isthmus (7). Contributory factors include tethering by the ligamentum arteriosum and the \u2018osseus pinch\u2019 which occurs between the anterior chest wall and the thoracic spine at impact (2). In clinical series, 90% of aortic ruptures occur at the isthmus, just distal to the origin of the left subclavian artery (3). 70% of all patients with aortic rupture die at the scene of trauma and 80-90% die before they can be treated in hospital. Of the 10-20% of patients with aortic rupture who make it to hospital, 60-70% will survive, compared with only 2% who survive if the diagnosis is missed or delayed (4, 5). The definitive treatment is surgical repair though antihypertensive treatment will help to preserve aortic integrity while the patient is being investigated or while other life threatening injuries are being dealt with (6).CT findings in traumatic aortic rupture include direct signs of rupture such as pseudoaneurysms, intimal flaps and aortic contour irregularity as well as the indirect signs of haemomediastinum and periaortic haematoma (5).",
    "differential_diagnosis": "Traumatic, Aortic, Transection",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006939/000001.jpg?itok=yxRL_cMO",
            "caption": "Chest radiograph showing widened mediastinum"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006939/000002.jpg?itok=C8zGkAr4",
            "caption": "Posterior fracture-dislocation of the left hip"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006939/000003.jpg?itok=MS1kXev3",
            "caption": "Coronal image showing widened mediastinum. The origin of the 3 vessels from the arch is demonstrated."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006939/000004.jpg?itok=Cjk8JLnC",
            "caption": "Coronal image slightly posterior to 3a demonstrating the isthmus and descending aorta. Extravasation of contrast and irregularity of the aortic contour is evident. Bilateral chest drains seen in cross-section."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006939/000005.jpg?itok=9_gS9ySC",
            "caption": "Axial image again demonstrating irregularity of the descending aorta. A right sided chest drain is present. Bilateral lower lode contusions, haemothorax and haemomediastinum seen along with multiple rib fractures."
          },
          {
            "number": "Figure 3d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006939/000006.jpg?itok=jpwlgJY_",
            "caption": "Sagittal image again demonstrating aortic transection at the level of the aortic isthmus."
          },
          {
            "number": "Figure 3e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006939/000007.jpg?itok=ohxuAOnf",
            "caption": "Coronal image showing origin of the left subclavian artery just proximal to the level of aortic transection. Note deviation of the NG tube secondary to haemomediastinum."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/6939",
    "time": "27.08.2008"
  },
  "6972": {
    "case_id": 6972,
    "title": "Chest Pain in a Pregnant Patient with Takayasu Arteritis",
    "section": "Chest imaging",
    "age": "30",
    "gender": "female",
    "diagnosis": "Chronic obstruction of the right pulmonary artery from Takayasu Arteritis",
    "history": "A 31 week pregnant patient with Takayasu arteritis (TA) presents to the emergency department with one day of low back pain, chest pain and shortness of breath.",
    "image_finding": "A 30 year old patient, with one prior uncomplicated pregnancy, presented at 31 weeks of pregnancy to our emergency department with complaints of low back pain radiating to her chest and shortness of breath for 1 day.  Physical exam revealed sinus tachycardia and a low grade fever.  Fetal and cervical exams were unremarkable.A computed tomography angiogram (CTA) was performed to evaluate primarily for pulmonary embolism (PE) but also to rule out aortitis secondary to TA. This showed complete occlusion of the right main pulmonary artery and significant narrowing of the lower thoracic aorta (Fig 1).  In retrospect the patient\u2019s prior chest x-rays and non-contrast CT scan of the patient\u2019s chest performed 4 years earlier supported the impression that the findings were chronic in nature (Fig 2).  Echocardiogram demonstrated normal ventricular function without pulmonary artery hypertension. The patient\u2019s work up for PE, myocardial infarct, and aortic dissection were negative. The fetal heart rate remained reassuring throughout her hospitalization but she was found to have preterm contractions and a positive influenza A titer.  After tocolysis and subsequent decrease in preterm contractions her pain and shortness of breath significantly improved, she was discharged home with scheduled follow up.  Dehydration secondary to influenza infection leading to preterm contractions were thought to be the cause of the patient's presenting symptoms.The patient returned to the hospital the following week with premature rupture of membranes at 32 weeks, 1 day and delivered a healthy baby with Apgar scores of 8 and 8.",
    "discussion": "Takayasu arteritis (TA) is a chronic inflammatory disease that affects the aorta and its major branches.  The disease usually affects women in their 2nd and 3rd decades of life during childbearing age.  Cellular inflammatory infiltrates in the wall of the artery, primarily within the media, cause thickening of the arterial wall.[1, 2] This is followed by intimal and adventitial fibrosis. This process leads to luminal narrowing which can eventually cause complete occlusion.  Alternatively, destruction of the media or elastic lamina of the vessel can lead to diffuse dilatation and formation of aneurysms.[1, 2] Traditionally, TA was thought to follow a triphasic pattern of expression consisting of a systemic/preinflammatory phase, a vascular inflammatory phase and finally a \"burn out\" phase characterized by fibrotic stenotic lesions.[3] However, currently it is recognized that all phases can coexist.[3] The distribution of vessels involved varies between patients.  The aorta, the great vessels of the aortic arch and pulmonary arteries are most commonly affected.  Renal and mesenteric arterial involvement is also seen.A search of \u201cTakayasu arteritis + pregnancy\u201d on both OVID/Medline and Pubmed revealed 88 and 80 articles respectively.  A search of \u201cTakayasu arteritis + pregnancy + pulmonary\u201d revealed only 2 articles.  Reviewing these results many articles reported outcomes of pregnant women with TA, however, only two reported outcomes of pregnant women with documented pulmonary artery involvement [4, 5]. These two cases both end with the delivery of babies with good Apgar scores, in the first case mother did well.  In the second the mother, who was diagnosed with TA during her pregnancy, died of postoperative complications after repair of a thoracic aortic aneurysm.  Both articles quote the high rate of pulmonary artery hypertension in women with TA, 50% [6].  The article by Jacquemyn et al. mentions the mortality of pulmonary artery hypertension in pregnant women to be 30 \u2013 36 % and the general recommendation to terminate the pregnancy in such cases [4]. The article they reference states maternal mortality to be 30% in women with primary pulmonary artery hypertension and even higher, 56%, in women with secondary vascular pulmonary hypertension, the group that includes pulmonary hypertension secondary to TA [7].  However, this paper states that SVPH is a very heterogeneous group of disorders some of which lead to severe pulmonary hypertension but in reference to TA they state, \u201cOn the other extreme, in Takayasu\u2019s arteritis \u2026 the pregnancy, delivery and postpartal period were experienced without difficulties\u201d [7].  The case presented here is of a patient with TA and severe pulmonary artery involvement but without pulmonary hypertension. This case documents pulmonary artery involvement in a pregnant woman with TA, more severe than the previous two cases reported in the literature, further supporting the claim that women with TA and pulmonary artery involvement can tolerate pregnancy with a good outcome for themselves and their babies.",
    "differential_diagnosis": "Chronic, obstruction, of, the, right, pulmonary, artery, from, Takayasu, Arteritis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006972/000001.jpg?itok=i3IHSMRH",
            "caption": "Contrast enhanced CT of the chest shows complete occlusion of the right main pulmonary artery (long arrow) but normal enhancement of the left main pulmonary artery (short arrow)."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006972/000007.png?itok=9ZJ4kfAc",
            "caption": "The same scan more inferior shows filling of peripheral pulmonary arteries on the left but no filling on the right."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006972/000008.png?itok=N6Ob1ZYS",
            "caption": "A coronal reformatted image further shows the lack of contrast within the right pulmonary arteries (long arrow) but enhancement of the left pulmonary arteries (short arrow). Also note the narrowing of the descending aorta."
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006972/000009.png?itok=3gPpON70",
            "caption": "A more inferior axial image shows narrowing of the inferior thoracic/upper abdominal aorta (arrow)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006972/000005.jpg?itok=-5j6hLJK",
            "caption": "Chest radiograph taken prior to the CT scan in figure 1 shows a subtle Westermark sign (cutoff of the pulmonary vessels) in the right hemithorax."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006972/000010.png?itok=r5iQcsLN",
            "caption": "A non-contrast CT from 4 years earlier shows narrowing of the right pulmonary artery (arrow)."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/6972",
    "time": "29.11.2008"
  },
  "6991": {
    "case_id": 6991,
    "title": "Hyperdense pleura: Diagnosis Please!",
    "section": "Chest imaging",
    "age": "46",
    "gender": "male",
    "diagnosis": "Talc Pleurodesis",
    "history": "A 46 year old male with pevious history of spontaneous pneumothorax presented with cough and shortness of breath.",
    "image_finding": "A 46 year old male with previous history of spontaneous pneumothorax presented with cough and shortness of breath with one week of evolution.Due to its previous history of spontaneous pneumothorax a non contrast chest CT was preformed. The chest CT revealed a hyperdense, spontaneous, nodular thickening of the right pleura, on the upper third of the right lung and with involvement of the mediastinal pleura (Fig. 1, 2, 3). On the lung window small subpleural bullae were seen (Fig. 4). There were no other significant changes.",
    "discussion": "Intrinsic high attenuation pleural thickening is a relatively common condition. It is usually of benign origin and often representing the presence of calcification, frequently related to asbestos exposure, previous tuberculosis infection or bacterial empyema or hemithorax. It can also be associated with pleural fibrosis or, more rarely, with metastatic calcification and amyloidosis [1]. Other causes of malignant origin like malignant pleural mesothelioma with osteoblastic heterotologos elements are extremely rare [2].Each one of the benign aetiologies is usually accompanied by a characteristic clinical history of previous infection or trauma or specific clinical condition or a particular professional exposure. Also the lungs usually present changes that suggest a specific diagnosis that most of the times corroborates the clinical history.Talc pleurodesis is used to treat patients with chronic pleural effusion, benign or malignant or patients with recurrent spontaneous pneumothorax. Talc is an effective sclerosing agent considered to be safe and cheap. However being a mineral it is intrinsically hyperdense at CT. This is an important feature to know and recognize as it might be confused with other pleural pathologies as the ones previously mentioned.Pleural talc deposits are not routinely seen on chest radiographs following talc pleurodesis [3].At CT when present the typical findings of talc pleurodesis are the presence of focal high attenuation areas or deposits usually linear, in the posterior basal areas of the pleural space. Nevertheless this is not always the case as it can have different appearances namely a nodular contour, presence in the apex and in paramediastinal region, as shown in this case. Other unusual presentations can be present when there is an extension of talc deposits to the fissures or as a variant of the split pleura sign [4]. In summary the presence of linear or nodular high attenuation areas in the pleura and pleural space with a previous history of recurrent pleural effusion or pneumothorax and without other lung findings is highly suggestive of talc pleurodesis not requiring further investigations. In the absence of supporting clinical history, follow up may be necessary.",
    "differential_diagnosis": "Talc, Pleurodesis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006991/000001.jpg?itok=_-lthDg9",
            "caption": "Non contrast CT at mediastinal window shows a spontaneous hyperdense pleural thickening (arrow)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006991/000002.jpg?itok=jgERfwtL",
            "caption": "Non contrast CT at mediastinal window shows a spontaneous hyperdense and nodular pleural thickening (arrow)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006991/000003.jpg?itok=t3fOc6FB",
            "caption": "Non contrast CT at mediastinal window shows a spontaneous hyperdense and nodular pleural thickening with envolvement of the mediastinal pleura (arrows)."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000006991/000004.jpg?itok=OBYuGe6E",
            "caption": "Axial CT scan shows normal lungs with the presence of small subpleural blebs at the periphery of the right upper lobe (long arrow)."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/6991",
    "time": "28.11.2008"
  },
  "7004": {
    "case_id": 7004,
    "title": "Non-Hodgkin&#039;s Lymphoma mimicking Bronchogenic Carcinom",
    "section": "Chest imaging",
    "age": "43",
    "gender": "male",
    "diagnosis": "Diffuse Large B Cell Non-Hodgkin's Lymphoma",
    "history": "A 43 year old, former intravenous drug user, presented with two week history of left sided pleuritic chest pain and dyspnoea.",
    "image_finding": "A 43 year old male, former intravenous drug user (quit 5 years ago), was admitted to the accidents and emergency department with a 2-3 week history of left sided pleuritic chest pain and dyspnoea. There was mild cough with yellow sputum. He denied haemoptysis, weight loss, night sweats, recent foreign travel, surgery or immobility. He was tachypnoic at rest, had early clubbing and oxygen saturations 64% on air which improved to 91% on 15 litre O2. Chest examination showed dull percussion at left base with reduced breath sounds on auscultation. ABG showed severe type 1 respiratory failure (pO2 of 5.7 kPa). Chest radiography demonstrated left lower lobe collapse/ consolidation. Routine blood tests were unremarkable and HIV test was negative. CT chest suggested advanced left sided bronchogenic malignancy with left atrial, aortic and pulmonary artery infiltration. Flexible bronchoscopy showed large tumour occluding the left main bronchus. Biopsy showed necrotic material only. After case discussion in a multidisciplinary meeting, the patient was started on dexamethasone and was referred to the oncology team.Meanwhile he complained of dysphagia; endoscopy showed candidiasis which was treated with fluconazole.  He was seen by the oncology team three days after he was started on dexamethasone and they found marked improvement in his symptoms. The follow up CT of chest and bronchoscopy showed marked reduction in the size of the tumour. He had mediastinoscopy and biopsy confirmed the diagnosis of diffuse Large B Cell, Non-Hodgkin's Lymphoma. He was treated with chemotherapy.",
    "discussion": "Our case illustrates that lymphoma can mimick lung cancer clinically, radiologically and bronchoscopically. Lymphomas are a heterogenous group of diseases caused by malignant lymphocytes. These are divided into Hodgkin's and non-Hodgkin's lymphomas based on histological presence of Reed-Sternberg (RS) cells in Hodgkin's lymphoma. Non-Hodgkin's lymphomas are tumours originating from lymphoid tissues and represent progressive clonal expansion of B cells or T cells and/or natural killer (NK) cells, involving genetic lesions. Chromosomal translocations play an important role in the pathogenesis of many lymphomas. Some viruses like Epstein-Barr virus, Human T-cell leukemia virus type 1 and Kaposi sarcoma-associated virus are implicated in pathogenesis. These lymphomas are more common in immunosuppressed patients. A small number of lymphomas originate from chronic antigen stimulation like Helicobacter Pylori infection appears to be possible causative agent for the development of gastric mucosa-associated lymphoid tissue (MALT). Non-Hodgkin's lymphomas are being classified according to various schemes, but REAL (Revised European-American Lymphoma) classification and WHO (World Health Organisation) classification are commonly used.The clinical features depend on factors such as the location, the rate of tumor growth, and the function of the organ being compromised or displaced by the malignant process. The most common intrathoracic manifestation of non-Hodgkin's lymphoma is mediastinal lymph node enlargement, seen in nearly 35% of patients. Bronchial obstruction or endobronchial involvement may occur but less frequently than in Hodgkin's lymphma. Another intrathoracic manifestation of non-Hodgkin's lymphoma is pleural effusions, which can be exudative or chylous.Chest radiographic findings in Non-Hodgkin's Lymphoma include alveolar opacities (masses, consolidation or nodules) and peribronchial disease. Other findings include chest wall, pleural and pericardial involvement. For the confirmation of diagnsosis, histology from biopsy of a lymph node, bone marrow or extra nodal mass is essential.  Accurate staging is essential to tailor appropriate therapy. CT is readily available and widely used for initial staging, but has the inherent limitation that the size of lymph nodes may not reliably indicate presence or absence of malignancy. CT is also used for assessing treatment and conducting follow up care. PET/CT scan is increasingly used to obtain functional and anatomical data that can result in alteration of clinical staging and management decisions. In a study of 103 consecutive newly diagnosed patients, addition PET/CT to CT scan changed the management decisions in approximately a quarter of non-Hodgkin's and a third of Hodgkin's lymphoma patients, mostly in early disease stages.  The treatment options of non-Hodgkin lymphomas depend on tumor stage, phenotype (B-, T- or Natural Killer cells), histology (low-, intermediate-, or high-grade), symptoms, performance status, comorbidities and the patient's age. The treatment options are radiotherapy, chemotherapy (most common is CHOP regime) or combination of both. The role of surgery is limited, useful in selected patients, especially if the disease is localized.",
    "differential_diagnosis": "Diffuse, Large, B, Cell, Non-Hodgkin's, Lymphoma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007004/000001.jpg?itok=SN8JCUsJ",
            "caption": "There is collapse of the left lower lobe and patchy consolidation in the remaining left upper lobe. The whole mediastinum is shifted to the left."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007004/000002.jpg?itok=UDXOa1eb",
            "caption": "This chest Xray which was done after the patient was started on chemotherapy showed clear lung fields. Hickman line in situ."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007004/000003.jpg?itok=w2iyBQQ2",
            "caption": "The first bronchoscopy showed large tumour obstructing left main bronchus."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007004/000004.jpg?itok=8B3WPtx8",
            "caption": "Repeat bronchoscopy, done seven days after the first one, showed resolution of previous noted tumour."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007004/000005.jpg?itok=p3_bHH8R",
            "caption": "There is a very large central left sided mediastinal mass measuring more than 10 cm in maximum diameter. This has occluded the left main bronchus and caused complete collapse of the left lower lobe."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007004/000006.jpg?itok=cUGcH4GR",
            "caption": "The mass also infiltrates the left atrium, the distal main pulmonary artery."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007004/000008.jpg?itok=TdSbze0N",
            "caption": "CT appearances were very suggestive of advanced left sided bronchogenic carcinoma."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007004/000009.jpg?itok=nWOjMA2U",
            "caption": "Dramatic improvement of central left lung and mediastinal mass."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007004/000010.jpg?itok=2SR5wRT-",
            "caption": "The huge mass now confined to the subcarinal fossa."
          },
          {
            "number": "Figure 4c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007004/000010.jpg?itok=2SR5wRT-",
            "caption": ""
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/7004",
    "time": "14.01.2009"
  },
  "7018": {
    "case_id": 7018,
    "title": "Bronchial Carcinoi",
    "section": "Chest imaging",
    "age": "30",
    "gender": "female",
    "diagnosis": "Bronchial Carcinoid",
    "history": "A 30 year old female was referred to the respiratory physician by her general practitioner because of recurrent respiratory tract infections for the past years. A chest radiograph was organized by the GP and because of history of recurrent chest infections, a CT scan was requested by the respiratory physician.",
    "image_finding": "The chest radiograph revealed patchy airspace shadowing in the right upper lobe consistent with consolidation. CT scan of the chest confirmed a right upper lobe consolidation. An elliptical enhancing mass was seen in the right upper lobe bronchus measuring approximately 2 x 0.6 cm causing obstruction. The distal bronchial tree was identified as negative contrast suggestive of inspissated secretions. The location, elongated nature and enhancement was felt to be consistent with carcinoid. Bronchoscspy and a biopsy confirmed the mass lesion to be a carcinoid. The patient underwent a right upper lobectomy with complete removal of the carcinoid.",
    "discussion": "Carcinoid is a serotonin-producing malignant tumor belonging to a class of neoplasm known as the neuroendocrine tumors [1]. Bronchial carcinoids arise from the neurosecretory Kulchitsky cells which are present normally in the bronchial mucosa. They account for 5% of all primary lung cancers. There is no relationship to smoking, inhalation of carcinogens, radiation or environmental factors. Two different types of carcinoids have been identified. About 80\u201390% are typical carcinoids, the remaining 10\u201320% atypical carcinoids. Typical carcinoid tumors are low-grade tumors, with 10-year survival rates approaching 90%. They are capable of local invasion, including invasion of local lymph nodes, but rarely metastasize. Atypical carcinoid is much more aggressive and carries a 5-year survival rate of 25-69% [2]. Bronchial carcinoids usually involve the proximal bronchi. They can grow primarily as a polypoid lesion or a predominantly infiltrative process with only minimal protrusion into bronchial lumen, known as iceberg tumor. Because the lesions grow slowly into the bronchial lumen, the typical presentation is of segmental or lobar atelectasis, leading to indolent symptoms of coughing, wheezing, recurrent infections or hemoptysis. Carcinoid syndrome due to bronchial carcinoid is rare (2-5%), and when present, it is usually associated with liver metastases (it can occur with very large bronchial carcinoid tumours in the absence of metastases). The carcinoid syndrome is associated with flushing, diarrhoea, wheezing and elevated urinary 5 Hydroxy Indole Acetic Acid (5 HIAA). Right sided valvular disease may develop after svereal years.The imaging features of typical and atypical carcinoids are too similar to be separated. Although the location of carcinoids varies, the majority are centrally located and therefore related to airways. Chest radiographs most often show a well-defined hilar or perihilar mass as an isolated finding or with associated distal parenchymal disease. The associated parenchymal change may be consolidation, which is suggestive of atelectasis, obstructive pneumonitis, or recurrent pneumonia [3]. At CT, carcinoid tumors appear as spherical or ovoid nodule or mass with a well-defined and slightly lobulated border. They are typically located close to central bronchi, often near the bifurcation area. Calcification is usually not visible on chest radiographs, but on CT images calcification or ossification can be seen in up to 30% of tumors and manifests in a punctate or diffuse pattern. Moreover, calcification is more frequent in central carcinoids than in peripheral carcinoids. Atypical carcinoids have been reported to be larger than typical carcinoids and are more likely to occur in the lung periphery. On MR imaging, bronchial carcinoids have high signal intensity on T2-weighted and STIR sequences, thus MR imaging may be helpful in distinguishing small carcinoids from the adjacent normal vascular structures. Carcinoid tumors have high numbers of somatostatin receptors, which allow scintigraphic imaging with the radiolabeled somatostatin analogue, octreotide [4]. 80% of bronchial carcinoids are visible at bronchoscopy. Metastases occur in 15% of bronchial carcinoids and usually involve the liver, bone, adrenal glands and brain [3].  In the absence of distant metastases, the treatment of choice is complete removal of the primary carcinoid with maximal parenchymal preservation.",
    "differential_diagnosis": "Bronchial, Carcinoid",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007018/000001.jpg?itok=IQHH9w4V",
            "caption": "An elliptical enhancing softtissue mass is seen in the right upper lobe bronchus. There is consolidation of the right upper lobe."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007018/000002.jpg?itok=bBFyse8_",
            "caption": "The distal bronchial tree is identified as negative contrast suggesting inspissated secretions."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007018/000003.jpg?itok=DcRO_upc",
            "caption": "An obstructing mass is seen in the right upper lobe bronchus with evidence of consolidation of the upper lobe."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007018/000004.jpg?itok=K6fFB3wm",
            "caption": "Soft tissue mass in the right upper lobe bronchus. Patchy consolidation of the right upper lobe."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007018/000005.jpg?itok=UqYUDOcW",
            "caption": "Mass is noted in the right upper lobe bronchus."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007018/000006.jpg?itok=UosQN6_w",
            "caption": "Patchy air space shadowing is seen in the right upper lobe."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007018/000007.jpg?itok=JOrPe5Vp",
            "caption": "Post-op radiograpgh following right upper lobectomy is relatively normal. Minor degree of tenting of right hemidiaphragm is seen."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/7018",
    "time": "11.11.2008"
  },
  "7022": {
    "case_id": 7022,
    "title": "Lung metastases from hemangiopericytom",
    "section": "Chest imaging",
    "age": "65",
    "gender": "female",
    "diagnosis": "Enlarging lung metastases from hemangiopericytoma",
    "history": "25 years ago, at age 40 , this woman was surgically treated for a cervical hemangiopericytoma. 3 years ago, at age 61, a CT of the lung demonstrated pulmonary metastases.",
    "image_finding": "This patient at age 40 underwent surgical removal of an hemangiopericytoma of the neck. After surgery, radiation therapy was performed.At age 61, after appearance of shortness of breath, she underwent some radiological exams: a conventional radiograph of the thorax followed by a CT examination (of the chest) with contrast agent, which showed pulmonary nodular lesions, that were biopsied and histologically classified as lung metastases from hemangiopericytoma. She underwent chemotherapy for three years. However follow-up CT examination (after three years) showed an increase in size of the lung metastases and the appearance of another metastic lesion near the third cervical vertebra causing bone erosion.",
    "discussion": "Hemangiopericytoma is an unusual vascular neoplasm that arises from the pericytes of Zimmerman. It is associated with capillaries, therefore they may occur anywhere in the body. Most common locations include the lower extremities, pelvic retroperitoneum, head and neck. Clinically, hemangiopericytoma is usually of insidious onset.The paucity of symptoms often allows the tumors to attain tremendous proportions before discovery. Presenting symptoms are varied, depending upon the location of the tumor. Patients with thoracic  hemangiopericytomas may have shortness of breath as the only symptom.Surgical removal is the primary treatment for this tumor. Adjuvant radiation therapy or chemotherapy often give poor results. Metastases affect predominantly the lung, bone, liver and regional lymp nodes. In general, survival rates are unfortunately poor, with less than 50% of patients being alive and well after 5 years.The plain radiographic findings are non-specific, and consist of a soft tissue mass with or without calcifications.At CT examination, these tumors have attenuation characteristic of soft tissue, and contain multiple areas of low attenuation consistent with necrosis, haemorrhage or cystic degeneration. In constrast-enhanced scans these tumors enhance prominently, particulary in the periphery of the lesion because of their hypervascularity.",
    "differential_diagnosis": "Enlarging, lung, metastases, from, hemangiopericytoma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007022/000001.jpg?itok=_DTMPX3W",
            "caption": "Lung reconstruction.\n2005"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007022/000002.jpg?itok=C6w2QTIR",
            "caption": "Lung reconstruction.\n2008\nIncreased number and dimension of metastases"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007022/000003.jpg?itok=Cz7TsJHt",
            "caption": "Chest Radiography 2005"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007022/000004.jpg?itok=Gvn5KE_f",
            "caption": "Chest Radiography 2008"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007022/000005.jpg?itok=SH3CTcW2",
            "caption": "Another metastatic lesion near a cervical vertebra, which contains necrotic areas."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007022/000006.jpg?itok=O7Iim46C",
            "caption": "The cervical lesion cause bone erosion"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007022/000007.jpg?itok=K04JINXN",
            "caption": "CT 2005. Soft tissue window."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007022/000008.jpg?itok=6suv2v2n",
            "caption": "CT 2005. Soft tissue window"
          },
          {
            "number": "Figure 4c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007022/000009.jpg?itok=IAIcp17x",
            "caption": "CT 2005. Soft tissue window"
          },
          {
            "number": "Figure 4d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007022/000010.jpg?itok=6HrGwzOs",
            "caption": "CT 2005. Soft tissue window"
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007022/000011.jpg?itok=GXs2WZ5r",
            "caption": "CT 2008. Soft tissue window."
          },
          {
            "number": "Figure 5b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007022/000012.jpg?itok=_RCQg4Rr",
            "caption": "CT 2008. Soft tissue window."
          },
          {
            "number": "Figure 5c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007022/000013.jpg?itok=07RJZV3B",
            "caption": "CT 2008. Soft tissue window."
          },
          {
            "number": "Figure 5d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007022/000014.jpg?itok=0pJMPm9F",
            "caption": "CT 2008. Soft tissue window."
          },
          {
            "number": "Figure 5e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007022/000015.jpg?itok=orLevL_2",
            "caption": "CT 2008. Soft tissue window."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/7022",
    "time": "29.11.2008"
  },
  "7074": {
    "case_id": 7074,
    "title": "Subsegmental acute pulmonary embolism with right ventricular overl",
    "section": "Chest imaging",
    "age": "50",
    "gender": "male",
    "diagnosis": "Pulmonary subsegmental embolism, pulmonary infarction and right ventricular overload.",
    "history": "A 50 year old patient presented to the emergency department because of sudden onset of dyspnea. On physical examination, there was a pretibial oedema and jugular engorgement.",
    "image_finding": "A 50 year old male patient, with unremarkable previous history, presented to the emergency department because of sudden onset of dyspnea. On physical examination, there was pretibial edema and jugular engorgement. Blood gases and chest radiography were unremarkable.Pulmonary angio-CT was then performed, showing bilateralcentral filling defects in lower lobe subsegmental pulmonary arteries , as well as inversion of the right ventricle/left ventricle ratio. A peripheral, pleural-based wedge-shaped focal opacity was also seen in the apical segment of the right lower lobe.",
    "discussion": "Pulmonary embolism (PE) is the third most common cause of cardiovascular death, after myocardial ischemia and stroke [4]. The diagnosis of pulmonary embolism is a challenge because of the scarce, nonspecific signs and symptoms [4]. CT pulmonary angiography is a relatively safe, non-invasive test which allows not only a quick diagnosis but also assessment of the extension of the PE [3,4]. The sensitivity and specificity of CT with pulmonary angiography has been consistently high, ranging from 53\u2013100% and 78\u2013100%, respectively [4]. Filling defects in the pulmonary vessels represent pulmonary emboli [1]. When emboli are located in the centre of the vessel and surrounded by contrast medium, they are related to acute embolism. When emboli are seen at the periphery of the vessel, with contrast medium running in the centre of the vessel, the emboli are not recent. Other signs of acute pulmonary embolism are pulmonary infarcts, which are seen as focal wedge-shaped pleural-based opacities, and right ventricle overload. Usually, the short-axis diameter of the right ventricle is the same as the left ventricle's [1]. A right ventricle (RV)/ left ventricle (LV) ratio larger than 1.0 is a CT sign of right ventricular overload [2]. The short axis of the RV is measured at the level of the tricuspid valve from inner wall to inner wall at the widest point, which is typically in the basal third of the ventricle. The short axis of the LV is measured at the level of the mitral valve from inner wall to inner wall at the widest point, which also is typically in the basal third of the ventricle [3]. This finding at CT in association with pulmonary embolism, may indicate right ventricular overload secondary to acute elevation of pulmonary artery pressure [1]. When the right atrium is also dilated, it is probably due to the elevated right-sided cardiac pressure. Left inward bowing of the inter-ventricular septum may also be seen. Cardiovascular CT findings, such as the RV/LV diameter ratio >1.0, have shown a significant correlation with fatal outcome on pulmonary embolism [3]. In our patient, although PE involved only subsegmental pulmonary arterial branches, there was right ventricular overload. Awareness of the CT signs of right ventricular overload is important since it allows risk stratification and helps in optimal therapeutic management [2,3].",
    "differential_diagnosis": "Pulmonary, subsegmental, embolism,, pulmonary, infarction, and, right, ventricular, overload.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007074/000004.jpg?itok=pABNq5Zs",
            "caption": "Central filling defect in right subsegmental pulmonary artery branch"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007074/000006.jpg?itok=LpGLHYCf",
            "caption": "Central filling defect in a right subsegmental pulmonary artery branch"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007074/000007.jpg?itok=jy4hiB1H",
            "caption": "Right ventricular/left ventricular diameter is >1, indicating right ventricular overload"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007074/000005.jpg?itok=e_ikp3u2",
            "caption": "Focal wedge-shape pleural-based opacity."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/7074",
    "time": "04.12.2008"
  },
  "7129": {
    "case_id": 7129,
    "title": "Hereditary Haemorrhagic Telangectasi",
    "section": "Chest imaging",
    "age": "18",
    "gender": "female",
    "diagnosis": "Hereditary Haemorrhagic Telangectasia (Osler Weber Rendu): Multiple PAVM",
    "history": "This 18 year-old female presented with pyrexia, headaches and a reduced conscious level.",
    "image_finding": "This 18 year-old female presented with pyrexia and symptomatology suggestive of a CNS infection.  As part of her initial work-up a pre and post contrast CT brain was performed in addition to a plain chest radiograph. The plain chest radiograph identified several ill-defined nodules in both lungs - the most apparent within the right mid and left upper zones.  Given the young age of the patient the differential diagnosis included multiple pulmonary AVM's (PAVM), especially in view of the apparent feeding artery and draining vein to the left upper zone lesion (Figure 1). Following an appropriate clinical assessment further imaging with CT chest (arterial phase) was performed indicating the presence of multiple PAVM's - the largest in the right middle lobe (Figure 2). CT Brain (pre and post contrast) revealed a large enhancing mass within the right parietal lobe with surrounding oedema, with mild mass effect consistent with a cerebral abscess (Figure 3).  Given the presence of mutilpe PAVM's this was inferred to be from a septic emboli.Following treatment for her cerebral abscess the decision was made to treat the right middle lobe PAVM.   Vasocclussion was successfully achieved by coil embolisation ('embolotherapy') under the care of the vascular radiology team (Figure 4).",
    "discussion": "Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant genetically inherited condition also known as Osler-Weber-Rendu disease. It characterized by abnormal dysplastic blood vessels which are delicate and prone to bleeding. These vessels are in the form of telangectasias, arteriovenous malformations (AVM) and aneurysms. These commonly occur on the tongue, hands/fingers, nose, lips, mouth/throat and conjunctiva. The internal organs that are most often affected are the lungs, brain, gastrointestinal tract and liver (1). It occurs in one in 50,000 people. Recurrent nosebleeds are a nearly universal symptom in this condition. Usually the nosebleeds begin in childhood and become worse with age. The skin changes begin at puberty, and the condition becomes progressively worse until about 40 years of age, when it stabilizes.  This condition is sometimes diagnosed upon investigating anaemia when endoscopy reveals angiodysplasia and/or AVMs. Radiological imaging and intervention is often at the heart of diagnosing and treating HHT (2). The lung is involved in 5-15% of HHT cases and takes the form of PAVM's. Up to 60% of patients with PAVM's have HHT. The imaging characteristics of PAVMs in HHT are the same as for the usual PAVM's, except that in HHT there are either multiple PAVM's or the patient has other features to support the diagnosis of HHT.  Imaging appearances include a sharply defined mass/nodule on plain film which may be lobulated/oval or round (Figure 1). These classically demonstrate a feeding artery and/or draining pulmonary vein. The PAVM's are beautifully outlined on arterial phase CT of the the thorax (Figure 2), which further delineate the feeding and draining vessels. These may be associated with cord like bands connecting the lesion to the hilum. PAVM's are most common in the lower lobes and increase in size with age. PAVM's may contain phleboliths. PAVMs are now typically treated with embolotherapy, with the delivery of coils or detachable balloons by selective catheterisation (Figure 4).  The siginificant impairment to pulmonary function that may result from PAVM's along with the secondary risks, such as stroke and cerebral abscess, associated with pulmonary shunts support the arguement for embolotherapy of PAVM's with feeding arteries greater than 3mm in diameter (3).  The long term outcome from this treatment is favourable (4), however residual shunting is known to persist despite successful embolotherapy, which is the rationale for continued antibiotic prophylaxis to prevent brain abscess formation (5). As the PAVM bypasses the capillary bed the lung loses its filter function allowing paradoxical emboli and bateria to pass directly into the systemic circulation with resultant stroke or cerebral abscess formation (6).",
    "differential_diagnosis": "Hereditary, Haemorrhagic, Telangectasia, (Osler, Weber, Rendu):, Multiple, PAVM",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007129/000001.jpg?itok=2up24ndK",
            "caption": "Ill defined nodules, particularly in the right middle and left upper zones"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007129/000002.jpg?itok=wO0K01LF",
            "caption": "Arterial phase CT demonstrating a right middle lobe PAVM"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007129/000003.jpg?itok=jfdRJhLc",
            "caption": "Right parietal lobe mass with surrounding oedema and mass effect"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007129/000004.jpg?itok=4K8H4YG1",
            "caption": "Appearances following coil embolisation with coils in the right mid-zone and disappearance of the PAVM"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/7129",
    "time": "18.04.2009"
  },
  "7135": {
    "case_id": 7135,
    "title": "Invasive aspergillosis.",
    "section": "Chest imaging",
    "age": "48",
    "gender": "male",
    "diagnosis": "Invasive aspergillosis.",
    "history": "A 48-year-old man with Acute Myelomonocytic Leukaemia (AML) was evaluated for fever and melaena.",
    "image_finding": "A 48-year-old man with AML developed severe neutropenia, fever and melaena after the first cycle of chemotherapy. A chest radiograph showed multiple bilateral, patchy, nodular opacities and left pleural effusion. Chest computed tomography (CT) confirmed a multifocal involvement of the lung parenchyma, characterized by multiple and bilateral cavitatory lesions, mainly distributed in the upper lobes. Some lesions contained hyperdense nodules, which were separated from the lesion walls by an air space (the \u2018air crescent\u2019 sign). The nodules appeared to be surrounded by a ground-glass attenuation area (the CT 'halo' sign). Bilateral pleural effusion was also present. These signs were suggestive for invasive pulmonary aspergillosis.An abdominal CT scan revealed a bowel subocclusion with significant wall thickening of some bowel loops, which was interpreted as a possible consequence of the mycotic infection. A few days later, the patient developed oral cavity mucositis and obstructive nasal symptoms. A brain and maxillo-facial CT revealed an involvement of the right ethmoidal sinus and of the maxillary sinuses, as well as an erosion of the palatine bones, the right lacrimal bone, and the right frontal and palatine processes of the maxilla, associated with involvement of right medial periorbital soft tissues. Nine days later, during the antimycotic treatment, a new chest and abdominal CT examination was performed, revealing imaging findings compatible with an initial improvement. In particular, the exam showed a numerical and dimensional decrease of the bilateral cavitatory pulmonary lesions, as well as a reduction of pleural effusion decrease and total resolution of bowel subocclusion.",
    "discussion": "Invasive aspergillosis is a potentially lethal opportunistic infection that primarily occurs in immunosuppressed patients, like patients with hematologic disorders (leukaemia, lymphoma) and those who have undergone bone marrow or other organ transplantation. Specifically, invasive aspergillosis should be suspected in any patient with neutropenia who develops fever not responding to antibiotics. Owing to its intrinsic high mortality rate, early diagnosis and treatment are essential for a successful clinical outcome in these patients. A tissue diagnosis may be difficult, because sputum cultures are positive in only 10% of patients. Alternatively, more invasive diagnostic approaches, including bronchoscopy with transbronchial biopsy, percutaneous needle aspiration biopsy, or open lung biopsy, may be required. However, possible thrombocytopenia or compromised respiratory status may be a relative contraindication to these invasive procedures. For these reasons, imaging findings that suggest the diagnosis of invasive aspergillosis are important. Initially, in the invasive pulmonary aspergillosis, chest radiograph may be normal, but as the infection progresses, single or multiple rounded opacities, pleural-based infiltrates (pulmonary infarctions) and cavitation can develop. In the early stages of infection, CT is more sensitive and specific than radiography. Typical chest CT scan findings are multiple nodules, the halo sign (zone of low attenuation due to haemorrhage surrounding the pulmonary nodule) and the air crescent sign (crescent-shaped lucency secondary to necrosis) that marks the recovery phase of the infection. Extensive paranasal sinus involvement is frequently associated with disseminated aspergillosis. In this particular involvement, CT scan can show focal or diffuse areas of increased attenuation in paranasal sinus. CT and MRI can also demonstrate invasive processes of the skull base and the facial bones, defining periorbital and intracranial spread. Moreover, the gastrointestinal tract can be affected by aspergillosis. In this site, aspergillosis can cause bowel infarction or diffuse peritonitis from a small bowel perforation. Findings of abdominal CT such as small bowel obstruction secondary to segmental mural thickening, diffuse small bowel distention, and inflammation of the peri-enteric fat, may be non-specific.The gold standard of systemic antimycotic treatment is voriconazole, which has proved to be significantly superior to conventional amphotericin B. Combined therapy with two antimycotic compounds may be a promising future strategy for first-line treatment.",
    "differential_diagnosis": "Invasive, aspergillosis.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007135/000001.png?itok=e5_oYtEW",
            "caption": "Chest X-ray showing multiple bilateral opacities, some of which with a cavitatory appearance. Left pleural effusion."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007135/000002.png?itok=O0RNcUiX",
            "caption": "Multiple bilateral cavitatory lesions with both 'halo' and 'crescent' signs."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007135/000003.png?itok=6suAf7BY",
            "caption": "Multiple bilateral cavitatory lesions with both 'halo' and 'crescent' signs."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007135/000004.png?itok=Q1Ysz5aQ",
            "caption": "Multiple bilateral cavitatory lesions with both 'halo' and 'crescent' signs. Bilateral basal pleural effusion."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007135/000005.png?itok=mOzbcbZI",
            "caption": "Reduction of bilateral nodules. Cavitatory lesions now have a more solid appearance."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007135/000006.png?itok=zivlh4Cr",
            "caption": "Reduction of bilateral nodules. Cavitatory lesions now have a more solid appearance."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007135/000007.png?itok=j-A2_HJb",
            "caption": "Reduction of bilateral nodules and pleural effusion. Cavitatory lesions now have a more solid appearance."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007135/000008.png?itok=QKqLV3D9",
            "caption": "Intestinal subocclusion with significant thickening of bowel loops."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007135/000009.png?itok=kDhfJ6B0",
            "caption": "Resolution of intestinal subocclusion with regression of bowel wall thickening and distention."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007135/000010.png?itok=AOAOiJ-T",
            "caption": "Axial image: involvement of maxillary sinuses bilaterally."
          },
          {
            "number": "Figure 5b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007135/000011.png?itok=8cQ8Q6zT",
            "caption": "Axial image: extension to right medial periorbital soft tissue."
          },
          {
            "number": "Figure 5c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007135/000012.png?itok=DdrjuB2_",
            "caption": "Axial image: right ethmoidal sinus involvement with lacrimal bone erosion."
          },
          {
            "number": "Figure 5d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007135/000013.png?itok=sugdSx5I",
            "caption": "Coronal image: erosion of palatine process of the right maxillary bone."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/7135",
    "time": "15.01.2009"
  },
  "7147": {
    "case_id": 7147,
    "title": "Chronic posttraumatic aortic pseudoaneurysm",
    "section": "Chest imaging",
    "age": "45",
    "gender": "male",
    "diagnosis": "Chronic posttraumatic aortic pseudoaneurysm",
    "history": "A 45 year old man was referred to CT examination in the diagnostic work-up for a solitary pulmonary nodule. He had no remarkable past personal history, other than a motor vehicle accident 20 years earlier.",
    "image_finding": "A 45 year old man was referred to CT examination in the diagnostic work-up for a solitary pulmonary nodule. He had no remarkable past personal history, other than a motor vehicle accident 20 years earlier, without recognisable complications at the time.Thoracic CT examination was performed and a small, peripheral nodule was found in the posterior segment of the right lower lobe. Additionally, near the aorthic isthmus, in the proximal descending aorta, a saccular aneurysm was identified, whith circumferential parietal calcification.",
    "discussion": "Blunt aortic injury is a significant cause of death in trauma patients, estimated to occur in 10\u201320% of all high-speed deceleration fatalities [1]. It is immediately fatal in 80\u201390% of cases and most deaths (85%) occur at the scene of the accident  [1]. In those patients who initially survive, mortality is high if it goes undetected and increases over time, ranging from 30% mortality at 6 h, to 50% at 24 h and 90% at 4 months [3]. Only 2% of patients with untreated traumatic aortic injury survive long enough to develop a chronic pseudoaneurysm [2].  Posttraumatic aortic aneurysms are typically located at the ligamentum arteriosum, at the aortic isthmus in the proximal descending thoracic aorta and are frequently calcified [2, 3]. There are 2 types of focal dilatation of a blood vessel: true aneurysms, which involve all layers of the vessel wall, and false aneurysms or pseudoaneurysms, which are secondary to dilatation of the outer layers of the vessel wall. Generally, there is a focal penetration of the intima and media, in the context of trauma, surgery, infection, or atherosclerosis. Nevertheless, the adventitia and perivascular connective tissue are spared and contain the process, preventing rupture and exsanguination [4]. Surgery or endovascular stenting is recommended for posttraumatic aortic pseudoaneurysms because these lesions may undergo delayed rupture [5].Due to the typical location (proximal descending thoracic aorta, near the aortic isthmus) and presentation of the aneurysm (saccular aneurysm with circumferential calcification), and the past history of the patient, the aneurysm was atributted to a deceleration injury from the motor vehicle accident the patient had suffered twenty years before and the patient was proposed for pseudoaneurysm repair.",
    "differential_diagnosis": "Chronic, posttraumatic, aortic, pseudoaneurysm",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007147/000001.jpg?itok=oOAAuA6h",
            "caption": "Circumferential calcification in the proximal descending thoracic aorta."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007147/000006.jpg?itok=DC2rx7Tg",
            "caption": "A saccular aneurysm with circumferential parietal calcification in the proximal descending thoracic aorta."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007147/000005.jpg?itok=qRa0t54U",
            "caption": "Aneurysm with circumferential parietal calcification at the proximal descending thoracic aorta."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007147/000006.jpg?itok=DC2rx7Tg",
            "caption": "A saccular aneurysm with circumferential parietal calcification at the undersurface of the proximal descending thoracic aorta."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/7147",
    "time": "15.01.2009"
  },
  "7150": {
    "case_id": 7150,
    "title": "Pulmonary arteriovenous malformations",
    "section": "Chest imaging",
    "age": "52",
    "gender": "female",
    "diagnosis": "Pulmonary arterio-venous malformation",
    "history": "A 52 year old women presented with symptoms of increasing dyspnea on exertion and a pulsatile retrosternal sensation.",
    "image_finding": "A 52 year old women presented with symptoms of increasing dyspnea on exertion (classified as NYHA class II-III), which did not improve with transfusion, and a  pulsatile retrosternalsensation. She had neither cough nor sputum production. She had been diagnosed with hereditary hemorrhagic teleangiectasia several years ago and had known multiple arteriovenous malformations in the liver. She also had a moderate insufficiency of the mitral valve. Chest radiography and contrast-enhanced multidetector CT of the thorax were performed. Chest X-ray showed a nodular opacity, paravertebral in the left lower lobe (Fig 1).Contrast enhanced chest MDCT showed a well-defined nodule (diameter 2.5cm), posteriorly in the left lower lobe with a hypertrophied feeding artery and a draining vein (Fig 2, 3); and a second well-defined nodule (diameter 0.6cm) was found posterior in the left lower lobe with also a feeding artery and a draining vein (Fig 4). Maximum intensity projection (MIP) images (Fig 5) and volume rendered technique (VRT) images (Fig 6) showed the pulmonary arteriovenous malformation demonstrating the simple angio-architecture of an AVM with a single feeding artery and a single draining vein, both connected to the aneurysmal sac (nidus).",
    "discussion": "In our patient, with hereditary haemorrhagic teleangiectasia (Osler-Weber-Rendu syndrome), imaging findings led to the diagnosis of two pulmonary arteriovenous malformations in the left lower lobe.Pulmonary arteriovenous malformations (PAVMs) are mostly congenital (80%) and classified as simple (80%; single feeding artery leading to a single draining vein) or complex (20%; two or more feeding arteries or draining veins) types. They commonly present in the lower lobes (53-70%) and can lead to chronic hypoxemia and systemic emboli. Approximately 70% of the PAVMs are associated with hereditary haemorrhagic teleangiectasia (HHT), and about 15-30% of individuals with HHT have a PAVM. HHT is an autosomal dominant disorder, which presents with arteriovenous malformations in skin, mucous membranes and visceral organs.PAVMs are usually asymptomatic, but symptoms can occur in the 4th to 6th decade of life with the development of congestive heart failure, respiratory failure with cyanosis, life threatening cerebrovascular complications including stroke and cerebral abscesses. The diagnosis of PAVMs can be suspected on chest radiography (98% abnormalities) as a well-defined oval mass of uniform density, ranging in size from 1-5cm, with connecting vessels from the hilus (Fig.1). However, chest CT scanning is invariably required to confirm the diagnosis. The characteristic appearance of a PAVM on contrast-enhanced CT scans is the presence of a homogeneous, circumscribed, non-calcified nodule with connecting blood vessels (Fig. 2,3). Three-dimensional (3D) spiral CT images are useful in the pre-therapeutic evaluation of the angioarchitecture, namely, the number and orientation of the feeding arteries (Fig 5,6). In our case, maximum intensity projection (MIP) and volume rendered technique (VRT) were used as 3D techniques (Fig. 5, 6). Pulmonary angiography is therefore not longer the golden standard and is only required when further intervention is planned. Magnetic resonance imaging (MRI) is less useful than contrast-enhanced CT scanning and not used in the diagnosis of PAVMs. Contrast enhanced 2D echocardiography (sensitivity 92%) and a 100% oxygen study can only confirm a right-to-left intrapulmonary shunt, but they both need further investigation because they cannot determine the number of PAVMs, their location in the lung and their size. The treatment of choice in symptomatic patients and PAVMs with feeding arteries >3mm includes embolotherapy. Surgery is only indicated for larger malformations or when there is a significant risk of embolotherapy.",
    "differential_diagnosis": "Pulmonary, arterio-venous, malformation",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007150/000001.jpg?itok=fP13W9ii",
            "caption": "Nodular opacity, paravertebral in the left lower lung."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007150/000002.jpg?itok=S6UW1y5b",
            "caption": "A well-defined contrast enhancing nodule (diameter 2.5cm) posterior in the left lower lobe with an hypertrophied feeding artery and a draining vein.\nNote simultaneous enhancement of the right ventricle and left loewer lobe nodule."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007150/000003.jpg?itok=Mvfe9c7J",
            "caption": "A well-defined nodule (diameter 2.5cm) posterior in the left lower lobe with an hypertrophied feeding artery and a draining vein."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007150/000004.jpg?itok=N-UEhP_t",
            "caption": "A second well-defined nodule (diameter 0,6 cm) posterior in the left lower lobe with also a feeding artery and a draining vein."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007150/000005.jpg?itok=4WEpqSN2",
            "caption": "Left lower lobe pulmonary arteriovenous malformation demonstrating the simple angioarchitecture of an AVM with a single feeding artery and a single draining vein, both connected to the aneurysmal sac (nidus)."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007150/000006.jpg?itok=uF3DTR-o",
            "caption": "Left lower lobe pulmonary arteriovenous malformation demonstrating the simple angioarchitecture of an AVM with a single feeding artery and a single draining vein, both connected to the aneurysmal sac (nidus)."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/7150",
    "time": "24.12.2008"
  },
  "7181": {
    "case_id": 7181,
    "title": "A case of CREST syndrome.",
    "section": "Chest imaging",
    "age": "58",
    "gender": "female",
    "diagnosis": "Pulmonary fibrotic disease in a CREST syndrome.",
    "history": "A case of CREST syndrome in a 58 woman.",
    "image_finding": "A 58 year old patient came to our attention with a remote history of Sjogren syndrome, calcinosis, Raynaud phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasia (CREST syndrome). At the age of 28 during her second pregnancy she suffered from gestational diabetes and, a year later, she was diagnosed type 2 diabetes for which she started insulin therapy. At the age of 42 after experiencing hands and knees arthralgia, she was diagnosed with scleroderma and treated with steroids. Two years later in 1994, she was diagnosed with Hashimoto's thyroiditis resulting in hypothyroidism treated with Eutyrox until now. In 2007, she was hospitalized for phlegmon of the left foot's first toe due to chronic microvascular disease. During hospitalization she underwent bilateral arteriography of the lower limbs that indicated obstruction of the posterior tibial and pedidia arteries and therefore started treatment with prostaglandin. A chest radiograph documented bilateral diffuse peri-articular soft tissue calcifications and bibasilar pulmonary fibrosis. Respiratory Function Test and the diffusion capacity of the lung for carbon monoxide (DLCO) were performed showing severe restrictive respiratory alterations and also a marked reduction of the CO diffusing capacity. This year because of the worsening of the respiratory condition, the patient received a repeat chest radiograph (Fig.1), that was similar to the one from 2007, so she underwent a thoracic high resolution computed tomography (HRCT) that pointed out the presence of a severe bilateral interstitial fibrosis (expecially of the posterior-basal segment),  thickening of the peribronchial-subpleuric interstitial tissues and several peri-articular soft tissue calcifications (Fig.2).",
    "discussion": "CREST syndrome (calcinosis, Raynaud phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasia) is a member of the heterogeneous group of scleroderma, or systemic sclerosis, a chronic connective tissue disease classified as one of the autoimmune rheumatic diseases. Three primary pathologic features are found in scleroderma and include increased collagen deposition, perivascular mononuclear cell infiltration, and vascular abnormalities. Mononuclear infiltration probably precedes fibrosis of tissues. While this inflammatory infiltrate can accompany fibrosis in tissues, it can also be present without fibrosis, suggesting that it is an early event in the pathogenesis of scleroderma. Ischemia is an important contributor to end organ damage in scleroderma patients.While the primary trigger for CREST syndrome is not known, a reasonable speculation is that vascular endothelial cell abnormalities incite mononuclear infiltration, resulting in abnormal fibroblast activity and increased collagen deposition. The incidence of systemic sclerosis in the USA is approximately 3-19 new cases per million adults p.a. The prevalence is 250-290 cases per million persons. Females have a greater incidence of scleroderma than males. The usual age of onset of scleroderma is 30-65 years. In the typical course of limited scleroderma, the patient first notices Raynaud phenomenon. Over the years, fingers become puffy, then the skin thickens slowly. Internal organ manifestations are delayed for many years. Calcinosis may be subclinical, but when symptomatic, tissues become tender and painful.  Patients find that the advancement of skin disease occurs slowly, over many years. While the entire intestine can be involved in scleroderma, esophageal involvement is most common and clinically relevant. Barrett oesophagitis and oesophageal adenocarcinoma have been found in scleroderma patients, perhaps at a higher rate. In CREST patients, telangiectases occur on the face, upper trunk, hands and also on mucosal surfaces (e.g. lips), throughout the GI tract in association with recurrent GI bleeding that can be chronic and cause anaemia. Autonomic dysfunction of the GI tract is also described. Other manifestations are: pulmonary hypertension in the absence of interstitial fibrosis, as a very late event; myocardial involvement; entrapment neurologic syndromes; sicca symptoms in approximately 35% of patients. CT scan can be performed in the prone position. The initial alterations on plain thoracic radiograph may be subtle with only a fine reticulation in the lower lobes, then it becomes thicker and diffuse. High Resolution Computed Tomography (HRCT) shows radiographical signs of intertitial disease, also in asymtomatic patients, for example, parenchymal and subpleural micronodules, intralobular linear opacities, ground glass and honey comb pattern lesions. CT scan also demonstrates the dilatation of the esophagus due to atrophy and atonia and air-fluid level.The differential diagnosis includes systemic lupus erythematosus, polymyositis, and rheumatoid arthritis. Lupus erythematosus is rarely associated with chronic pulmonary fibrosis; up to 20% of patients with rheumatoid arthritis and 10% of those with  polymyositis develop pulmonary fibrosis superimposable of the one in CREST. Scleroderma is associated with an increased risk of cancer, in particular lung cancer.The survival rate from time of diagnosis was computed to be 78% at 5 years, 55% at 10 years, 37% at 15 years, and 26% at 20 years.",
    "differential_diagnosis": "Pulmonary, fibrotic, disease, in, a, CREST, syndrome.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007181/000001.jpg?itok=O8tLrP_n",
            "caption": "Chest radiograph shows diffuse subcutaneous eggshell calcifications, located in the infraclavicular region, widespread on the thoracic wall and surrounding the shoulders."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007181/000002.jpg?itok=kQBsF54V",
            "caption": "The radiograph also shows interstitial fibrosis especially of the lower and posterior lobes, with emphysema."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007181/000003.jpg?itok=FwZ_Eo6Z",
            "caption": "High resolution computed tomography (HRCT) rules out severe bilateral interstitial fibrosis with thickening of the peribronchial-subpleuric interstizial tissues, bronchiectasies and cystic lesions expecially of the posterior and basal regions.\nThe exam shows the diffuse pattern of soft tissues calcifications located around  the thoracic wall and shoulders and also the dilatated esophagus."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007181/000004.jpg?itok=ny90syUW",
            "caption": ""
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007181/000005.jpg?itok=7UKr-Jf7",
            "caption": ""
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007181/000006.jpg?itok=-GiIncmA",
            "caption": ""
          },
          {
            "number": "Figure 2e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007181/000007.jpg?itok=eWmWWDIp",
            "caption": ""
          },
          {
            "number": "Figure 2f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007181/000008.jpg?itok=gyKqb-fI",
            "caption": ""
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/7181",
    "time": "23.02.2009"
  },
  "7197": {
    "case_id": 7197,
    "title": "Fire-eater&#039;s pneumonia.",
    "section": "Chest imaging",
    "age": "30",
    "gender": "male",
    "diagnosis": "Fire-eater's pneumonia.",
    "history": "A 30-year-old male fire-eater, who had accidentally ingested liquid paraffin, was evaluated for chest pain and dyspnoea.",
    "image_finding": "A 30 year old fire-eater came to our attention because of chest pain exacerbated by respiratory acts and dyspnoea associated with severe hypoxemia, three days after accidental aspiration of a mouthful of paraffin-containing ignition fluid. Chest X-ray showed multiple areas of consolidation with smooth margins predominantly located in the lung bases. Subsequently, a chest spiral CT examination was performed revealing multiple pulmonary consolidations in the middle lobe, lingula, and left lower lobe, which were characterized by air bronchogram signs associated with air-containing pseudocavities and lipid-like density areas. The consolidations were surrounded by inter- and intralobular septal thickening. In the same day a bronchoalveolar lavage (BAL) was performed, which showed an increase of eosinophils and neutrophils with a decrease of lymphocytes and macrophages. All the above findings were compatible with exogenous lipoid pneumonia (ELP) related to fire-eating activity. The patient received antibiotic and metilprednisolone therapy, resulting in very fast clinical and radiological resolution of pneumonia.",
    "discussion": "Exogenous lipoid pneumonia (ELP) is an uncommon condition resulting from aspiration or inhalation of fatty material. The first cases described in the literature are about debilitated adults or children who often had local anatomic defects such as cleft palate, but more recently, several reports have indicated that this condition can occur in healthy people too. In fact, humans may be exposed to liquid hydrocarbons (LH) derived from petroleum in different ways. Accidental ingestion is most common in young children and most non-occupational cases are related to aspiration of medications containing liquid paraffin, such as nose drops, throat gargles, and purgatives. Fire-eaters are obviously at risk for ingestion or aspiration of different kinds of LH; there are also reports of people using such chemicals for suicide. Aspiration of low viscosity LHs (e.g. kerosene) tends to cause acute infectious lung disease, whereas aspiration of high viscosity LHs (e.g. paraffin oil) usually leads to pseudo-tumoural ELP. Patients with ELP show a range of radiologic findings on chest X-ray, including consolidations with predominant bilateral lower lobe involvement in the majority of cases with acute disease. Chest spiral CT displays ground-glass or linear/nodular areas of increased density and/or pulmonary consolidation areas with hypodense (typically fat-like) attenuation values, associated with septal lines and centrilobular interstitial thickening. In some cases, a crazy-paving pattern can be present, either isolated or surrounding a pulmonary consolidation. Pleural effusion can occur. In chronic cases, traction bronchiectases and cystic changes consistent with fibrosis can develop. Clinical and radiological findings are important for the diagnosis of ELP, but knowledge of patient's history is crucial, as in our case. Prophylactic use of antibiotics is not recommended for prevention of hydrocarbon pneumonitis. However, once signs of secondary infection have appeared after LH aspiration, antibiotic and corticosteroid therapy should be started in order to achieve resolution of ELP as early as possible.",
    "differential_diagnosis": "Fire-eater's, pneumonia.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007197/000001.png?itok=z1W6lIIb",
            "caption": "Bilateral, partly nodular consolidation areas predominantly distributed in the lower pulmonary fields."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007197/000002.png?itok=PUs99Wbs",
            "caption": "Bilateral, partly nodular consolidation areas predominantly distributed in the lower pulmonary fields."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007197/000003.png?itok=4hzKxSYC",
            "caption": "CT image shows bilateral consolidation areas with air bronchogram inside them, surrounded by a ground-glass halo."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007197/000004.png?itok=wp2xK7Ul",
            "caption": "CT image shows a large parenchymal consolidation in the left lower lobe, surrounded by a 'crazy-paving' area."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007197/000005.png?itok=ypgMO0p0",
            "caption": "The left basal consolidation is hypodense with negative attenuation values."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007197/000006.png?itok=lIa49Fwy",
            "caption": "Contrast-enhanced CT image well depicts blood vessels inside the left basal consolidation (the 'CT angiogram' sign)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007197/000007.png?itok=NJHyU64U",
            "caption": "Post-treatment chest X-ray shows improvement of lung findings."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007197/000008.png?itok=Uv92oU_L",
            "caption": "Post-treatment chest X-ray shows improvement of lung findings."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/7197",
    "time": "08.02.2009"
  },
  "7214": {
    "case_id": 7214,
    "title": "Left unilateral abscence of pulmonary artery (UAPA) right aortic arch and situs inversus abdominis",
    "section": "Chest imaging",
    "age": "23",
    "gender": "male",
    "diagnosis": "Unilateral abscence of pulmonary artery, right aortic arch, situs inversus.",
    "history": "A 23 year old male presented with left parasternal chest pain radiating to the arm.",
    "image_finding": "The clinical symptoms occurred one week before admission to the hospital. No connection between the sharp thoracic pain and effort could be established. No sign of dyspnea or expectoration was present. The patient had a clinical history of a right middle lobectomy for congenital lung emphysema at the age of two. The physical examination at the current presentation was unremarkable. The physical examination of lungs and abdomen, blood pressure, heart rate, oxygen saturation test, and the laboratory findings (hematogram, liver enzymes, calcium) were normal. The chest radiograph demonstrated an elevated left hemidiaphragm, a gross shift of mediastinal organs to the left, and concomitant herniation of the right lung across the midline (Fig 1).MSCT confirmed the left lung hypoplasia, associated with the left pulmonary artery interruption (Fig 2). Enlarged right pulmonary artery branches and left bronchial arteries were noted, as well as and the right-sided aortic arch  (Fig 3). The azygos vein was dilated, and demonstrated vena cava continuation. The lungs were clear of any acute pathology. The right atrial and ventricular enlargement and left atrial hyperthrophy were seen during the heart sonography. Ultrasound and MSCT of the abdomen revealed situs inversus, with an accessory spleen (Fig 4).",
    "discussion": "Unilateral absence of a pulmonary artery (UAPA) is a rare anomaly characterized by short-segment atresia of the proximal left or right pulmonary artery. More distal segments of the arteries in the hila and in the lung are usually present. The term, \u201cinterruption of pulmonary arteries\u201d has also been used by several authors to describe this condition [1]. The absence of the left pulmonary artery is usually associated with a right-sided aortic arch and other congenital cardiovascular anomalies, most commonly the tetralogy of Fallot. Right pulmonary artery absence is more common, and it is an isolated finding in most instances [2,3].The affected lung is usually hypoplastic, because of deficient growth, but has a normal number of lobes and segments, and the bronchial anatomy is normal. [4].Most patients have symptoms that include frequent pulmonary infections, dyspnoea, and limited exercise tolerance. Hemoptysis and signs of pulmonary hypertension are less frequently found. Chest radiographs typically show a volume loss in the hemithorax, depicted as a diaphragmatic elevation with the heart and mediastinum shifted to the affected side. The contralateral lung is hyperinflated and herniates into the smaller hemithorax. In addition, the absence of the left or right pulmonary artery, and ipsilateral grossly diminished pulmonary vascular markings may be demonstrated. In patients with enlarged intercostal and transpleural arteries, fine linear opacities are seen at the periphery of the lung. When a pulmonary artery anomaly is suspected on the basis of chest radiographic findings, computed tomography (CT) is valuable for examining the pulmonary vessels [5]. CT also has an advantage over angiography in that it allows the lung parenchyma and the heart to be evaluated at the same time as the vessels.Contrast-enhanced MR angiography [CE MRA] provides a clear identification of all forms of vascular anomalies. CE MRA may be used to establish the diagnosis, as well as for monitoring, which is particularly valuable in pediatric patients, because it spares them from unnecessary consecutive irradiation. Although MRA and perfusion MRA have not been widely applied in routine practice yet, steady technological progress has enabled CE MRA to be quite competitive with CTA, and even to conventional pulmonary angiography [6]. The method, however, has its limitations in patients who have difficulties in holding their breath, or holding their arms above the head during the screening.This is a case report of a male patient who presented with a non-specific symptom\u2014chest pain\u2014and in whom MSCT examination helped to demonstrate a complex vascular anomaly.",
    "differential_diagnosis": "Unilateral, abscence, of, pulmonary, artery,, right, aortic, arch,, situs, inversus.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007214/000001.jpg?itok=1pkjQ6LT",
            "caption": "Figure 1: Chest X ray showing a  mediastinal shift, right aortic arch and elevated left hemidiaphragm."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007214/000002.jpg?itok=ZYBc_clN",
            "caption": "Figure 2: MSCT shows an absence of the left pulmonary artery, the enlargement of the right pulmonary artery branches, and the dilatation of the azygos vein and numerous bronchial and thoracic wall collateral branches (arrows)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007214/000003.jpg?itok=krTxQMt0",
            "caption": "Figure 3: MPR revealed the left lung hypoplasia and enlargement of the right pulmonary artery branches."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007214/000004.jpg?itok=hdaE-Un6",
            "caption": "Figure 4: Situs inversus abdominis."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/7214",
    "time": "18.04.2009"
  },
  "7236": {
    "case_id": 7236,
    "title": "Pneumopericardium in polytrauma with bilateral pneumothorax, lung contusion and laceration.",
    "section": "Chest imaging",
    "age": "35",
    "gender": "male",
    "diagnosis": "Post-traumatic pneumopericardium with bilateral pneumothorax, lung contusion and laceration",
    "history": "A 35 year old polytraumatised patient (cranial, thoracic and orthopaedic trauma) after a traffic accident was admitted for investigation.  CT examination was performed and the findings are presented.",
    "image_finding": "A 35 year old patient was admitted to the Radiology Department after a traffic accident.  Chest radiography demonstrated left pneumothorax and, after insertion of a chest drain, the patient was transferred to the CT unit for further investigation.  CT scans of the neck and chest revealed bilateral pneumothoraces with contusions of the pulmonary parenchyma (fig 1), pneumomediastinum (fig 2) and pneumopericardium (fig 3) without pericardial or pleural effusion.  Subcutaneous left-sided emphysema was also present (partially as a result of the insertion of the chest drain).  Rib fractures as well as fractures of left scapula were identified (fig 4a,b).  Multiple thin streaks of air extending to the superior mediastinum and neck were noticed (fig 5).  The patient was admitted to the intensive care unit and a control CT scan after 2 days demonstrated complete resolution of the pneumopericardium and pneumothorax (fig 6).  In addition, lung laceration with formation of pneumatoceles had occurred and a small pneumomediastinum was still evident (fig 7).",
    "discussion": "Pneumopericardium secondary to blunt chest trauma is generally due to 1 of 3 mechanisms: 1) penetration along pulmonary venous perivascular sheaths from ruptured alveoli to the pericardium, 2) pneumothorax with pleuropericardial tear, or 3) direct tracheobronchial\u2013 pericardial communication.  Pneumopericardium has been reported to result from blunt and penetrating chest trauma, as a complication of invasive procedures, from abnormal communications such as fistulas from the pericardium to the adjacent structures containing air from different causes, from barotrauma and from pericardial infections.  There have been reported cases of pneumopericardium after proctocolectomy, after laparoscopy, as a complication of AIDS, and after administration of the Heimlich manoeuvre. Positive pressure ventilation with large tidal volumes or high end expiratory pressure may cause or worsen the condition, particularly in neonates or infants.  Pneumopericardium is usually self-limited and resolves spontaneously, but possible complications, such as tension pneumopericardium leading to cardiac tamponade, can occur.Clinical signs of pneumopericardium such as distant heart sounds, shifting precordial tympany, and a succussion splash with metallic tinkling and ECG findings such as low voltage, ST segment changes, and T wave inversion are non-specific and unreliable. Sufficient accumulation of pericardial gas may impair right ventricular filling, resulting in pericardial tamponade with increase and equalisation of intracardiac pressures, pulsus paradoxus, arterial hypotension, and cardiogenic shock.  The diagnosis of pneumopericardium can be confirmed by conventional chest radiographs, computed tomography, or echocardiography.Radiographic findings of pneumopericardium and pneumomediastinum can be similar in the lower mediastinum. In posteroanterior chest radiographs, a continuous thin radiolucent rim of air follows the cardiac silhouette and is outlined by a fine line representing the pericardial sac. At the base of the heart, the gas may outline the superior surface of the normally obscured parts of the diaphragm, which can be seen on the lateral radiograph as the continuous left hemidiaphragm sign and on a frontal radiograph as the continuous diaphragm sign.  CT examination is the best imaging tool for demonstrating even small pneumopericardium, when radiographs can have a normal appearance of the lower mediastinum. Pulmonary contusions are caused by hemorrhage and radiographically they are demonstrated as peripheral, nonsegmental and ill-defined parenchymal opacities that usually underlie the region of chest wall impact (90%) but may be contrecoup (10%).  All pulmonary contusions are present on chest radiographs and CT scans within 24 hr and new on evolving opacities seen on radiographs after 24 and 72 hr suggest superimposed aspiration or infectious pneumonia on adult respiratory distress syndrome, respectively.  Typically, the air-space consolidation from contusion clears during the 1st week after trauma.  Pulmonary lacerations represent tears in the lung parenchyma and they usually occur after chest trauma. When the laceration is filled with blood, a hematoma forms but when it fills with air, a traumatic pneumatocele forms, us in our case.  CT scan is more sensitive method comparing with plain radiography in the detection of contusions and lacerations in the trauma patient.",
    "differential_diagnosis": "Post-traumatic, pneumopericardium, with, bilateral, pneumothorax,, lung, contusion, and, laceration",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007236/000001.jpg?itok=tQwGMMiC",
            "caption": "CT image demonstrating bilateral pneumothorax and contusions of the pulmonary parenchyma"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007236/000002.jpg?itok=-LEDakFw",
            "caption": "CT image showing pneumomediastinum"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007236/000003.jpg?itok=Nufw7SlM",
            "caption": "CT image demonstrating pneumopericardium"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007236/000004.jpg?itok=O4PeudY8",
            "caption": "CT image demonstrating rib fractures (a,b) as well as fractures of left scapula (a,c)"
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007236/000005.jpg?itok=vIw5ljCs",
            "caption": "CT image demonstrating rib fractures (a,b) as well as fractures of left scapula (a,c)"
          },
          {
            "number": "Figure 4c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007236/000006.jpg?itok=EUm2htjT",
            "caption": "CT image demonstrating rib fractures (a,b) as well as fractures of left scapula (a,c)"
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007236/000007.jpg?itok=q-3_IXNJ",
            "caption": "CT image identifying thin streaks of air extending to the neck"
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007236/000008.jpg?itok=NItLSitZ",
            "caption": "Complete resolution of the pneumopericardium and pneumothorax - persistence of the pulmonary contusions"
          }
        ]
      },
      {
        "number": "Figure 7",
        "subfigures": [
          {
            "number": "Figure 7",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007236/000009.jpg?itok=a-Yl01A8",
            "caption": "On 2nd CT examination small pneumomediastinum is still evident.  In addition, lung laceration with formation of pneumatoceles had occurred"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/7236",
    "time": "18.04.2009"
  },
  "7239": {
    "case_id": 7239,
    "title": "Bronchocentric granulomatosis presenting as bronchial carcinom",
    "section": "Chest imaging",
    "age": "34",
    "gender": "female",
    "diagnosis": "Bronchocentric granulomatosis of the lung",
    "history": "A 34 year old woman presented with cough, occasional chest pain at inspiration, low-grade fever, headache and weight loss of 8-10 kg during the last 4 months. She started smoking at the age of 12 years and now smoked 20 cigarettes a day.",
    "image_finding": "Chest radiography taken before an obstetric procedure showed a lobulated mass at the left hilum (Figure 1). Chest CT revealed a large, homogeneous, fairly well demarcated mass in the left hilum without calcification that encased bronchial branches and blood vessels, but did not invade the mediastinum or pleura (Figures 2 and 3). There were some pleural adhesions with modest pleural thickening in the right costophrenic angle. Mediastinal lymph nodes, MRI of the head and skeletal scintigraphy were normal.The erythrocyte sedimentation rate on admission was 49. Spirometry demonstrated mild to moderate airway obstruction. Concentric narrowing of the left bronchial lumen was noticed in the lingular segment at bronchoscopy. Biopsies from the upper lobe bronchus mucosa showed areas of squamous cell metaplasia and severe dysplasia. Considering her young age, smoking history, weight loss and suspicious radiological and histological findings, a left sided pneumonectomy was performed.Histological examination of the resected lung showed a mass with a poorly demarcated mass containing multiple granulomas, some of which were located within and around partially destroyed bronchioles consistent with bronchocentric granulomatosis (Figure 4). Some granulomas were large with confluent necrosis surrounded by a rim of histiocytes and fibroblasts with scattered multinucleated giant cells. Only few eosinophils were present. Some hilar lymph nodes were enlarged containing a few granulomas with central necrosis. There was no serological or histological evidence of malignancy, vasculitis or microbial, including fungal and mycobacterial infection.Control chest CT\u2019s with intravenous contrast and clinical examinations performed up to five years after surgery showed no recurrence.",
    "discussion": "The term bronchocentric granulomatosis is most often restricted to asthmatic patients in whom the lesion may be a manifestation of allergic bronchopulmonary aspergillosis, or non-asthmatic subjects with no other causes of granulomatous inflammation as in our case (1). The disorder is characterized histologically by granuloma formation and necrosis that begins within and is centered around bronchial and bronchiolar walls (2;3). The clinical course is often asymptomatic and the prognosis is good.The radiological findings of bronchocentric granulomatosis are varied but may present as centrally located mass lesions, multiple or single as in our case (4-6). CT findings in bronchocentric granulomatosis has been reported to be spiculated mass lesion or lobar consolidation with slight volume loss (6). These findings reflect the presence of granuloma formation with or without associated bronchial obstruction. Positron emission tomography (PET) was not available in our institution at the time of presentation, but would most likely not have made a substantial influence to the clinical outcome.It has previously been reported that bronchocentric granulomatosis may exhibit morphological features suggesting malignancy, a finding which was also seen in our patient (7). Thus, morphological material obtained from lesions suggestive of lung cancer without a verified diagnosis must be interpreted with caution. It is possible that an inflammatory process with long-standing irritation of the bronchial mucosa may give rise to reactive epithelial changes which subsequently can be interpreted as premalignant dysplasia (7). However, in our case, a transthoracic or open lung biopsy was not performed due to the central location of the lesion. Expectation was not considered an option because this could negatively affect the outcome in case of a lung cancer.Sarcoidosis, Wegener\u2019s granulomatosis and infection were possible differential diagnosis. However, sarcoidosis does not usually present with necrosis of granulomas and extensive destruction of bronchi. Wegener\u2019s granulomatosis usually affects several organs and presents histologically with angiocentric granulomatosis which was not seen in our case. Also, this disease often affects several organs including the upper airways. Exclusive peribronchial localization of granulomas can occur in certain infections like mycobacterial and fungal infections that may mimic bronchocentric granulomatosis. We did not find any fungal hyphae, mycobacteria or other evidence of infection in our patient who came from a population with a very low incidence of tuberculosis. To our knowledge, there has been no previous report describing granulomas in involved lymph nodes in cases of bronchocentric granulomatosis. No microbe was detected, but it is of course impossible to fully exclude an infectious cause (8).Our case demonstrates that bronchocentric granulomatosis can be mistaken as a malignancy as mentioned previously (7). On the other hand, the presence of bronchocentric granulomatosis in the biopsy of a mass does not exclude the presence of an accompanying bronchogenic carcinoma associated with obstruction of bronchioles (9). Therefore, it is of utmost importance to gain sufficient histological material which may require surgical lung biopsy so that malignancy can conclusively be diagnosed or excluded.",
    "differential_diagnosis": "Bronchocentric, granulomatosis, of, the, lung",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007239/000001.jpg?itok=79e1Y4CQ",
            "caption": "Contrast medium enhanced CT shows a 5 cm lesion in the left hilus which affects both the upper and lower lobes."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007239/000002.jpg?itok=V2mRD4I8",
            "caption": "Note encasement of vessels and small satellite (1 cm) lateral to the mass."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007239/000003.jpg?itok=hq7Yn1j7",
            "caption": "Section of lung mass shows granulomas centered on bronchi with invasion of bronchial mucosa and lumen. The respiratory epithelium (arrowhead) has to a large extent been destroyed by the inflammatory infiltrate and the airway lumen is filled with cellular debris containing numerous histiocytes (arrow). (Hematoxylin &amp; Eosin stain, original magnification x 10)."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007239/000004.jpg?itok=chHhd41a",
            "caption": "Chest radiograph with anteroposterior view shows an enlarged left hilum."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/7239",
    "time": "08.02.2009"
  },
  "7271": {
    "case_id": 7271,
    "title": "A primitive lung carcinoid tum",
    "section": "Chest imaging",
    "age": "68",
    "gender": "male",
    "diagnosis": "Primitive lung carcinoid tumors",
    "history": "A 68 year old man was referred to our department for a pre-surgical chest radiography (colon resection).",
    "image_finding": "After a period of fever and abdomen distension, the patient underwent a colonoscopy that demonstrated a cancer of the sigma. Pre-surgical chest radiography showed pulmonary nodules that were initially interpreted as metastases. The patient underwent Hartmann resection and pathological analysis of the surgical specimen was conclusive for adenocarcinoma. Lymph node infiltration was not documented.For this reason a pulmonary transbronchial needle-biopsy was requested. Cellular elements reactive for TTF-1 were obtained, raising the suspicion for a primary lung neoplasia with a neuroendocrine differentiation. A CT-guided biopsy confirmed the suspicion of a primitive neuroendocrine lung neoplasm.",
    "discussion": "Primary lung carcinoid tumours appear at chest radiographs most often as a well-defined hilar or perihilar masses with associated distal parenchymal disease. At CT, carcinoid tumours appear as a spherical or ovoid nodule or mass with a well-defined and slightly lobulated border. They are typically located close to central bronchi, often near the bifurcation area. Calcifications are usually not visible on chest radiographs, but on CT images calcifications or ossification can be seen in up to 30% of tumours in punctuate or diffuse pattern. Carcinoids tend to be hypervascularized and may demonstrate intense enhancement. This is particularly helpful for distinguishing the tumour from obstructive atelectasis or an adjacent mucus plug. Also, in a dynamic contrast-enhanced CT study, typical and atypical carcinoid show high enhancement, that is, more than 30 HU of net enhancement. Both typical and atypical carcinoids may be associated with hilar or mediastinal lymphadenopathy due to reactive hyperplasia from recurrent pneumonia or lymph node metastasis (the latter is more frequently associated with atypical carcinoids).",
    "differential_diagnosis": "Primitive, lung, carcinoid, tumors",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007271/000001.jpg?itok=b5EwqUMG",
            "caption": "Postero-Anterior chest radiography.\nSeveral nodules are seen bilaterally."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007271/000002.jpg?itok=jPoVAmhv",
            "caption": "Latero-Lateral projecton confirms the presence of large nodules."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007271/000003.jpg?itok=nVuXtvgJ",
            "caption": "CT image before i.v. contrast administration.\nCalcificatios are visible in the pulmonary lesions."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007271/000005.jpg?itok=9QVgf9QL",
            "caption": "Arterial phase shows early enhancement of the lesions."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007271/000004.jpg?itok=y8R13kvo",
            "caption": "Venous phase."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007271/000006.jpg?itok=Yx2jJbjS",
            "caption": "CT image before contrast administration.\nIsodense mediastinal lymph node."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007271/000007.jpg?itok=FD4A-K8M",
            "caption": "Arterial phase shows enhancement of the lymph node."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007271/000008.jpg?itok=cVyVEzOA",
            "caption": "Venous phase."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/7271",
    "time": "17.03.2009"
  },
  "7277": {
    "case_id": 7277,
    "title": "Focal lung lesion: diagnosis please!",
    "section": "Chest imaging",
    "age": "79",
    "gender": "female",
    "diagnosis": "Rounded atelectasis due to pleural effusion of unknown cause.",
    "history": "A 79 year old female patient of whom a chest CT was requested because of a nodular opacity seen on routine chest radiography.",
    "image_finding": "The patient had rectal cancer 5 years ago.  A chest radiography, made outside our institution, showed a \u201cnodular opacity\u201d and pleural effusion on the right lung. A chest CT was requested with the following clinical information: \u201cLung metastases?\u201d.",
    "discussion": "The term \u201crounded atelectasis\u201d refers to the presence of focal rounded lung collapse. It usually occurs in the presence of pleural thickening or effusion, and likely results from local constriction of lung expansion. It is most commonly associated with asbestos exposure, empyema, tuberculous effusions, renal failure and pleural neoplasm but may occur with pleural effusion of any cause. On plain radiographs, rounded atelectasis may mimic neoplasm, but its CT appearance is often characteristic.To suggest the diagnosis of rounded atelectasis on CT images, the opacity should be: 1) round or elliptical; 2) associated with an ipsilateral pleural abnormality, either effusion or pleural thickening; 3) peripheral in location, having significant contact with the abnormal pleural surface; 4) associated with curving of pulmonary vessels or bronchi into the edge of the lesion (the so-called \u201ccomet-tail\u201d sign) and 5) associated with volume loss in the affected lobe. If all of these criteria is met (as in the present case), a confident diagnosis can usually be made and radiographic follow-up should be sufficient.The \"comet-tail\" sign is often the key to the diagnosis and a strong effort should be made to demonstrate it. Sometimes MDCT with multiplanar reconstructions are the only way to see the curving of pulmonary vessels and bronchi.Rounded atelectasis may have acute or obtuse angles where it contacts the pleura. Since rounded atelectasis represents collapsed lung parenchyma, it can show significant enhancement on CT following the intravenous injection of contrast agents (not given in this case because the most important diagnostic criteria were present). Air bronchograms may be visible within the collapsed lung.  Atypical examples are often encountered in patients who have pleural thickening and fibrosis rather than pleural effusion. For equivocal cases in which the distinction between rounded atelectasis and a lung tumor is difficult, fluorodeoxyglucose positron emission tomography (PET) may prove useful. A high specific uptake value would support performing a biopsy for diagnosis; low uptake would support close observation by serial follow-up CT scanning.",
    "differential_diagnosis": "Rounded, atelectasis, due, to, pleural, effusion, of, unknown, cause.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007277/000001.jpg?itok=vL236R1Q",
            "caption": "CT scans of four adjacent levels. An elliptical opacity is visible (arrows), which has significant contact with the mediastinal pleural surface. Vessels and bronchi curve into the edge of the lesion \u2013 \u201ccomet-tail sign\u201d (arrowheads). In cine mode it was perceptible a whorled appearance, produced by the crowding of the bronchovascular bundle."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007277/000002.jpg?itok=kGrcZD6_",
            "caption": "CT scans of four adjacent levels. An elliptical opacity is visible (arrows), which has significant contact with the mediastinal pleural surface. Vessels and bronchi curve into the edge of the lesion \u2013 \u201ccomet-tail sign\u201d (arrowheads). In cine mode it was perceptible a whorled appearance, produced by the crowding of the bronchovascular bundle."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007277/000003.jpg?itok=1CmnLmkh",
            "caption": "CT scans of four adjacent levels. An elliptical opacity is visible (arrows), which has significant contact with the mediastinal pleural surface. Vessels and bronchi curve into the edge of the lesion \u2013 \u201ccomet-tail sign\u201d (arrowheads). In cine mode it was perceptible a whorled appearance, produced by the crowding of the bronchovascular bundle."
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007277/000004.jpg?itok=lLuW61Ld",
            "caption": "CT scans of four adjacent levels. An elliptical opacity is visible (arrows), which has significant contact with the mediastinal pleural surface. Vessels and bronchi curve into the edge of the lesion \u2013 \u201ccomet-tail sign\u201d (arrowheads). In cine mode it was perceptible a whorled appearance, produced by the crowding of the bronchovascular bundle."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007277/000005.jpg?itok=E7pbH5jC",
            "caption": "There is ipsilateral pleural effusion. The opacity has soft tissue attenuation with significant contact with the mediastinal pleura. Note also the presence of air bronchogram."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007277/000006.jpg?itok=zTI0Au48",
            "caption": "There is ipsilateral pleural effusion. The opacity has soft tissue attenuation with significant contact with the mediastinal pleura (arrows). Note also the presence of air bronchogram."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007277/000007.jpg?itok=oByKTkHf",
            "caption": "There is apparent thickening (arrowhead) of the minor fissure due to pleural effusion. An ill-defined, vaguely nodular opacity is seen at the right base (arrow). Note also substantial cardiomegaly."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/7277",
    "time": "13.02.2009"
  },
  "7354": {
    "case_id": 7354,
    "title": "Pleuritic chest pain in pregnancy - not just a straightforward P",
    "section": "Chest imaging",
    "age": "31",
    "gender": "female",
    "diagnosis": "Tuberous sclerosis",
    "history": "A pregnant patient came to the hospital with left sided pleuritic chest pain and underwent investigation for possible pulmonary embolus.",
    "image_finding": "The 31 year old female with a previous history of epilepsy underwent her routine obstetric ultrasound examination and was noted to have an incidental abnormality on examination of her urinary tract. Multiple well-defined lesions of increased echogenicity were seen in both kidneys measuring approximately 3cm. At 27 weeks of pregnancy she presented with shortness of breath and left sided back and pleuritic chest pain. Chest radiograph demonstrated extensive bilateral reticular shadowing. CT pulmonary angiogram performed for possible embolus did not show any filling defect within the pulmonary vasculature but demonstrated diffusely distributed thin-walled irregular cysts of different sizes. A subsequent MRI examination was performed because the patient continued to experience back and chest pain. This demonstrated a high signal collection surrounding the left kidney on fat-saturated T1 weighted MR images consistent with peripheric haematoma. The patient underwent subsequent angiogram via a 4Fr catheter in the right common femoral artery. This demonstrated pathological circulation and vascular lakes in the mass projecting from the middle of the left kidney. The feeding artery was selectively embolised with one vial of PVA 250-355 micron diameter particles and a single steel coil. This gave satisfactory stasis of flow in this vessel whilst preserving the rest of the main branches of the left renal artery. The patient recovered well following embolisation therefore avoiding nephrectomy.",
    "discussion": "Tuberous sclerosis complex (TSC) is inherited in an autosomal dominant fashion with low penetrance causing frequent skips in generations and characterized by widespread hamartomatous lesions. 50-80% occur as spontaneous mutations. There are 2 genes recognised in the pathogenesis called TSC1 and TSC2. Although lung involvement has been quoted at only occurring in 1-4% of patients with tuberous sclerosis the presence of lymphangioleiomyomatosis is a major criterion for diagnosis and in patients with sporadic LAM point mutations in the TSC2 gene have been identified. Comparison of the features in LAM alone and in LAM/TSC have demonstrated more extensive lung involvement, pleural effusions, ascites and thoracic duct dilatation in LAM and more renal angiomyolipomata, embolisations and nephrectomies in patients with LAM/TSC. The renal involvement in tuberous sclerosis is usually asymptomatic but angiomyolipomata occur in 30-90% of patients. The angiomyolipomata seen in tuberous sclerosis are typically multifocal and bilateral and may be the only imaging evidence of tuberous sclerosis. Small angiomyolipomata are asymptomatic but angiomyolipoma greater than 4cm bleed spontaneously in 50-60%. Abdominal and pelvic imaging in this patient was complicated by her pregnancy and MRI was used to identify the perinephric haematoma rather than CT imaging. The chest findings of multiple bilateral small cysts in the lung parenchyma with no zonal predominance are typical of lymphagioleiomyomatosis. Intralobular lines and interlobular septal line thickening can be an associated finding. Repeated episodes of spontaneous pneumothorax occur in 50% of these patients and this patient\u2019s recovery was limited by repeated episodes of chylothorax which required ligation of the thoracic duct.",
    "differential_diagnosis": "Tuberous, sclerosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007354/000005.jpg?itok=HB4QjGuq",
            "caption": "Ultrasound image demonstrating longitudinal section though the right kidney with multiple well defined lesions of increased echogenicity"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007354/000006.jpg?itok=-fTWMVp_",
            "caption": "Frontal chest radiograph demonstrating widespread reticular changes"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007354/000007.jpg?itok=eAhRyT87",
            "caption": "Axial CT image on lung window settings demonstrating irregular cysts bilaterally"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007354/000008.jpg?itok=MIyYf2DG",
            "caption": "Coronal MR T1 weighted fat saturated image demonstrating high signal surrounding the left kidney consistent with haemorrhage"
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007354/000009.jpg?itok=zLUiqPiu",
            "caption": "Angiogram of the left kidney demonstrating angiomyolipoma with abnormal vasculature in the interpolar region"
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007354/000010.jpg?itok=tYUxGH-E",
            "caption": "Left kidney angiogram demonstrating satisfactory embolisation with steel coil and PVA"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/7354",
    "time": "18.04.2009"
  },
  "7368": {
    "case_id": 7368,
    "title": "Incidental lung adenocarcinom",
    "section": "Chest imaging",
    "age": "67",
    "gender": "male",
    "diagnosis": "Lung adenocarcinoma.",
    "history": "The patient was a 67 year old man, former smoker, affected by COPD and periarthritis of the left shoulder. A routine preoperative chest radiograph revealed a right upper lobe opacity. Furthermore, a contrast-enhanced CT showed a spiculated mass (54x30mm) with pleural tags in the posterior segment of upper right lobe.",
    "image_finding": "The patient was a 67 year old man, former smoker, affected by COPD, grade I MRC dyspnoea, expectoration and in therapy with inhaled long acting beta-2-adrenoreceptor-agonists and corticosteroids.The routine preoperative chest radiograph, obtained before shoulder surgery, revealed a right upper lobe opacity. Subsequently a thoracic CT was performed to characterize the lesion. It revealed a mass with spiculated and irregular margins involving the posterior segment of the right uper lobe and the apical segment of the lower lobe. It also had pleural tags and its size was 54x30mm. The patient underwent right upper lobectomy with resection of the apical segment of the lower lobe. Final pathological diagnosis was poorly differentiated adenocarcinoma with acinal and large cell features infiltrating the visceral pleura, pT2N0M0 G3, corresponding to stage 1B. The patient did not receive adjuvant therapy. Follow-up evaluation included history and physical examination, routine hematologic and biochemical analysis, lung cancer markers (CEA, NSE, TPA), and chest radiography.",
    "discussion": "Lung cancer is the leading cause of death from cancer worldwide, and has surpassed death for breast cancer in woman. Although the cause of this malignancy is multifactorial, about 85% of lung cancer deaths are directly attributable to cigarette smoking.Adenocarcinoma is the most common form of lung cancer. Although a large part of this cell type is found in smokers, it is also the most frequent type of lung cancer in non-smokers, in women and patients under the age of 45 years. Adenocarcinoma is also associated with concomitant lung diseases that produce focal or diffuse fibrosis such as chronic pneumonia, bronchiectasis and tuberculosis.Adenocarcinoma specimens show glands and papillary structures. The neoplastic cells have round to oval nuclei, prominent nucleoli and a moderate amount of cytoplasm. Histochemical stains such as mucicarmine demonstrate typical intra and extracellular mucosubstance. Clinical abnormalities associated with lung cancer are myriad. In a small percentage, the initial presentation is an abnormal chest radiograph that was obtained for other reasons. When lung cancer is diagnosed as an incidental finding in an asymptomatic patient survival is better than when the diagnosis is based on symptoms.The majority of patients present with symptoms and have advanced disease. Symptoms may result from the primary tumour, metastases, or systemic manifestations caused by non-metastatic (paraneoplastic) syndromes. Conventional chest radiography (CXR) usually demonstrate the tumour, especially in peripheral lesions. Central tumours may be associated with atelectasis or obstructive pneumonitis. The proximal extent of central tumours is determined with bronchoscopy. CXR may also show pleural effusion, direct extension into the chest wall with destruction of ribs or vertebrae, phrenic nerve involvement with elevation of a hemidiaphragm, or mediastinal widening due to lymphadenopathy. CT is superior for demonstrating direct extension of the primary neoplasm into the mediastinum or chest wall and detecting enlarged mediastinal lymph nodes, particularly in the pretracheal, aortopulmonary, and subcarinal areas. It also reveals obstruction/pneumonitis distal to the tumour and the relationship between lesion and chest wall and pleura.The typical radiologic manifestation of adenocarcinoma is a solitary peripheral pulmonary nodule or mass that can have well marginated, lobulated, irregular, or poorly defined borders, involving adjacent pleura and like most lung cancers, typically affects the upper lobes.Patients with stage IA and IB disease usually undergo surgical resection. Adequate surgery usually consists of either a lobectomy, bilobectomy, or a pneumonectomy with mediastinal node dissection for staging purposes.Patients with stage IIIA, IIIB and IV disease almost never meet the criteria for primary surgery.Adjuvant chemotherapy after resection of stage II-IIIA NSCLC is now the standard of care. The role of adjuvant chemotherapy for stage I disease remains controversial, in particular a recent meta-analysis showed no survival benefit in stage IB disease Typical 5-year survival for resected patients with stage IA and IB are 70-80% and 50-60%, respectively.",
    "differential_diagnosis": "Lung, adenocarcinoma.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007368/000006.jpg?itok=_4nzqqkn",
            "caption": "Photomicrograph (x40; H-E stain) shows neoplastic cells with round to oval nuclei, prominent nucleoli and moderate amount of cytoplasm."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007368/000007.jpg?itok=tkLGkYBO",
            "caption": "Posteroanterior chest radiograph reveals a right upper lobe opacity."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007368/000013.jpg?itok=gV6Cd0Jj",
            "caption": "lateral chest radiograph"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007368/000010.jpg?itok=3vTfeMW6",
            "caption": "CT shows an ill-defined mass in the posterior segment of right upper lobe with desmoplastic retractions"
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007368/000008.jpg?itok=VtuMX6a1",
            "caption": "CT shows a mass with spiculated and irregular margins involving the posterior segment of the right upper lobe and the apical segment of the right lower lobe."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007368/000011.jpg?itok=_Ti6oCXj",
            "caption": "Unenhanced CT shows the lesion."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007368/000012.jpg?itok=rDfgX2vm",
            "caption": "Contrast-enhanced CT."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/7368",
    "time": "02.05.2009"
  },
  "7438": {
    "case_id": 7438,
    "title": "Late Presentation of Traumatic Diaphragmatic Hernia in a Kickboxe",
    "section": "Chest imaging",
    "age": "36",
    "gender": "male",
    "diagnosis": "Tramatic Diaphragmatic Rupture",
    "history": "A 36 year old smoker was referred to a chest clinic following an employment medical. He had restrictive spirometry and a subsequent chest radiograph suggested a significant left sided pleural effusion.",
    "image_finding": "His only complaint was of mild exertional dyspnoea. Past medical history included Ramstedt pyloromyotomy for pyloric stenosis as a neonate and a road traffic accident (RTA) aged 16 sustaining left sided rib and pelvic fractures.  He was a competitive full contact kick boxer from his early teens, training with weightlifting and admitted illicit anabolic steroid use. Chronic haematothorax was suspected but multi-detector computer tomography (MDCT) of the thorax confirmed a large left sided diaphragmatic defect with herniation of abdominal contents. Elective repair was scheduled but the patient presented with acute abdominal pain and type 1 respiratory failure (Pa02 of 7.1kPa with Fi02 of of 60%). Gastric volvulus was diagnosed clinically and decompressed with nasogastric tube insertion. Definitive surgical repair occurred several days later.",
    "discussion": "Traumatic diaphragmatic rupture (TDR) occurs in 6% of patients after blunt abdominal trauma [1,2] and 8% in those having laparotomy [3]. Most occur in young men reflecting higher RTAs and misadventure in this demographic. Side impact collisions in RTAs produce shearing diaphragmatic forces [4], while penetrating trauma is the other recognised cause.TDR is three times more common on the left side [5]. This is partially explained by the relative protective effects of the liver in absorbing transmitted forces. Blunt trauma can cause tears of 10cm or more [1] (at the embryologically weak musculotendinous junction) whilst penetrating injuries cause defects < 1cm in diameter [2]. Both are equally dangerous with the pleuro-peritoneal pressure gradient causing progressive thoracic herniation [4]. Intubation and positive pressure ventilation after trauma appears to delay presentation and diagnosis [6].TDR is associated with significant morbidity and mortality, due to the difficulty in making the diagnosis and the high incidence of associated injuries [5,6]. The initial CXR is usually diagnostic of TDR in 50% of left sided injuries but only 17% for right-sided injuries [3,5]. MDCT has a sensitivity of 61-71% and a specificity of 87-100% [1] but is still more sensitive for left sided injuries over right. CT signs include localized defects of the diaphragm, herniation of hollow organs and omentum into the hemithorax and \u2018waist-like\u2019 constriction of the herniated bowel, the so-called \u201ccollar sign.\u201d [1,7]. Bergin et al in 2001 observed that if the diaphragm ruptures the herniated viscera can be seen to fall to a dependent position against the posterior ribs as they are no longer supported by the injured diaphragm (the \u2018dependent viscera sign\u2019);seen in 90% of their 28 patient population and useful in both right and left sided ruptures [1]. The diagnostic role of barium studies and fluoroscopy has been superseded by MDCT, but can be diagnostic when the examination is done for a different indication. The use of MR and nuclear imaging in acute trauma settings have not gained widespread acceptance for TDR.In our patient we assume that pyloroplasty would have highlighted a congenital diaphragmatic defect. It is almost certain that the defect was traumatic in origin with the RTA and kickboxing as potential synergistic agents. The possibility that sport may have led entirely to the defect cannot be ruled out however the RTA would seem to be the more plausible aetiological factor. Any diaphragmatic defect could well have been exacerbated by not only valsalva manouevres during weightlifting, but also by the use of anabolic steroids weakening connective tissue integrity.Most patients presenting late with TDR suffer from dyspnoea or upper abdominal pain [8,9]. This case highlights the risk of acute intestinal strangulation and respiratory compromise that can occur with late presentation TDR. A mortality rate of 30% has been quoted by some in cases of bowel strangulation [5]. Thoracotomy is necessary for surgical repair of delayed TDRs to reduce the hernia and separate intrathoracic adhesions. We highlight the potential multifactorial nature of this diagnosis.",
    "differential_diagnosis": "Tramatic, Diaphragmatic, Rupture",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007438/000001.jpg?itok=RxMHoi9S",
            "caption": "PA chest film organised as outpatient that resulted in initial referral.  Density occupying most of left hemithorax with fluid level."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007438/000003.jpg?itok=I-i0_XeK",
            "caption": "Coronal multiplanar reconstruction at the level of the carina showing herniated stomach, small and large bowel together with the associated mesentery."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007438/000004.jpg?itok=y9NIfEnr",
            "caption": "Axial image at the level of the carina."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007438/000002.jpg?itok=TfIe6all",
            "caption": "Coronal multiplanar reconstruction showing stomach within left hemithorax"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007438/000005.jpg?itok=oIgfhpK9",
            "caption": "Chest radiograph obtained when the patient presented with abdominal pain and shortness of breath.  The nasogastic tube is seen curled within the stomach within the left hemithorax"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/7438",
    "time": "12.06.2009"
  },
  "7470": {
    "case_id": 7470,
    "title": "Mediastinal Paragangliom",
    "section": "Chest imaging",
    "age": "48",
    "gender": "male",
    "diagnosis": "Mediastinal Paraganglioma",
    "history": "A 48 years old man without any relevant pathological history except for mild hypertension and hypercholesterolemia, on December 2006 was admitted to the emergency department for chest pain, tachycardia and moderate hypertension (160/90 mmHg). ECG showed atrial fibrillation with 130 bpm.",
    "image_finding": "Cardiac MRI was then performed in order to characterize the unexpected finding (Fig. 2). Cardiac CT scan was accomplished one month later to better define the relationship of the mass with coronary vessels and monitor its potential growth (Fig. 3).Fig. 1: Echocardiography showed normal ventricular morphology and function, and mild mitral valve prolapse; a mass with hyperechoic tissue was detected at the level of mitro-aortic junction(arrow in Fig. 1). Fig. 2: MRI shows a round, well defined 4 cm mass localized in epicardial fat among left ventricular outflow tract (LVOT), right ventricular outflow tract (RVOT), left coronary artery (LCA), pulmonary artery (PA), aortic root and left cardiac chambers. The lesion appeared isointense-to-heterogeneous on T1 weighted sequences, very bright on T2 weighted with fat suppression sequences and showed low contrast enhancement on perfusion (FGRET) sequences. No pericardial or pleural effusion was observed. Fig. 3: CT scan confirmed the presence of the mass (white arrows), characterized by low-to-mid tissue density (mean value 40-50 UH) and low contrast enhancement. No signs of local invasivity, especially about coronary arteries (completely surrounded by the lesion, red arrows), aortic root and pulmonary trunk. No dimensional growth was note, neither pericardial/pleural effusion or mediastinal lymph nodes.Differential diagnoses include Paracardiac Cyst, Coronary Aneurysm, Mediastinal Lymphoma, Mediastinal Paraganglioma and Cardiac Lipoma.",
    "discussion": "The lesion described here is a rare case of mediastinal, paracardiac hyposecreting paraganglioma. Differential diagnosis includes a paracardiac cyst, which usually presents with dark signal on MR T1 weighted sequences and very low density (0-30 HU) on CT scan, with no contrast enhancement.Also coronary aneurysm is not supported by evidence: The mass involves both, the anterior descending and circumflex artery, as well as the left main. Furthermore, shape, borders and size of coronary arteries are normal.Mediastinal lymphoma looks like the above mentioned lesion, but some features are different: Lymphoma affects immunocompromised patients, generally involves the right atrium and is frequently associated with pericardial effusion. At CT, lymphoma is quite bright on un-enhanced scans, is usually locally invasive and mediastinal lymphadenopathy is often seen. Finally, this lesion does not have the characteristics of cardiac lipoma, which has low signal on fat suppression sequences and low density (fat usually presents negative HU values) on CT scan.Mediastinal, paracardiac paraganglioma typically affects young adults and involves the left atrium, coronary arteries or aortic root. The lesion is frequently associated with cathecholamine syndrome and has a hyperechoic signal. On MRI there is a hypo-isointensity signal on T1 weighted sequences and bright signal on T2 weighted sequences.  The density on CT scan is low and normally contrast enhancement is strong, but it depends on vascularization and secerning activity.  The patient is just mild symptomatic and hypertension is only moderate. This feature, together with low contrast enhancement (poor vascularization), support the hypothesis of an hyposecerning type.The usefulness of CT or MRI scans in localizing extraadrenal catecholamine-producing tumors as cardiac  paragangliomas has been showed in this case. Given their noninvasive nature and wide availability, either imaging technique represent a reasonable first step in the localization procedure, although MRI may be preferred. In this case, indeed, Multidetector CT was performed as a complement of MRI, just to emphasize anatomic details of  coronary artery involvement.  Additional  \u201csecond step\u201d imaging procedures are generally required, including iodine-131 or, better, 123 metaiodobenzylguanidine (MIBG, a norepinephrine analogue) radionuclide scintigraphy scanning.MIBG scintigraphy, a functional rather than topographic test that allows scanning of the entire body, is now considered the gold standard for localization of small adrenal lesions or extraadrenal tumors including cardiac paraganglioma. However, the high specificity of up to 100% of MIBG scintigraphy has to be balanced against its relatively low sensitivity (78%), expecially in case of low-secreting tumors: The radioisotope 123MIBG, indeed, accumulates preferentially in these tumours in proportion with catecholamine synthesis.In this case MIBG study correctly located and confirmed the presence of an hyposecreting paraganglioma (low MIBG enhancement).Because the tumor generally tends to engulf the coronary arteries (as in this case), surgical resection is often difficult and several deaths have been reported from intraoperative or postoperative hemorrhage.The patient refused surgical treatment because of his good clinical conditions (actual absence of  cathecholamine syndrome) versus complexity of the surgical approach.A MR study performed one year after diagnosis  didn\u2019t show any change in morphology, dimension and signal.",
    "differential_diagnosis": "Mediastinal, Paraganglioma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007470/000001.jpg?itok=IDQ_NFM5",
            "caption": ""
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007470/000002.jpg?itok=sm90IYve",
            "caption": ""
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007470/000003.jpg?itok=xr-YNzcU",
            "caption": ""
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/7470",
    "time": "11.05.2009"
  },
  "7475": {
    "case_id": 7475,
    "title": "Paracoccidioidomycosis (South American Blastomycosis)",
    "section": "Chest imaging",
    "age": "33",
    "gender": "male",
    "diagnosis": "Paracoccidioidomycosis (South-american blastomycosis)",
    "history": "A 33-year-old brasilian man presented with a 5-years history of cough and exertion dyspnea. His medical symptoms worsened in the last month presenting with low grade fever and weight loss. The physical examination revealed chronic cutaneous lesions.",
    "image_finding": "Conventional chest radiograph revealed hazy opacities in the left upper lobe. CT scan showed multiple bilateral ground-glass opacities surrounded by crescent or ring areas of consolidation (\u201creversed halo\u201d).Potential diagnoses were BOOP, Sarcoidosis, Paracocidioidomycosis, Wegener\u00b4s granulomatosis, or Angioinvasive aspergillosis.",
    "discussion": "Paracoccidioidomycosis is the most frequent endemic systemic mycosis in South America [1]. The disease is acquired by inhalation of infectious particles that reach the lungs and initiate the primary infection. Clinical forms range from a benign self-limited infection to a severe, progressive, and sometimes fatal disease involving pulmonary and extrapulmonary tissues. Paracoccidioidomycosis is usually asymptomatic but can progress to severe pulmonary involvement leading to progressive cough and shortness of the breath. The lungs are the main target organ and the main cause of morbidity and mortality in these patients [2]. A \u201creversed halo sign\u201d, characterized by a central ground-glass opacity surrounded by an air-space consolidation, was initially described as relatively specific CT finding of cryptogenic organizing pneumonia [3, 4]. Gasparetto et al. described a \u201creversed halo sign\u201d in 10% of 148 patients with paracoccidiodomycosis [5].",
    "differential_diagnosis": "Paracoccidioidomycosis, (South-american, blastomycosis)",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007475/000001.jpg?itok=TLm3Lyk5",
            "caption": ""
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007475/000002.jpg?itok=G_UbKQ_I",
            "caption": ""
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007475/000003.jpg?itok=oQaQU5oU",
            "caption": ""
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/7475",
    "time": "23.06.2009"
  },
  "7479": {
    "case_id": 7479,
    "title": "Dual energy chest radiography facilitates pneumothorax detection",
    "section": "Chest imaging",
    "age": "24",
    "gender": "male",
    "diagnosis": "Left sided pneumothorax",
    "history": "A previously healthy 24 year old smoker presented to his primary care physician (General Practitioner) with left sided pleuritic chest pain. On examination there were reduced breath sounds on the left. Dual energy chest radiography identified a small, otherwise subtle left sided pneumothorax.",
    "image_finding": "A 24 year old man presented to his primary care physician (General Practitioner) with a one day history of left sided pleuritic chest pain. He did not have a cough or shortness of breath. He had not felt feverish nor had rigors. Although he was a regular smoker, he had no significant past medical history. On examination he was slim and of average height. His trachea was central. There were reduced breath sounds on the left.The patient was referred for plain chest radiography. At our institution we use dual energy chest radiography for all outpatient primary care referrals (we hope to introduce it for all departmental chest radiographs in the future).A dual energy chest radiograph (DECXR) was performed. The soft tissue reconstruction image demonstrated a left apical pneumothorax. The pneumothorax was much more difficult to detect on the standard reconstruction image.",
    "discussion": "Dual energy techniques are being increasingly exploited in both digital plain radiography and computed tomography. These techniques rely on the differential absorption of higher and lower energy photons by different elements. In the case of dual energy radiography, structures containing calcium can be differentiated from those mainly containing carbon, hydrogen and oxygen (i.e. soft tissues). This allows the reconstruction of images either highlighting or suppressing bones and other tissues containing calcium [1].There are two types of dual energy radiography equipment: single-exposure and double-exposure [2]. Single-exposure systems use two detectors separated by a thin copper plate. The detector behing the copper plate receives only the higher energy photons. More commonly a double-exposure technique is used (as in this case). Two images are acquired, one each at 60 and 120 kV. The time between the two exposures is small (200 msec), in order to reduce the likelihood of misregistration artefacts caused by movement or breathing. Dual energy CXR is thought to only increase the dose slightly. One group reported an increase in dose of 14% for a typical combined PA and lateral CXR [3]. In summary, dual energy CXR increases the detection of pneumothoraces, nodules, bone lesions, pleural plaques and a variety of other chest diseases with only a small increase in the radiation dose.",
    "differential_diagnosis": "Left, sided, pneumothorax",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007479/000001.jpg?itok=_XPrLY52",
            "caption": "The left apical pneumothorax is only just visible on the standard reconstruction (equivalent to a \\\"non-dual energy\\\" CXR."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007479/000002.jpg?itok=eYIaQ_QU",
            "caption": "The left apical pneumothorax is much more conspicuous on the DE CXR soft tissue image owing to the subtraction of the overlying ribs."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007479/000003.jpg?itok=2k5j72E3",
            "caption": "The DE CXR bone reconstruction image is useful to evaluate for bone abnormalities, as well as other calcium containing structures, such as pleural plaques."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007479/000004.jpg?itok=NNIe3UeY",
            "caption": "The left apical pneumothorax is only just visible on the standard reconstruction (equivalent to a \\\\\\\"non-dual energy\\\\\\\" CXR."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007479/000005.jpg?itok=CSaE0e83",
            "caption": "The left apical pneumothorax is much more conspicuous on the DE CXR soft tissue image owing to the subtraction of the overlying ribs."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/7479",
    "time": "17.06.2009"
  },
  "7484": {
    "case_id": 7484,
    "title": "Low-grade lymphom",
    "section": "Chest imaging",
    "age": "56",
    "gender": "female",
    "diagnosis": "Low-grade B-cell Lymphoma of Bronchus-Associated Lymphoid Tissue (BALT)",
    "history": "A 56-year-old woman, asymptomatic, non-smoker and without relevant medical history, underwent a preoperative chest X-ray for safenectomy in April 2005 (Fig. 1) showing multiple opacities in both lungs.",
    "image_finding": "CT of the chest confirmed the presence of parenchymal abnormalities (Fig. 2). Bronchoscopy with bronchoalveolar lavage did not demonstrate atypical cells suggestive of malignancy. In January 2006 the patient was referred to our hospital because of persistence of chest opacities. She did not report any symptoms. Pulmonary functional tests, blood gas analysis, DLCO, walking test, laboratory and immunological tests as well as neoplastic markers were negative. Chest CT (Fig. 3) and bronchoscopy with multiple transbronchial biopsies were then performed.Fig.1: Chest radiograph (frontal view) shows multiple and bilateral homogeneous opacities, predominantly with ill-defined margins, in both mid and lower zones of the lungs.Fig.2-3: Chest CT scans (axial images) demonstrate multiple and bilateral airspace consolidations with subpleural and peribronchovascular distribution, associated with multiple small nodules along the bronchovascular bundles, mainly located in the lower lobes. No hilar and mediastinal lymphadenopathy is detected.Fig.4-5: A nine-months follow-up chest CT shows a substantial stability of the pulmonary abnormalities. Potential diagnoses were Bronchioloalveolar carcinoma, Organizing pneumonia, Sarcoidosis, Low-grade lymphoma (MALT or BALT lymphoma) or Wegener\u00b4s granulomatosis.Histological Findings:Fig.6: Transbronchial biopsy specimen stained with hematoxilin-eosin shows monotonous infiltrate of small lymphocytes with clear cytoplasm (monocytoid cells) invading bronchial and bronchiolar epithelium (lymphoepithelial lesions). Fig.7: Immunohistochemical staining (brown color) for CD20, a B-cell marker, shows positive neoplastic lymphocytes blended with normal nonstained cells of bronchiolar epithelium. Fig.8: The analysis of immunoglobulin heavy gene rearrangement by PCR of the sample (A) shows a monoclonal bundle, like bundle D, suggestive of monoclonal neoplastic proliferation.",
    "discussion": "Histological and immunoistochemical findings of our case were coherent with B-cell Lymphoma of Bronchus-Associated Lymphoid Tissue (BALT Lymphoma), a rare disorder which represents a subgroup of low-grade B-cell extranodal non-Hodgkin's lymphoma, classified as marginal zone lymphoma. BALT lymphoma is slow-growing neoplasm with apparently benign clinicopathologic features. It complicates the Sjogren\u2019s syndrome in about 25% of patients; it may be also seen in patients with dysgammaglobinemia, collagen vascular diseases and AIDS as well as in patients without known autoimmune disorder or chronic antigenic stimulus. Patients range in age from 25 to 85 years and are often asymptomatic. The prognosis of BALT lymphoma depends on the predominant cell type and the disease stage. Recommended treatment options include, surgical resection for limited disease, radiotherapy and immunosuppressive chemotherapy for locally advanced and disseminated diseases respectively. Recurrence is seen in 10%\u201315% of cases. The commonest radiological manifestations of pulmonary BALT lymphoma are solitary or multifocal areas of central or peripheral parenchymal consolidation with air bronchogram, which do not cavitate and are rarely associated with pleural effusion; it may also shows a ground glass appearance. Less common imaging features include multiple unilateral or bilateral nodules and diffuse infiltrates along the bronchovascular bundles and interlobular septa, simulating a perilymphatic spread disease. Hilar and mediastinal lymphadenopathy is not a prominent radiologic finding in BALT lymphomas. In our case, an association of multiple consolidations with peribronchovascular small nodules was observed. In some patients, chest abnormalities remain stable for several years before biopsy and definitive histologic diagnosis. Multiple persistent air space consolidations may represent a great number of diseases and we should include in the differential diagnosis, bronchioloalveolar carcinoma, organizing pneumonia, as well as Wegener\u00b4s granulomatosis or sarcoidosis. An overlap of radiologic findings among these diseases is expected even if they can show some typical appearances. Organizing pneumonia usually shows unilateral or bilateral patchy consolidation with air bronchogram, a peripheral or peribronchial distribution and a lower lobes involvement; nevertheless, consolidations have a tendency to migrate over time and to resolve after steroid therapy. In Wegener\u00b4s granulomatosis the most common findings are multiple nodules or irregularly marginated masses with peribronchovascular distribution and no zonal predominance; in approximately 50% of cases, cavitations occur within the nodules and they may resolve with therapy. Sarcoidosis typically demonstrates multiple small nodules with a perilymphatic distribution and upper lobes predominance; consolidation is less commonly seen and coexistence of mediastinal lymphadenopathies can also help in the differentiation. Differential diagnosis with bronchioloalveolar carcinoma is extremely difficult because multiple consolidations with air bronchograms are a common finding and mediastinal lymphadenopaties and pleural effusion are not characteristic as with BALT lymphoma. In conclusion, CT findings of multiple and bilateral consolidations without cavitations and the absence of mediastinal or hilar nodes may allow to reduce the differential diagnosis. The indolent nature of lesions and a history of autoimmune disease may help perform a proper diagnosis. Tissue confirmation, using core or surgical biopsy with the help of immunohistochemical staining, is generally needed to make the ultimate diagnosis.",
    "differential_diagnosis": "Low-grade, B-cell, Lymphoma, of, Bronchus-Associated, Lymphoid, Tissue, (BALT)",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007484/000001.jpg?itok=gD27B1jn",
            "caption": ""
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007484/000002.jpg?itok=7OdweNzf",
            "caption": ""
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007484/000003.jpg?itok=MKEmiVRu",
            "caption": ""
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007484/000004.jpg?itok=qJUjAota",
            "caption": ""
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007484/000005.jpg?itok=CwY1Bxgt",
            "caption": ""
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007484/000006.jpg?itok=sbTBZbje",
            "caption": ""
          }
        ]
      },
      {
        "number": "Figure 7",
        "subfigures": [
          {
            "number": "Figure 7",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007484/000007.jpg?itok=WwqvZQqP",
            "caption": ""
          }
        ]
      },
      {
        "number": "Figure 8",
        "subfigures": [
          {
            "number": "Figure 8",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007484/000008.jpg?itok=-T24p9nd",
            "caption": ""
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/7484",
    "time": "03.05.2009"
  },
  "7575": {
    "case_id": 7575,
    "title": "Azygos Lobe",
    "section": "Chest imaging",
    "age": "43",
    "gender": "female",
    "diagnosis": "Incidental finding of Azygos Lobe in a preoperative chest radiograph.",
    "history": "A 43 year old patient underwent a preoperative chest radiograph.",
    "image_finding": "A pilonidal cyst had to be removed in this patient, situated near the coccyx, which caused to her pain and tumefaction. The preoperative standard chest radiograph did not show any pleuro-parenchymal lesion and the dimensions of the heart were normal. Incidentally, we describe the presence of an Azygos Lobe.",
    "discussion": "The Azygos Lobe is found in about 1% of autopsies and in 0.4% of radiograms. Usually in embryonic stages, the precursor of the azygos vein, the right posterior cardinal vein, first sets itself on the medial surface of the right upper lobe, and then descends in a position situated two centimetres cranially to the right superior lobar bronchus.Two principal hypotheses about the origin of Azygos Lobe have been made. In some authors\u2019 opinion the Azygos Lobe would derive from the precocious displacement of the heart from the cervical position to the thoracic one, before the azygos vein has reached its normal position. According to others authors, it would form because of an excessive development of the pulmonary apex so that the azygos vein would remain entrapped in it. In both cases, the azygos vein will be surrounded by two layers of parietal pleura and by two layers of visceral pleura. These layers link the azygos vein to the thoracic wall through a structure of mesenterial type.On the chest radiograph, 4 structures can be noticed in the right upper pulmonary field: 1) the shadow of the azygos vein (unusually situated at the level of the pulmonary parenchyma); 2) a fine, convex line departing from the shadow of the azygos vein in cranial direction. This line is constituted by the apposition of the two layers of visceral pleura and by the two layers of parietal pleura (these two internal layers are known as mesoazygos); 3) the Azygos Lobe, which represents the portion of pulmonary parenchyma delimitated by the previously mentioned  line; 4) a triangular area (trigonum parietale) near the thoracic wall, where the two internal layer of mesoazygos continue with costal pleura.According to its size, the Azygos Lobe has been classified in three types: type A (the trigonum parietale is located in the lateral aspect of the pulmonary apex); type B (the mesoazygos has a vertical path); and type C (the trigonum is located medially).Axial CT images give a more accurate representation of the anomalous course of the azygos vein, of the presence of the Azygos Lobe and of their relations with mediastinal organs. The Azygos Lobe is not a pathological finding, but it can create problems during surgery of the pulmonary apex or in sympaticectomy operations (e.g. for hyperhidrosis).",
    "differential_diagnosis": "Incidental, finding, of, Azygos, Lobe, in, a, preoperative, chest, radiograph.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007575/000001.jpg?itok=gLlMVbeJ",
            "caption": "Presence of Azygos Lobe"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/7575",
    "time": "05.06.2009"
  },
  "7588": {
    "case_id": 7588,
    "title": "Iatrogenic Pulmonary Artery Pseudoaneurysm",
    "section": "Chest imaging",
    "age": "68",
    "gender": "female",
    "diagnosis": "Iatrogenic Pulmonary Artery Pseudoaneurysm.",
    "history": "A 68 year old woman was referred to the respiratory outpatient clinic for investigation of pulmonary artery (PA) hypertension.",
    "image_finding": "Following an initial clinical work up and chest radiograph, right heart catheterisation was performed.  A Swan Ganz catheter was inserted via right femoral venous access and the tip positioned in the right middle lobe pulmonary artery under fluoroscopic guidance.  The catheter balloon was inflated to record a pressure of 78/23mmHg (mean= 42mmHg). Immediately after the balloon was inflated, the patient experienced small volume haemoptysis.",
    "discussion": "A CTPA was performed later the same day to investigate the cause of her PA hypertension. This demonstrated a 3cm sized pseudoaneurysm arising from a right middle lobe subsegmental PA with associated pulmonary haemorrhage (Fig 1). The patient remained haemodynamically stable and was scheduled for elective embolization of the pseudoaneurysm.  Prior to this, cardiac MRI was performed (six days post catheterisation) to assess right ventricular dimensions, allowing the opportunity to visualise the pseudoaneurysm on MRI (Fig 2).  A catheter angiogram was performed the following day with embolization of the inflow artery by uncoated platinum coils (Fig 3).",
    "differential_diagnosis": "Iatrogenic, Pulmonary, Artery, Pseudoaneurysm.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007588/000001.jpg?itok=0flNZjjU",
            "caption": "A round, enhancing lesion is seen to arise from a branch of the right middle lobe pulmonary artery."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007588/000002.jpg?itok=ZLsZDjBg",
            "caption": "Axial image from CT pulmonary angiogram demonstrates patchy consolidation surrouding the enhancing lesion."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007588/000003.jpg?itok=948oloKl",
            "caption": "Turbulent flow is seen within the pulmonary artery pseudoaneurysm."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007588/000004.png?itok=NFSiRnSM",
            "caption": "Following selective microcathter angiography of the right middle lobe pulmonary arteries, the pseudoaneurysm is identified as arising from a subsegmental branch."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007588/000005.png?itok=dGXcACwv",
            "caption": "Following uncoated platinum coil embolisation, no residual filling of the pseudoaneurysm is demonstrated."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007588/000006.jpg?itok=HrqVL6hU",
            "caption": "No recurrence of the pseudoaneurysm is identified.  Longstanding cardiomegaly is noted."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/7588",
    "time": "17.06.2009"
  },
  "7603": {
    "case_id": 7603,
    "title": "Bochdalek hernia in an adult simulating  pleural effusion",
    "section": "Chest imaging",
    "age": "30",
    "gender": "male",
    "diagnosis": "Right sided Bochdalek hernia",
    "history": "A 30 year old male evaluated for dyspepsia, abdominal pain and short breath.",
    "image_finding": "A 30 year old male with one month history of mild symptoms of dyspepsia, short breath and abdominal pain, radiating to his back, was referred to our hospital for evaluation. His previous history was unremarkable and free of traumatic injuries. Blood tests results and body temperature were in normal range. The clinical evaluation revealed absent breath sounds and dullness to percussion to the right hemithorax. His abdomen was soft and non-tender with normal bowel sounds. Abdominal films revealed a possible right lower lobe pneumonia but were otherwise normal. A chest radiograph (AP and right oblique) was consistent with right lower and middle lobe consolidation and associated pleural effusion (Fig 1). Previous investigations included a negative plain (AP) radiograph one year earlier which was requested for evaluation of lower respiratory tract infection (Fig 2). Thoracentesis was attempted twice but no fluid was drained. A chest CT was obtained for further investigation of the pleural space which revealed a large diaphragmatic hernia containing a part of small and large intestine, a large mass of omentum and a part of the right lobe of the liver without pleural fluid. A large diaphragmatic defect on the right side is also depicted (Fig 3-5). The patient had laparoscopic reduction of the abdominal viscera, repair of the diaphragmatic defect and was discharged 3 days later.",
    "discussion": "The foramen of Bochdalek is a 2x3cm opening in the posterior aspect of the diaphragm in the foetus, through which the pleuroperitoneal canal communicates between the pleural and peritoneal cavities. This canal normally closes by the 8th week of gestation, failure or incomplete fusion of the lateral (costal) with the posterior (crural) components of the diaphragm leads to the development of Bochdalek hernia. Since the left canal closes later than the right, this type of hernia is found on the left side in 85% of cases. It has been postulated that the liver normally obstructs herniation through a right-sided defect accounting for the previous reported prevalence of the left-sided hernias. Congenital diaphragmatic hernias clinically presenting in adulthood are exceedingly rare lesions with approximately one hundred cases only recorded in the literature. Adult Bochdalek hernias can present in two ways. They can give rise to vague, mainly gastrointestinal (abdominal pain, nausea and vomiting, constipation) or respiratory (chest pain, dyspnoea, wheezing) symptoms, followed by severe attacks and episodes of incarceration with serious consequences. Characteristically, these symptoms can be intermittent, as herniated viscera can spontaneously reduce causing symptom regression. In such cases, radiological investigations demonstrate reduction of the hernia with symptom resolution. Others will present with serious complications associated with strangulation of herniated viscera, especially when the diagnosis has been missed or treatment delayed. The organs that most commonly herniate into the thorax through this defect are stomach, ileum, colon and spleen. The liver and the right kidney may herniate along with the bowel loops if the defect is on the right side as in our patient. Without the use of CT nearly 38% of adults are misdiagnosed as pleural effusion, empyema, lung cyst and pneumothorax.",
    "differential_diagnosis": "Right, sided, Bochdalek, hernia",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007603/000001.jpg?itok=IIjAnvpO",
            "caption": "Negative (AP) radiograph obtained one year before onset of symptoms."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007603/000002.jpg?itok=pCu995LN",
            "caption": "Chest radiograph interpreted as showing right lower and middle lobe consolidation and associated pleural effusion"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007603/000005.jpg?itok=k1aELAus",
            "caption": "Chest radiograph interpreted as showing right lower and middle lobe consolidation and associated pleural effusion"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007603/000004.jpg?itok=Pu6wjY38",
            "caption": "Large diaphragmatic hernia containing a part of small and large intestine, a large mass of omentum and a part of the right lobe of the liver without pleural fluid."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007603/000011.jpg?itok=8pEhv8rM",
            "caption": "Large diaphragmatic hernia containing a part of small and large intestine, a large mass of omentum and a part of the right lobe of the liver without pleural fluid."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007603/000006.jpg?itok=v76L0Wku",
            "caption": "Large diaphragmatic hernia containing a part of small and large intestine, a large mass of omentum and a part of the right lobe of the liver without pleural fluid."
          },
          {
            "number": "Figure 3d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007603/000009.jpg?itok=xr8aJPPW",
            "caption": "Large diaphragmatic hernia containing a part of small and large intestine, a large mass of omentum and a part of the right lobe of the liver without pleural fluid. Arrow indicates diaphragm with defect"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007603/000007.jpg?itok=ZB63b6og",
            "caption": "Atelectasis of midle and right lower lobe."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007603/000008.jpg?itok=_9gRB7h_",
            "caption": "Atelectasis of midle and right lower lobe."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007603/000010.jpg?itok=RhmydiVm",
            "caption": "Parts of small and large intesine with mesenteric vessels."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/7603",
    "time": "29.08.2009"
  },
  "7609": {
    "case_id": 7609,
    "title": "Multiple Pulmonary nodules, Diagnosis and Differential diagnosis",
    "section": "Chest imaging",
    "age": "39",
    "gender": "female",
    "diagnosis": "post primary pulmonary tuberculosis",
    "history": "A 39-year-old nulligravida indian female patient with type I diabetes mellitus and skin manifestations. She was complaining from chest pain and nausea. She had a chest x ray upon which she was investigated by CT chest study. Pulmonary function tests were within normal ranges.",
    "image_finding": "Fig. 1 and 2: Plain chest X-ray (Fig. 1) PA and (Fig. 2) lateral views revealed multiple rounded rather ill defined pulmonary nodules seen scattered throughout both lower lung zones being more numerous on the right side. Blunted right costophrenic angle was also noticed with patent left angle. CT chest study was then performed to further characterize, localize these nodules and to evaluate for associated mediastinal or hilar adenopathy. The CT chest findings (Fig. 3-8), superiorly revealed that some of these nodules show cavitation with few air pockets inside. No calcifications have been found. No pathologically enlarged hilar or mediastinal lymph nodes were noticed as well. Fig. 3-5: CT chest images displayed in lung window settings showing the tree in bud pattern of the distribution of the nodules, few air pockets within some of the nodules and with vicinity to the blood vessels as well.Fig. 6-8: CT chest images displayed in mediastinal window settings showing no evidence of calcifications within the nodules nor pathologically enlarged hilar or mediastinal lymph nodes.",
    "discussion": "The correct diagnosis is post primary pulmonary tuberculosis based on CT guided biopsy.The imaging findings that suggest tuberculosis are the followings:The nodules of tuberculosis (TB) are mainly involving the superior and anterior basal segments of lower lung lobes with cavitation which is typically thick walled and irregular. The nodules are rather ill defined. The absence of lymphadenopathy, cavitations and pleural involvement distinguishes post primary TB from primary TB [1].Why not Sarcoidosis?Hilar and/or mediastinal lymphadenopathy is the most common finding in sarcoidosis with frequently affected both hilar and right paratracheal lymph nodes. Cavitation of sarcoid parenchymal nodular lesions occurs rarely [2].Why not metastases?Typical radiologic findings of a pulmonary metastasis include multiple round variable-sized nodules and diffuse thickening of the interstitium. Cavitation occurs most frequently in squamous cell tumors in comparison to adenocarcinomas and sarcomas which also cavitate occasionally. Cavitation of squamous cell tumors is commonly upper lobar. Calcification can occur in a metastatic sarcoma or adenocarcinomas [3].Why not Aspergilloma?In cases of aspergilloma, CT scan images demonstrate a soft-tissue attenuation mass within a lung cavity which is typically separated from the cavity wall by airspace (\"air crescent\" sign) and is often associated with thickening of the wall and adjacent pleura [4].Why not Wegener granulomatosis?The most common radiographic finding of Wegener granulomatosis is multiple irregularly marginated nodules with no zonal predominance and often having a peribronchovascular distribution. Cavitation of the nodules occurs in approximately half of cases and usually having irregular thick walls. Mediastinal and hilar adenopathy and pleural effusions are relatively uncommon [5].DISCUSSION:Chest radiography is the primary imaging method in the diagnosis of tuberculosis, but the importance of CT is still increasing, as CT is more sensitive in the detection of cavitation, hilar and mediastinal lymphadenopathy, endobronchial spread and complications [6]. The diagnosis of sarcoidosis is commonly established on the basis of clinical and radiologic findings supported by histologic findings.  The radiologic stages of intrathoracic sarcoidosis are stage 1, lymphadenopathy only; stage 2, lymphadenopathy with parenchymal infiltration; stage 3, parenchymal disease only and stage 4, pulmonary fibrosis [7]. The lung is a common site for metastases. The breast, colon, kidney, uterus and head and neck are the most common primary sites with a pulmonary metastasis [3]. Pulmonary aspergillosis can be subdivided into five categories; saprophytic aspergillosis (aspergilloma), allergic bronchopulmonary aspergillosis, chronic necrotizing aspergillosis, airway-invasive aspergillosis and angioinvasive aspergillosis [4]. Wegener Granulomatosis is one of idiopathic systemic autoimmune process predominantly affecting male patients and is characterized by granulomatous vasculitis of the respiratory tracts, glomerulonephritis and small-vessel vasculitis [5].Conclusion: Although no single radiologic feature is diagnostic of post primary TB, a combination of opacities commonly involving the upper lobe apical and posterior segments or lower lobe superior segment with a dominant cavitary process increases confidence in the diagnosis of TB.",
    "differential_diagnosis": "post, primary, pulmonary, tuberculosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007609/000001.jpg?itok=aA1cmIIu",
            "caption": ""
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007609/000002.jpg?itok=XL0Gzs9W",
            "caption": ""
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007609/000003.jpg?itok=XLTqsnKP",
            "caption": ""
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007609/000004.jpg?itok=vmwx-pJ2",
            "caption": ""
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007609/000005.jpg?itok=EnGbjOia",
            "caption": ""
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007609/000006.jpg?itok=sT4EXpdY",
            "caption": ""
          }
        ]
      },
      {
        "number": "Figure 7",
        "subfigures": [
          {
            "number": "Figure 7",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007609/000007.jpg?itok=fCQywm-O",
            "caption": ""
          }
        ]
      },
      {
        "number": "Figure 8",
        "subfigures": [
          {
            "number": "Figure 8",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007609/000008.jpg?itok=2cmTjlRa",
            "caption": ""
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/7609",
    "time": "27.08.2009"
  },
  "7627": {
    "case_id": 7627,
    "title": "Pneumomediastinum in patient with lung fibrosis",
    "section": "Chest imaging",
    "age": "77",
    "gender": "female",
    "diagnosis": "Spontaneous pneumomediastinum in a patient with pulmonary fibrosis",
    "history": "A 77 year old female patient with unremarkable history, who developed pulmonary fibrosis, evaluated for dyspnoea and cough.",
    "image_finding": "A 77 year old woman was referred to the emergency department with worsening of cough episodes and dyspnoea.  The patient has no history of  connective tissue disease.A PA and lateral chest radiograph taken at the time of admission showed the occurrence of pneumomediastinum and diffuse reticular opacities in both lungs (Fig 1). The chest CT (Fig 2) demonstrated extensive pneumomediastinum with diffuse interstitial thickening in both lungs with multiple traction bronchiectases.",
    "discussion": "Pneumomediastinum (PNMD) is characterized by the presence of gas in mediastinal tissues outside the oesophagus and the tracheobronchial tree, which almost invariably originates from the alveolar space or the conducting airways. Many authors distinguish spontaneous PNMD as a form of pneumomediastinum that is not associated with blunt force or penetrating chest trauma, endobronchial or oesophageal procedures, neonatal lung disease, mechanical ventilation, chest surgery or other invasive procedures. The association between lung fibrosis and pneumomediastinum is well known.  The pathogenesis responsible for pneumomediastinum in this case is due to alveolar or honeycomb cyst rupture due to increased intrapulmonary pressure on strain with consequent dissemination of air through the blood vessel sheath  to the mediastinum.   Manoeuvres that usually precede spontaneous pneumomediastinum are those that involve an increase in lung volume followed by a dramatic increase in pleural pressure, such as coughing, sneezing, vomiting, or parturition. Patients with PNMD commonly report transient stabbing chest pain, which may radiate to the shoulders, arms or back. The pain is usually located substernally and worsens with movement, breathing or position change. They tend to have dyspnoea and coughing. Dysphagia and dysphonia may also be present if retropharyngeal or perilaryngeal air dissection is present. Pneumomediastinum is difficult to diagnose at physical examination alone. The diagnosis is usually made following imaging studies.  The radiographic signs depend on the depiction of the normal anatomic structures that are outlined by the air as it accumulates in the mediastinum.  Infants and young adults with pneumomediastinum may have the \"thymic sail sign\" in which the thymic lobes are shifted upward resembling a sail. Air anterior to the pericardium is a frequent manifestation and requires a lateral view for diagnosis. Streaks or pockets of air outlining visceral planes or tissue compartments can also be seen and constitute air surrounding the pulmonary artery or its branches and mainly involve the intramediastianal segment of the right pulmonary artery.  When there is air adjacent to the major branches of the aorta both sides of the vessel depicted.When air resides along a major bronchus, the bronchial wall visualized giving the double bronchial wall sign.  A thin, radiolucent line at the left heart border or a \"continuous diaphragm\" (unbroken radiolucent line from one hemi-diaphragm to the other beneath the heart) is usually present when air is trapped posteriorly to the pericardium. Air between the parietal pleura and the diaphragm can produce the extrapleural sign. CT scan is used to better visualize pneumomediastinum not seen on plain x-ray or to provide further information on coexisting disease or causes for the patient's presentation.Therapeutic procedures are generally not necessary. Spontaneous pneumomediastinum typically resorbs within a period of 1 to 2 weeks without treatment, and rarely recurs.",
    "differential_diagnosis": "Spontaneous, pneumomediastinum, in, a, patient, with, pulmonary, fibrosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007627/000002.jpg?itok=8ENQgV0S",
            "caption": "a) axial view at the level of the aortic arch, extensive pneumomediastinum (arrows) with diffuse interstitial thickening in both lungs"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007627/000003.jpg?itok=-RCTajvh",
            "caption": "b) lower level. Same findings with air around ascend-,descending aorta and pulmonary vessels(arrows)."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007627/000004.jpg?itok=UPM3k8e_",
            "caption": "c)  lower level. Subdiaphragmatic free air (arrows)"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007627/000006.jpg?itok=4qRGVYMa",
            "caption": "a) anteroposterior (AP) view, in the  77-year-old female, demonstrates pneumomediastinum (arrows) and  reticular opacities diffusely distributed to the lung parenchyma"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007627/000005.jpg?itok=2Qr_vDkD",
            "caption": "b) lateral projection"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/7627",
    "time": "03.08.2009"
  },
  "7655": {
    "case_id": 7655,
    "title": "Wegener\\&#039;s granulomatosis",
    "section": "Chest imaging",
    "age": "11",
    "gender": "male",
    "diagnosis": "Wegener's granulomatosis",
    "history": "An 11-year-old boy had 2 episodes of pneumonia within 7 months. In the first episode he presented with fever, cough and left abdominal pain. Seven months later he mentioned again fever, abdominal pain and also pain on the left shoulder.",
    "image_finding": "In his first admission in another hospital, the chest radiograph showed consolidation in the left upper lobe (Fig. 1).Seven months later, he presented with the above mentioned symptoms in our hospital. The chest radiograph demonstrated again consolidation in the left upper lobe and also consolidation in the right upper lobe (Fig. 2). His clinical examination was normal. Tuberculosis was excluded (negative Mantoux). CRP and IgA were increased. Spirometry and bronchoscopy were normal.The next step was a CT of the chest, which demonstrated multiple consolidations with central necrosis (cavitations) in both upper lobes and in the posterior basic segment of the left lower lobe (Fig. 3). The differential diagnosis of cavitated pulmonary lesions includes septic emboli, pulmonary infarcts, mycotic infection and metastases [1, 2]. The abdominal ultrasound revealed calcifications of the liver, which were confirmed on the CT of the abdomen (Fig. 4).A serum test for antineutrophil cytoplasmic antibodies was positive.Biopsies of the kidney, skin and nasal mucosa were performed.",
    "discussion": "A diagnosis of Wegener\u2019s granulomatosis requires a high-degree of clinical suspicion and a thorough history. The constellation of radiographic findings may lead to empiric treatment. It is a small vessel disease characterised histologically by a necrotising vasculitis with granuloma formation. The disease can affect any organ, but it has a predilection for the upper airway, lung, and kidney [1]. Clinical manifestations include shortness of breath, haemoptysis, pleuritic chest pain, and cough. Airway symptoms include bloody rhinorrhea, sinus pain, and oral and nasal ulcers. Extrapulmonary symptoms include conjunctivitis, proptosis, rash and subcutaneous nodules. ANCA is positive in roughly 90% of Wegener\u2019s patients, with most being of the C-ANCA subset.The clinical presentation of Wegener\u2019s granulomatosis often leads to radiologic evaluation via chest radiograph and chest CT. Chest radiographs show multiple nodules with irregular and thick walls that exhibit cavitation about 50% of the time [1]. There is no zonal predilection. Although it is less frequent, the nodules can be solitary. A CT examination will show the nodules to have a peribronchovascular preponderance and irregular margins. The differential diagnosis of cavitated, vessel-related pulmonary lesions includes septic emboli, pulmonary infarcts and haematogenous metastases [1, 2].  A pleural effusion is seen less than 10% of the time. There can also be subglottic tracheal stenosis.The diagnosis requires histologic evidence of vasculitis with concurrent clinical presentation. It is often difficult to obtain adequate samples, and open biopsy is the norm [1]. Otolaryngologic biopsies are nonspecific about half of the time. Renal biopsy is also nonspecific, showing focal segmental necrotising glomerulonephritis. The American College of Rheumatology includes the presence of two out of four criteria in the classification of Wegener\u2019s granulomatosis, which include nasal or oral inflammation, abnormal chest radiograph, abnormal urinary sediment, and granulomatous inflammation on biopsy [1].",
    "differential_diagnosis": "Wegener's, granulomatosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007655/000001.jpg?itok=ylr_4MjT",
            "caption": "Chest radiograph shows consolidation in the left upper lobe."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007655/000002.jpg?itok=CwraegyM",
            "caption": "Chest radiograph 7 months later shows consolidation in the left upper lobe and in the right upper lobe."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007655/000003.jpg?itok=aIuLZC_B",
            "caption": "Consolidation with central necrosis (cavitation)"
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007655/000004.jpg?itok=t6zfMFfY",
            "caption": "Consolidations with central necrosis"
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007655/000005.jpg?itok=eMJ0C17m",
            "caption": "Consolidation with central necrosis(cavitation)."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007655/000006.jpg?itok=asBoxFRi",
            "caption": "Calcifications in the liver"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/7655",
    "time": "04.12.2012"
  },
  "7657": {
    "case_id": 7657,
    "title": "Aortoesophageal fistula due to chicken bone demonstrated by CT",
    "section": "Chest imaging",
    "age": "74",
    "gender": "male",
    "diagnosis": "Aortoesophageal fistula due to chicken bone ingestion",
    "history": "A 74 year old male patient was admitted to our hospital for hematemesis evaluation. On clinical examination the patient was hypotensive with tachypnea. The patient underwent CT, esophageal endoscopy and surgical repair.",
    "image_finding": "On clinical examination of the abdomen there was not any abdominal tenderness or pain, while the patient was mild hypotensive (80mmHg) with tachypnea. The patient underwent CT examination. At non-contrast enhanced CT (Fig 1), at subcardinal level, a linear hyperdense lesion was demonstrated between the oesophagus and descending aorta, with a lucency within it. Gas effusion and increased density of the adipose tissue at the interval between oesophagus and descending aorta were also visualized (Fig 2). The presence of blood and gas effusion was compatible with oesophageal rupture whereas the lucency within the hyperdense lesion was similar to that of bone marrow. The probable diagnosis was that of oesophageal rupture due to bone swallowing. The patient was asked and confirmed our suspicion. At contrast enhanced CT (Fig 3), in addition to the bone lesion an abnormal active contrast leakage was observed due to aortoesophageal fistula. Thereafter an endoscopic examination of oesophagus was performed and the diagnosis was confirmed (Fig 4). An operation was performed and the foreign body was removed and the aorta and the oesophagus were sutured. The patient was admitted to the intensive care unit and discharged several days later.",
    "discussion": "Aortoesophageal fistula (AEF) is a rare condition that can cause upper gastrointestinal tract haemorrhage. Rupture of an aneurysm of the descending aorta into the oesophagus is the most common cause of AEF. Less frequent causes with decreasing frequency are foreign body ingestion, mid oesophagus carcinoma, bronchogenic carcinoma, Barrett\u2019s ulcer. Secondary AEF occurs following an aortic or oesophageal surgery.Chiari was the first one to describe the clinical presentation of an AEF consisting of mid-thoracic pain, sentinel haemorrhage followed by a symptom free interval leading finally to exsanguination. AEF is rarely being diagnosed before massive hematemesis.A chest radiograph may show mediastinal widening due to an aortic aneurysm. Oesophageal contrast series can be useful in some cases either by showing contrast material around the aortic prosthesis in patients with oesophagoparaprosthetic fistula or by demonstrating oesophageal perforation. Angiography has been used in diagnosis with partial success, but can provide useful information for the surgical planning. Oesophagoscopy is a very important tool in the diagnosis and evaluation of AEF, but CT scanning is the most valuable diagnostic method.In our case AEF was caused by the ingestion of chicken bone. The CT scanning revealed the lesion and oesophagoscopy confirmed the diagnosis. The false aneurysm between the oesophagus and the descending aorta as well as the presence of gas effusion are typical findings of AEF in CT scanning.A foreign body impaction usually occurs at the places where oesophagus normally narrows. Because of the close proximity of the aorta, foreign bodies can cause perforation of the aortic wall. The most commonly used treatment for AEF repair is left thoracotomy.As a conclusion we can say that AEF caused by a foreign body is a very rare condition that could be fatal. AEF should be suspected in a patient who presents with the characteristic symptoms of Chiari\u2019s syndrome and a history of foreign body ingestion. CT scanning and endoscopy will confirm the fistula, but the most important factor for the proper diagnosis is the awareness of the clinician.",
    "differential_diagnosis": "Aortoesophageal, fistula, due, to, chicken, bone, ingestion",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007657/000001.jpg?itok=AHEUnEO_",
            "caption": "Noncontrast enhanced chest CT, at subcarinal level. A linear hyperdense lesion was demonstrated between the esophagus and descending aorta."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007657/000002.jpg?itok=kNu7jt7Q",
            "caption": "Noncontrast enhanced chest CT, at 5 mm  lower level. Within the linear hyperdense lesion a low density was observed.  Gas bubbles and increased density of the adipose tissue between the esophagus and descending aorta were visualized"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007657/000003.jpg?itok=_VSJbCv_",
            "caption": "Contrast enhanced CT, at the same level as figure 1.  At contrast enhanced CT, in addition to the hyperdense lesion (bone) an increased density representing an abnormal active contrast leakage was also observed."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007657/000005.jpg?itok=oU54Y-hI",
            "caption": "Endoscopic examination  revealed  fistula and thrombus between esophagus and the descending aorta"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/7657",
    "time": "27.08.2009"
  },
  "7659": {
    "case_id": 7659,
    "title": "HRCT findings in pulmonary Leptospirosis, a case report.",
    "section": "Chest imaging",
    "age": "61",
    "gender": "male",
    "diagnosis": "Leptospirosis",
    "history": "A 61 year old patient presented to the emergency room referring cough, generalized musculoskeletal pain and fever for the last 4 days. Chest radiograph and high-resolution CT examination were performed and the findings are presented.",
    "image_finding": "The patient had no history of prior medical problems. He referred exposure to infected contaminated environment as 15 days ago while he was cleaning up an old storage room, he noted animal urine and faeces. Initially  the symptoms were acute febrile illness, headache, myalgia, and prostration. When he presented to the emergency room he had cough, fever up to 38.5\u00b0C, hypotonia, heart rate 140 bpm and an icteric colour.Initial chest radiograph showed fine reticulonodular opacities throughout both lungs. High-resolution CT scan obtained later in the same day revealed patchy alveolar infiltration, ground-glass attenuation, interlobular septa thickening, ill-defined small nodular hyper-attenuating areas and mediastinal and axillary lymphadenitis.    Specific microbiological tests showed leptospirosis. During his staying in hospital he developed acute respiratory distress, jaundice, anuria and hepatic and renal insufficiency. He passed away 20 days after his admission in hospital.",
    "discussion": "Leptospirosis is a worldwide zoonotic infection caused by pathogenic species of the genus Leptospira. Leptospires infect many types of mammals (rats, dogs, cats, cattle, pigs, squirrels, raccoons, mongooses, and bandicoots). Humans are dead-end hosts for the Leptospira. Nosocomial and congenital leptospirosis have also been described but are rare.Leptospirosis is most common among adult males, resulting from occupational and recreational exposures. Leptospires infect humans by invasion across mucosal surfaces or non-intact skin. Infection may occur via direct contact with urine or through contact with contaminated water and soil. The most consistent pathologic finding in leptospirosis is vasculitis of capillaries manifested by endothelial oedema, necrosis, lymphocytic infiltration. Clinical presentation varies from a flu-like syndrome to Weil disease, which includes jaundice, renal failure, and hemorrhagic complications. In 90% of cases, leptospirosis manifests as an acute febrile illness with a biphasic course and an excellent prognosis. In 10% of cases, the presentation is more dramatic, reaching mortality rates of 10%. Other organ systems (i.e. pulmonary system, cardiac system, CNS, skeletal muscle) are also frequently involved.Pulmonary involvement seems to be common and associated with a high death rate for patients with severe leptospirosis cases. Pulmonary manifestations include cough, hemoptysis (mild or severe), dyspnea and pneumonia. The severe pulmonary form of leptospirosis is accompanied by pulmonary haemorrhage. Pulmonary findings are caused by alveolar capillary injury, either focal or diffuse. The patients may develop acute respiratory distress syndrome, multiple organ dysfunction syndrome or acute respiratory insufficiency. Radiographic findings may include small nodular opacities, confluent areas of consolidation, diffuse bilateral ground-glass areas of increased opacity, as well as pleural effusions. These findings are compatible with the pathologic features of petechial and multifocal pulmonary haemorrhage. Patients with mild, flu-like symptoms require only symptomatic treatment. Patients with more severe anicteric leptospirosis require hospital admission and close observation. Icteric leptospirosis requires admission to the intensive care unit initially. Patients in acute renal failure require dialysis urgently. Early initiation of antibiotic therapy is important in acute disease. Doxycycline therapy initiated soon after the onset of symptoms can prevent severe complications and mortality.Improved specific microbiological diagnostic tests for leptospirosis are urgently needed to help in the clinical diagnosis during the initial phase of the disease and for the rapid case confirmation during outbreak surveillance.  Radioimmunoassay (RIA), an enzyme-linked immunosorbent assay (ELISA) method and MAT (microscopic agglutination testing) can confirm the diagnosis.",
    "differential_diagnosis": "Leptospirosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007659/000001.jpg?itok=J_Pylzk8",
            "caption": "Presence of fine reticulonodular opacities throughout both lungs"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007659/000002.jpg?itok=lc_Zmu1h",
            "caption": "Mediastinal lymphadenitis is noticed."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007659/000003.jpg?itok=7_Lj751Y",
            "caption": "Presence of mediastinal and axillary lymphadenitis"
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007659/000004.jpg?itok=q099rhcV",
            "caption": "Presence of mediastinal and axillary lymphadenitis"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007659/000005.jpg?itok=c2OUzoo4",
            "caption": "HRCT images showing the patchy alveolar infiltration, ground-glass attenuation, interlobular septa thickening and the ill-defined small nodular hyperattenuating areas"
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007659/000006.jpg?itok=pHF-Lvsl",
            "caption": "HRCT images showing the patchy alveolar infiltration, ground-glass attenuation, interlobular septa thickening and the ill-defined small nodular hyperattenuating areas"
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007659/000007.jpg?itok=20LhzpvO",
            "caption": "HRCT images showing the patchy alveolar infiltration, ground-glass attenuation, interlobular septa  thickening and the ill-defined small nodular hyperattenuating areas"
          },
          {
            "number": "Figure 3d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007659/000008.jpg?itok=Enio5WLd",
            "caption": "HRCT images showing the patchy alveolar infiltration, ground-glass attenuation, interlobular septa thickening and the ill-defined small nodular hyperattenuating areas"
          },
          {
            "number": "Figure 3e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007659/000009.jpg?itok=2waJsyJj",
            "caption": "HRCT images showing the patchy alveolar infiltration, ground-glass attenuation, interlobular septa thickening and the ill-defined small nodular hyperattenuating areas"
          },
          {
            "number": "Figure 3f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007659/000010.jpg?itok=uv78KlTi",
            "caption": "HRCT images showing the patchy alveolar infiltration, ground-glass attenuation,  interlobular septa thickening and the ill-defined small nodular hyperattenuating areas"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/7659",
    "time": "25.10.2009"
  },
  "7724": {
    "case_id": 7724,
    "title": "Herpes simplex pneumonia and ARDS in an immunocompromised patient",
    "section": "Chest imaging",
    "age": "62",
    "gender": "female",
    "diagnosis": "Herpes pneumonia and ARDS",
    "history": "We present the case of a 62 year old female Caucasian patient, who was transferred to our intensive care unit (ICU) because of respiratory distress.",
    "image_finding": "The patient received a renal transplantation 10 years ago due to hypertensive glomerulonephritis. The immunosuppressive regimen of the patient consisted of 125mg cyclosporine per day.  The chest x-ray showed bilateral interstitial opacities as well as moderate pleural effusions (Fig 1). The patient developed severe respiratory distress and was transferred to the ICU. The follow up chest x-ray showed central airway consolidations in both lungs (Fig 2). Antibiotic therapy with Piperacillin / Tacobactam (urin 106 CFU/ml E.coli) was started but nevertheless the patient\u2019s condition deteriorated.  Because of the high suspicion of nosocomial infection and the lack of improvement under wide spectrum antibiotic therapy, a bronchoalveolar lavage (BAL) was carried out. Cytologic examination of the BAL fluid showed cells according to high grade neutrophil alveolitis.The workup of the BAL was positive for HSV type 1 (HSV1 HSV2 VZV R-gene TM Quantification kit, Argene SA, Varilhes, France) as well as a weak positivity for HSV type 6. This result was received on day 9 of ICU treatment. Antiviral therapy with Aciclovir 10 mg/kg body weight b.i.d. due to restricted renal function was started immediately. However the patient\u2019s condition further deteriorated, making invasive respiration therapy and tracheotomy necessary. Further chest x-rays showed central, bilateral mixed interstitial and airway consolidations with moderate pleural effusions and intermitted lung oedemas, which were frequently observed in patients with a manifest ARDS (Fig 3).",
    "discussion": "Because of clinical deterioration a BAL of the distal airways in this patient was performed to screen for pulmonary pathogens.Screening for viral infection was performed by real time PCR and was positive for HSV1. In our case the most likely cause for HSV1 infection was reactivation of a latent infection by immunosuppression [2]. The patient developed ARDS with serve hypoxemia. An association between ARDS and HSV 1 has already been described by A. Francois- Dufresne et al.The identification of risk factors for HSV reactivation and the typical morphologic pattern in conventional chest radiographic led to the suspicion of HSV pneumonia and the results of the BAL confirmed the diagnosis of HSV pneumonia. However, there are no pathognomonic signs for HSV pneumonia on conventional chest radiographs. A study by Umans et al. found out that most patients with HSV pneumonia had diffuse bilateral opacities with predominantly an airspace or mixed airspace and interstitial pattern, as we found in our patient (Fig. 1). Unilateral consolidations, large atelectasis and significant amounts of pleural effusions were less frequently observed [1].Linssen et al. showed that HSV type 1 was present in approximately one third of all BAL fluid samples acquired from ICU patients. Furthermore a high HSV1-viral load lead (105 / ml) to a poor outcome in critically ill patients with an increase mortality rate of 21%.",
    "differential_diagnosis": "Herpes, pneumonia, and, ARDS",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007724/000001.jpg?itok=9Lqagx3s",
            "caption": "Bilateral interstitial opacities and pleural effusions on both sides."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007724/000002.jpg?itok=ZbWOOjG0",
            "caption": "Mixed interstitial and airway consolidations in both lungs."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007724/000003.jpg?itok=9b0uQg3y",
            "caption": "Pronounced central airway consolidations in both lungs."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/7724",
    "time": "15.09.2009"
  },
  "7726": {
    "case_id": 7726,
    "title": "Pulmonary findings in patient with RA",
    "section": "Chest imaging",
    "age": "57",
    "gender": "female",
    "diagnosis": "Rheumatoid arthritis, symmetric form of hands and feet with lung involvement",
    "history": "A 57year old woman with an active form of rheumatoid arthritis was admitted to the University Hospital for review and initiation of therapy. Previous medical history except RA was unremarkable. The patient had cold manifested with upper tract respiratory symptoms. No cough, dyspnea, fever or weight loss occurred.",
    "image_finding": "The patient was in a good clinical status, without dyspnea or fever, only symtoms of cold. Breathing was alveolar, without pathologic findings. Because of the smoking history a chest radiograph was indicated. During local examination small nodules on the hands and feet were found. AP joint radiographs showed typical findings for RA. Especially at the hands and feet were bone erosions with disfiguration of the proximal line of carpal bones, heads of metacarpal bones, cystoid hyperlucency in the structure, deepening or concavity of joints and bone degradation. Also soft tissue reaction around affected joints was remarkable.A PA chest radiograph was done because of a long term smoking history. The radiograph showed accidental finding of ring - like shadows predominantly in the lower lung lobes, their wall was irregular. Effusion, abscess or enlargement of the pulmonary hilus was not found. Heart and mediastinum were normal. CT examination followed to define the character of th cavitary nodules and to exclude any other pathology. Numerous irregular thin wall cavitary nodules were found. No effusion or lymphadenopathy was detected. Over time the patient underwent several CT controls and we detected a change in the character of the lesions, mostly growth. No lymphadenopathy or free fluid, no pleural thickening was found at following CT examinations.",
    "discussion": "Rheumatoid arthritis (RA) is a subacute or chronic inflammatory disease (polyarthropathy) of unknown cause in which the body's immune system attacks joints and other tissues. Onset is usually between 25 and 50years, women are more likely to develop RA than men (3x more).  Heavy long - term smoking is a very strong risk factor for RA as well as other lungs affections (cancer most of all). Primary sites of inflammation are synovial membranes and articular structures. X-rays generally have not been helpful to detect the presence of early rheumatoid arthritis because they cannot show soft tissue. Swelling and pain in the joints occur for at least 6 weeks before a diagnosis of RA is considered. The pattern of joints affected is usually symmetrical. Although RA almost always develops in the wrists and knuckles, the knees and small foot joints are often affected as well. Indeed, many joints may be involved (cervical spine, shoulders, elbows, tips, temporomandibular joint, inner ear). RA does not usually show up in the fingertips, where osteoarthritis is common. Disease is characterized with relapses and remissions.Extraarticular RA is more common in male\u2019s age 50-60years. Patients are asymptomatic; most have arthritis, positive rheumatoid factor and cutaneous nodules. Lung changes are found in 90% patients. Pulmonary involvement is a serious complication of rheumatoid arthritis and may be seen as airway disease, rheumatoid nodules, interstitial lung disease and pleurisy. In literature are described a broad range of pathologic features in the lungs.  Four predominant CT patterns are: usual interstitial pneumonia (UIP), nonspecific interstitial pneumonia (NSIP), bronchiolitis obliterans (BO) and organizing pneumonia (OP). Ground-glass opacity or reticulation is the most common CT finding. Honeycombing, traction bronchiectasis and architectural distortion also frequently occurred. The multiplicity of CT patterns is commonly seen and might help differentiate these patients from those with idiopathic diffuse lung disease. Necrobiotic pulmonary nodules are well established among the extra-articular manifestations of RA, but their manifestation is rare. The nodules may be solitary or, more commonly, multiple, ranging in size from a few millimeters to 7cm or more. They are well-circumscribed, localized peripheral, predominantly in lower lobes. The nodules may multiply or regress independently of the disease process elsewhere, and during their existence they may calcify or cavitate and even lead to pyopneumothorax. Necrobiotic nodules occur more frequently in men than woman, compared to the female predominance of rheumatoid arthritis.Differential diagnosis of lung nodules is not easy. Nodules can imitate bronchial carcinoma radiologically and bronchoscopically. In differential diagnosis of tumor can help irregularity inner lining and cavitations only in 10% of lung tumours. Wegener\u2019s granulomatosis shows nodules with frequent cavitation, but pleural effusion and hilar lymph node enlargement is very rare. Also in full-blown form kidneys, nose and paranasal sinuses are involved. Sarcoidosis is commonly associated with some type of reticulonodular lung disease, but can simulate metastatic lung disease.Treatment is based on steroids and immunosuppressive therapy.5 years survival is 40%, death is usually caused by infection, respiratory failure, cor pulmonale or amyloidosis.",
    "differential_diagnosis": "Rheumatoid, arthritis,, symmetric, form, of, hands, and, feet, with, lung, involvement",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007726/000012.jpg?itok=T1rn7zUO",
            "caption": "PA chest radiograph shows cavitated nodularity at the left lung base and also incipient nodularity at the right middle lung area"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007726/000013.jpg?itok=Lw-S7qEf",
            "caption": "after 6 and 12 month later is visible progression"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007726/000014.jpg?itok=_Mj4iSj8",
            "caption": "Anteroposterior radiograph of the hands shows erosive changes of the processus styloideus ulnae, proximal interphalangeal and metacarpophalangeal joints with joint space widening. Destruction and disfiguration of carpal bones is visible, also advanced osteoporosis. RA is the most common purely erosive inflammatory arthropathy."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007726/000015.jpg?itok=Rgc_OOcz",
            "caption": "Anteroposterior radiograph of the foots shows erosive changes"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007726/000016.jpg?itok=SCIvOorz",
            "caption": "Axial CT images show necrobiotic nodules"
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007726/000017.jpg?itok=cPpqIuj0",
            "caption": "nodules are bilateral, multiple with cavity"
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007726/000018.jpg?itok=ETZVHv7r",
            "caption": "in one year follow - up progression was found"
          },
          {
            "number": "Figure 3d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007726/000019.jpg?itok=1_XqBIBs",
            "caption": "Pulmonary nodules precede the systemic findings of RA."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007726/000020.jpg?itok=UAsGhEWI",
            "caption": "Frontal view shows small necrobiotic nodule with cavity"
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007726/000021.jpg?itok=i3OjmObY",
            "caption": "Frontal view shows necrobiotic nodule with cavity"
          },
          {
            "number": "Figure 4c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007726/000022.jpg?itok=Ef_U6ODT",
            "caption": "Progression in 1  year follow-up"
          },
          {
            "number": "Figure 4d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007726/000023.jpg?itok=C4eg-1ke",
            "caption": "Progression in 1  year follow-up"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/7726",
    "time": "30.11.2009"
  },
  "7733": {
    "case_id": 7733,
    "title": "Pulmonary Artery Sling",
    "section": "Chest imaging",
    "age": "62",
    "gender": "female",
    "diagnosis": "Anomalous left pulmonary artery (pulmonary artery sling)",
    "history": "A 62 year old female underwent a chest CT after a car accident.",
    "image_finding": "The patient was involved in a traffic accident and she had no prior medical problems. Chest CT examination-multiplanar imaging reconstruction revealed a vascular abnormality in which the left pulmonary artery arises irregularly from the posterior tract of the normal right pulmonary artery. The anomalous vessel passes through the space between the lower tract of the trachea and the oesophagus and reaches the left lung hilum, without causing compression symptoms to these anatomical structures.",
    "discussion": "Anomalous left pulmonary artery (pulmonary artery sling) is a rare vascular abnormality in which the left pulmonary artery arises irregularly from the posterior tract of the normal right pulmonary artery. The anomalous vessel passes through the space between the lower tract of the trachea and the oesophagus and reaches the left lung hilum, causing frequently compression symptoms to these anatomical structures that may lead to(produce) left displacement of trachea, atelectasis, obstructive emphysema and dysphagia. This condition is considered the result of the involution of the proximal left sixth arch. Due to this missing development, an anastomotic vessel links the primitive pulmonary circulations and evolves in the aberrant left pulmonary artery. There has been described a frequent association with other congenital malformations involving mostly the tracheobronchial tree and the cardiovascular system. Tracheobronchial anomalies include a bronchus that arises directly from the trachea to supply a segment of the right upper lobe, hypoplasia of distal trachea, incomplete cartilaginous tracheal ring and stenosis of left main bronchus. Cardiovascular anomalies consist of atrial septal defect, ventricular septal defect, patent ductus arteriosus, tetralogy di Fallot, aortic stenosis, and persistent left superior vena cava and aortic arch anomalies. In infants and newborns it usually presents with intermittent cyanosis, dyspnoea, expiratory stridor and wheezing due to the airway obstruction by the abnormal vessel and associated with high mortality especially if not treated. The severity of the symptoms and the prognosis are also related to the eventual association with other congenital abnormalities. On the other hand in adults it may be asymptomatic and discovered accidentally, as described in our case.",
    "differential_diagnosis": "Anomalous, left, pulmonary, artery, (pulmonary, artery, sling)",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007733/000003.jpg?itok=-vNgRXxV",
            "caption": "Left pulmonary artery arises irregularly from the posterior tract of the normal right pulmonary artery. The anomalous vessel passes through the space between the lower tract of the trachea and the esophagus and reaches the left lung hilum"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007733/000007.jpg?itok=qHI8M8A2",
            "caption": "Sagittal view of left pulmonary hilum"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007733/000004.jpg?itok=FrbxYXNi",
            "caption": "Pulmonary artery sling. Abnormal origin and course of the left pulmonary artery."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007733/000005.jpg?itok=5XWvrOCR",
            "caption": "Pulmonary artery sling. Abnormal origin and course of the left pulmonary artery."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007733/000006.jpg?itok=VcNTy7jJ",
            "caption": "Pulmonary artery sling. Abnormal origin and course of the left pulmonary artery."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/7733",
    "time": "20.08.2009"
  },
  "7735": {
    "case_id": 7735,
    "title": "Plain Film Signs in Pulmonary Embolism (with CT correlate)",
    "section": "Chest imaging",
    "age": "43",
    "gender": "male",
    "diagnosis": "Pulmonary Embolism",
    "history": "This 43 year old male patient presented with shortness of breath (SOB) and cough.",
    "image_finding": "This 43 year old male patient presented to the accident and emergency unit with SOB and cough. Significant past medical history included a deep vein thrombosis (DVT) 7 years ago. On examination, he was tachycardic and the arterial blood gas analysis demonstrated marked hypoxia. A chest radiograph was performed followed by a CT Pulmonary Angiogram (CTPA). Apart from mild neutrophilia the rest of the admission blood tests were normal. On the PA chest radiograph the right inferior pulmonary artery was enlarged (Fleischner sign) with an abrupt change in its calibre giving it an amputated appearance (Chang\u2019s or Knuckle sign). Subpleural wedge shape consolidation was also apparent within the right upper lobe (Hampton hump). In view of the symptoms, past history of DVT, tachycardia and hypoxia along with signs on the chest radiograph there was high index of suspicion of Pulmonary Embolism (PE). Hence the patient had an urgent CTPA performed. The CTPA showed multiple PE's involving both main pulmonary arteries extending into the lobar divisions of all the lobes bilaterally. The diameter of the pulmonary trunk was greater than that of ascending aorta. There was also straightening of the inter-ventricular septum indicating right ventricular strain. Subpleural wedge shape consolidation, due to infarction, was confirmed within the right upper lobe and the left lower lobe (Hampton's hump). Following the initiation of warfarin therapy the patient was discharged home with anticoagulation clinic follow-up for monitoring of the INR levels following a period of inpatient care.",
    "discussion": "CT is the first line imaging modality for PE. However, there are a number of interesting signs historically described on plain radiograph in pulmonary embolism (PE).A prospective observational study at 52 hospitals in 7 countries which included 2,454 patients showed that the most common chest radiographic interpretations were cardiac enlargement (27%), normal (24%), pleural effusion (23%), elevated hemi diaphragm (20%), pulmonary artery enlargement (19%), atelectasis (18%) and parenchymal pulmonary infiltrates (17%)(1). An elevated diaphragm, atelectasis or enlargement of descending pulmonary artery has been reported as being the most common finding in other studies. In our case, there was cardiomegaly, an elevated hemi diaphragm, but more specifically pulmonary artery enlargement and wedge shaped atelectasis were present on the plain radiograph. Hampton's hump appears as a well-defined pleural-based area of increased opacity with a convex medial border; this finding aids in the differentiation of pulmonary infarction from pleural thickening or free pleural fluid. Westermark sign is an area of oligemia distal to a large vessel that is occluded by PE. Fleischner sign is a prominent central artery that can be caused either by pulmonary hypertension that develops secondary to peripheral embolization or by distension of the vessel by a large clot (Figure 1).  Chang\u2019s sign is dilatation and abrupt change in calibre of the right descending pulmonary artery (Figure 4). The earliest consistent sign in pulmonary infarction is widening of a previously normal descending pulmonary artery [2]. This sign usually appears within 24 hours of the onset of symptoms and shows its maximal measurements within two to three days. Serial chest radiographs can be used to monitor the resolution of the pulmonary infarcts by observing the reduction in the size of the descending pulmonary artery. However, neither the cardiomegaly or the pulmonary artery enlargement a appears sensitive or specific indicator for right heart strain which is an important predictor of mortality associated with acute pulmonary embolism [1].  CTPA is now the standard of care for the evaluation of patients with suspected PE. The above mentioned findings on a plain radiographs can help raise the index of suspicion and may provide clues to unrecognised PE. The main value of the chest radiograph is to exclude diagnoses that may clinically mimic PE such as pulmonary oedema, pneumonia or pneumothorax, however it cannot alone exclude PE [3]. Eventhough there may be findings on a plain radiograph in patients with PE, a negative plain chest radiograph cannot rule out a PE. Hence, CTPA is the investigation of choice in patients with high probability for PE.",
    "differential_diagnosis": "Pulmonary, Embolism",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007735/000001.jpg?itok=Q0Mn87YK",
            "caption": "Enlarged right descending pulmonary artery, Wedge shaped consolidation in the right upper lobe and mild cardiomegaly."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007735/000002.jpg?itok=5cpx-PqF",
            "caption": "Normal appearances of the hila"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007735/000003.jpg?itok=dpEd1Lxg",
            "caption": "Multiple pulmonary emboli including the enlarged right descending pulmonary artery"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007735/000004.jpg?itok=mo5A5aS5",
            "caption": "Enlarged right pulmonary artery distended with clot"
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007735/000005.jpg?itok=U2mzkFHv",
            "caption": "Reduction in size of the right descending right pulmonary artery following treatment."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/7735",
    "time": "25.10.2009"
  },
  "7738": {
    "case_id": 7738,
    "title": "Cryptogenic organizing pneumonia (C.O.P.)",
    "section": "Chest imaging",
    "age": "44",
    "gender": "female",
    "diagnosis": "Cryptogenic organizing pneumonia (C.O.P.).",
    "history": "A 44 year old woman presented to our hospital with dry cough of 3 months duration and mild shortness of breath. She had been under treatment with antibiotics with no recession of symptoms.",
    "image_finding": "A 44 year old woman presented to our hospital with dry cough of 3 months duration and mild shortness of breath. She had been under treatment with antibiotics with no recession of symptoms. Personal history was unremarkable. Blood laboratory tests and serologic exams were within normal limits. Pulmonary function tests revealed a restrictive ventilatory defect. The cell count of the bronchoalveolar lavage showed 55% macrophages, 39% lymphocytes, 39% neutrophiles, many foamy macrophages and large activated lymphocytes, findings indicative of hypersensitivity pneumonia or cryptogenic organizing pneumonia (COP). Chest radiograph revealed bilateral multifocal patchy consolidations and nodular opacities. CT imaging confirmed the presence of scattered bilateral peribronchial consolidations with air bronchogram and nodular opacities. Enlarged upper pre-tracheal and pre-vascular lymph nodes were also noted. The findings were suggestive of COP and the patient initiated a treatment with corticosteroids. Follow up chest CT was performed one month later and demonstrated a remarkable recession of lesions and residual ground glass opacities in the place of the initial lesions. Fibrous bands were also visible in the apical-posterior segment of the left upper lobe. The enlarged mediastinal lymph nodes previously observed, were now absent.",
    "discussion": "Cryptogenic organizing pneumonia (COP) also known as bronchiolitis obliterans organizing pneumonia (BOOP) belongs to the group of idiopathic interstitial pneumonias (IIPs). COP is characterized by the presence of granulation tissue polyps in the alveolar ducts and alveoli that often are occluded and various degree of infiltration of surrounding parenchyma with foamy macrophages and large mononuclear cells. The consolidations in COP do not represent an active pneumonia but a way of response through a process of granulation tissue  proliferation, deposition of fibrin and fibroblast colonization within the distal pulmonary airspaces.The causative factors of organizing pneumonia include infection, drugs, transplantation, inhalation of toxic gas and collagen-vascular diseases. Exclusion of the above leads to the diagnosis of COP therefore the term \u201ccryptogenic\u201d should be used only in idiopathic cases. COP manifests mainly with patchy peripheral or peribronchovascular consolidations with basal predominance and preservation of lung architecture. Air bronchograms and mild cylindrical bronchial dilatation are common findings. The lesions have various extensions (from focal to whole lobe) and may show migratory nature. Less common findings include irregular linear opacities, solitary focal lesions and multiple nodules that may cavitate.  There is no association with cigarette smoking. Men and women are equally affected and the mean age of patients is around 55 years. The onset of symptoms is generally subacute with flu-like symptoms, non productive cough, low grade fever and dyspnoea. Usually they  develop over a few weeks. Lung function tests commonly show a mild or moderate restrictive ventilatory defect. The majority of patients recover completely after administration of corticosteroids but relapses occur frequently within 3 months after the end of therapy. The definitive diagnosis should be made after the exclusion of all the other possible causes of organizing pneumonia.",
    "differential_diagnosis": "Cryptogenic, organizing, pneumonia, (C.O.P.).",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007738/000001.jpg?itok=s3yOerRh",
            "caption": "Bilateral peribronchial consolidations  with air bronchogram and nodular opacities, with relative sparing of the lung periphery."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007738/000002.jpg?itok=t52JEJHP",
            "caption": "Bilateral peribronchial consolidations  with air bronchogram and nodular opacities, with relative sparing of the lung periphery."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007738/000003.jpg?itok=yv-Abg2E",
            "caption": "Bilateral peribronchial consolidations  with air bronchogram and nodular opacities, with relative sparing of the lung periphery."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007738/000004.jpg?itok=zm4U4dm6",
            "caption": "Lesions have subsided leaving residual ground glass opacities."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007738/000005.jpg?itok=v6S9PmwZ",
            "caption": "Lesions have subsided leaving residual ground glass opacities."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007738/000006.jpg?itok=1YNTb7U_",
            "caption": "Lesions have subsided leaving residual ground glass opacities."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/7738",
    "time": "03.09.2009"
  },
  "7744": {
    "case_id": 7744,
    "title": "Lipoid Pneumoni",
    "section": "Chest imaging",
    "age": "53",
    "gender": "male",
    "diagnosis": "Lipoid Pneumonia",
    "history": "The patient was a 53 year old male with a previous stroke.",
    "image_finding": "A 53 year old smoker with a history of stroke presented with a recent abnormal chest radiograph.",
    "discussion": "Lipoid pneumonia is an uncommon disease which could be classified into either acute vs. chronic or exogenous vs. endogenous forms. The chronic exogenous form is more common and is due to repeated aspiration or inhalation of oil-containing material. The classic scenario is in the case of an elderly or debilitated patient using mineral oil for constipation or oily nasal drops for sinusitis. This condition has also been described in the paediatric age group in the case of cod liver oil or milk aspiration. These substances may accumulate in the distal airway and lead to an inflammatory reaction that is pathologically characterised by lipid-laden macrophages. If the process is chronic, granulomatous and fibrotic changes might be found as well. The chronic endogenous forms has been described with lipid-laden changes occurring distal to a chronic airway obstructive lesion. The less common acute forms occur in the cases of accidental petroleum poisoning or in the case of fire-eating pneumonitis.The patients are usually asymptomatic and the abnormality is detected incidentally on imaging studies required for other reasons. Some patients may complain of chronic cough or progressive shortness of breath. The conventional radiograph usually shows consolidation, masses or a reticulonodular pattern. The changes are usually basal in location, as expected for aspiration-related lung disease. The computed tomographic examination typically demonstrates a lesion with characteristic internal areas of fat-attenuation. Areas of consolidation, ground glass opacities, crazy-paving, interstitial thickening or mass-like lesions can be seen. The more chronic forms are associated with a fibrotic reaction which can lead to traction bronchiectatic changes or mass-surrounding spiculations. This latter appearance can be confused with more sinister neoplastic processes.It is important not to confuse this entity with lung carcinoma. It is also equally important to ensure that the endogenous form is not secondary to a proximal airway-obstructing neoplastic process. This may become problematic, since some reports show that lipoid pneumonia can be avidly positive on PET scans even in the absence of a neoplastic process. Thus, recognizing the classical attenuation-specific features of lipoid pneumonia on CT can prevent unnecessary surgical intervention. However, there are some literature reports in which lipoid pneumonia was considered a risk factor for future lung carcinoma. Another unusual but well-documented potential complication is infection. In  particular, mycobacterium fortuitum has been addressed as a classical agent in such patients.Given the asymptomatic or non-specific clinical presentation, imaging plays a major part in the management of such patients. In addition to suggesting the diagnosis, CT imaging follow-up is needed in the majority of cases to ensure stability or resolution. The diagnosis can be supported by results from bronchoalveolar lavage, trans-bronchial sampling or trans-thoracic needle biopsy.",
    "differential_diagnosis": "Lipoid, Pneumonia",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007744/000001.jpg?itok=svGmKJjU",
            "caption": "Trans-axial mid-lung CT image as seen on the lung window."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007744/000002.jpg?itok=RTnX6L4-",
            "caption": "Trans-axial mid-lung CT image as seen on soft tissue window."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/7744",
    "time": "29.08.2009"
  },
  "7762": {
    "case_id": 7762,
    "title": "Round Pneumoni",
    "section": "Chest imaging",
    "age": "5",
    "gender": "female",
    "diagnosis": "Round Pneumonia",
    "history": "A 5 year old female patient presented to the emergency department with a 3 day history of cough and fever.",
    "image_finding": "The frontal and lateral chest radiographs show a partially ill-defined rounded left lower lobe opacity with an apparent base on the posterior pleura.The follow-up image after treatment reveals resolution of the abnormality.",
    "discussion": "This is a classical case in the radiology literature. The diagnosis is actually round pneumonia. The patient was treated with a course of antibiotics. The symptoms subsequently resolved. The follow-up chest radiograph 4 weeks latter demonstrated resolution of the abnormality as well. Round pneumonia is actually just another typical imaging presentation of bacterial pneumonia in children. Variable infectious organisms have been proposed, however, streptococcal pneumonia is considered the most common cause.Unlike adults, the collateral pathways of air circulation are usually not well-developed in children of less than 8 years of age. This pathophysiological separation is thought to restrict the spread of infection and result in the occasional round appearance of pneumonia in children. Round pneumonia could have variable sizes and appears classically in the posterior portions of the lower lobes. This process respects the lobar anatomy and does not cross fissures. An air bronchogram could also be occasionally seen. The disease could spread to become lobar in nature.If the patient has symptoms of pneumonia in addition to a round opacity seen on the chest radiograph, no additional imaging is needed. However, appropriate antibiotic treatment should be started and a follow-up in several weeks is needed to ensure resolution. CT could be performed if the symptoms persist or are atypical. A CT would also be obtained if the radiographic abnormality does not undergo expected resolution on the follow-up radiographs after appropriate treatment.The take-home points are: (1) If a child has symptoms of pneumonia in conjunction with a round opacity on a chest radiograph, the diagnosis is round pneumonia and no CT evaluation is initially needed.(2) A follow-up several weeks after treatment is needed to ensure resolution.",
    "differential_diagnosis": "Round, Pneumonia",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007762/000001.jpg?itok=RSmMNpzP",
            "caption": "Frontal chest radiograph of a 5-year-old patient on presentation."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007762/000002.jpg?itok=PxdgXsrE",
            "caption": "Lateral chest radiograph of a 5-year-old patient on presentation."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007762/000003.jpg?itok=v9Jx978Q",
            "caption": "Frontal chest radiograph four weeks later, after treatment."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/7762",
    "time": "25.10.2009"
  },
  "7807": {
    "case_id": 7807,
    "title": "Mediastinal Thymolipom",
    "section": "Chest imaging",
    "age": "17",
    "gender": "female",
    "diagnosis": "Mediastinal Thymolipoma",
    "history": "We present a case of a 17 year old asymptomatic female with an incidental finding seen on a chest radiograph.",
    "image_finding": "The abnormality was further investigated by an IV-contract enhanced CT scan of the chest. The selected image shows a large well-defined fat-attenuated mass lesion at the left cardiophrenic angle. The lesion has an internal whorl-like appearing soft tissue component. The lesion drapes around the left cardiac border with no obvious associated mass effect.",
    "discussion": "This case illustrates the classical appearance of an anterior mediastinal thymoplipoma. This is considered a rare aunt minnie in the radiology literature.Thymolipomas are rare benign thymic lesions, accounting for 2-9% of thymic neoplasms.  These lesions have a well formed capsule and are pliable. Since they are slow growing tumours, they are usually large in size when seen.  In addition, they sag inferiorly along the anterior mediastinum. They also usually insinuate in between adjacent lung, mediastinum and diaphragm. Histologically, these lesions are mainly composed of mature adipose tissue with intermixed elements of normal thymic tissue and intervening fibrous septations.This lesion occurs equally in both sexes. Although thymolipomas are typically seen in young adults, an age range of 3-60 years has been documented. Most patients are asymptomatic, with lesions discovered incidentally on radiography or computed tomography (CT). Some patients present with pain, cough, dyspnoea and arrhythmias secondary to mass effect. Fewer cases present with a clinical picture of myasthenia gravis, Graves disease or haematological disorders.On chest radiography, the lesion usually appears as a sizable mediastinal abnormality. Since the lesion drapes over adjacent structures, it can be confused with cardiomegaly, pericardiac masses, atelactasis, pleural effusion or pulmonary sequestration. One hint to the fatty nature of this neoplasm is that the central dense region enhances with contrast with the periphery enhancing less. However, this is not an easy prospective observation. Smaller lesions might occupy the anterior mediastinum.The CT appearance usually correlates well with the known gross histological composition of this lesion. The well-defined border reflects the encapsulation of this tumour. A clear-cut fat-attenuated portion is easily observed, representing the mature adipose component. Internal linear soft-tissue whorls are also usually seen, corresponding to the normal thymic tissue and the fibrous septations. No invasive features are seen. The differential considerations for fat-containing lesions on CT would include: teratomas, lipomas, liposarcomas, fat pads, Mediastinal lipomatosis and diaphragmatic hernias.No treatment is needed for asymptomatic patients, since no malignant potential has been described with such lesions. In symptomatic cases, surgical resection is curative. Some cases show adherent portions to adjacent mediastinal structures, adding technical difficulty to the surgical procedure. No recurrence has been ever documented.",
    "differential_diagnosis": "Mediastinal, Thymolipoma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007807/000001.jpg?itok=uYK0XYnD",
            "caption": "IV-enhanced trans-axial CT of the chest as seen on soft tissue window."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/7807",
    "time": "27.12.2009"
  },
  "7819": {
    "case_id": 7819,
    "title": "pipericardial Fat Necrosis",
    "section": "Chest imaging",
    "age": "77",
    "gender": "female",
    "diagnosis": "Epipericardial Fat Necrosis",
    "history": "A 77 year old female with acute pleuritic left-sided chest pain was admitted to our department. No other significant medical or surgical history was provided.",
    "image_finding": "The chest radiographs (Fig 1a,b) show an anterior mediastinal, left para-cardiac, well-defined, mass-like opacity. The IV-contrast enhanced CT images (Fig 2a,b) demonstrate a mass-like lesion in the left epicardiac region. The abnormality is well-defined and shows internal soft-tissue heterogeneity. On closer observation, the lesion has a few internal fat-attenuated foci. Minimal focal pericardial thickening is seen in the area that abuts the lesion.",
    "discussion": "Epipericardial Fat Necrosis is a rare entity of unclear aetiology. Although this entity was described since 1957, it was only recently addressed in the radiology literature. This entity has a very similar appearance and natural history to that of epiploic appendagitis seen in the abdomen.Several pathogeneses have been postulated. One school believes that this is related to actual torsion of the epicardiac fat. Others proposed hemorrhagic necrosis secondary to elevation of the vascular bed pressure due to intrathoracic pressure variations. The gross appearance depends on the chronicity of the condition. Initially, acute necrotic features and cellular infiltrates are seen. As time passes, chronic cellular infiltration is noted. At the end, this could turn into a scar or become encapsulated by a fibrous wall.  This entity might occur in healthy individuals. The classic clinical presentation is acute chest pain, which usually is pleuritic in nature. Thus, this could be confused with an acute pulmonary embolic event on clinical basis. The condition is short-lasting and self-limited; however, some reports describe less typical presentations, such as chronic symptoms for one year.On plain radiography of the chest, the radiograph can be normal or show a well-defined paracardiac opacity. This is more commonly seen on the left side. On computed tomography (CT), this lesion appears as an epicardiac, well-encapsulated, fat-containing, space-occupying abnormality. The lesion shows internal soft-tissue heterogeneity and surrounding focal inflammatory changes. Focal adjacent pericardial thickening can be observed. Pleural effusions have been described, as well. Since this lesion contains fat, it can be potentially confused with a liposarcoma, a Morgagni herniasor even a teratoma.This is a self-limited condition. Although most literature-reported cases have been proven by surgical excision, invasive measures are not actually needed. Combining the clinical presentation with the typical CT findings could suffice to make a correct diagnosis and obviate the need for unnecessary interventions. Thus, the general radiologist should be aware of such an entity.",
    "differential_diagnosis": "Epipericardial, Fat, Necrosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007819/000001.jpg?itok=WtVV3T-M",
            "caption": "Frontal chest radiograph."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007819/000002.jpg?itok=X5K9SV96",
            "caption": "Lateral chest radiograph."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007819/000003.jpg?itok=A788JODF",
            "caption": "Trans-axial CT of the chest with iv-contrast enhancement, at mid-chest level."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007819/000004.jpg?itok=MxAZRbmr",
            "caption": "Trans-axial CT of the chest with iv-contrast enhancement, at a slightly lower level."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/7819",
    "time": "25.09.2009"
  },
  "7878": {
    "case_id": 7878,
    "title": "Multifocal Micronodular Pneumocyte Hyperplasia (MMPH) in Tuberous Sclerosis (TS)",
    "section": "Chest imaging",
    "age": "65",
    "gender": "female",
    "diagnosis": "Multifocal Micronodular Pneumocyte Hyperplasia (MMPH) in Tuberous Sclerosis (TS).",
    "history": "A 65 year old female patient with tuberous sclerosis (TS).",
    "image_finding": "A few selected trans-axial computed tomography (CT) images of the chest show multiple randomly-distributed and variably-sized ground-glass nodular opacities. The nodules do not exceed 1cm in size. The abnormality is seen throughout both lungs; however, a slight upper lobar and peripheral predominance is noted. No cystic changes, lymphadenopathy, pleural effusions or pneumothoraces seen. The findings were stable over more than three years of imaging follow-up.",
    "discussion": "Although cystic changes of lymphangioleiomyomatosis (LAM) is typically the first consideration when facing a chest image of a tuberous sclerosis (TS) patient, it is not the only imaging manifestation that could be encountered in that clinical sitting. The entity of multifocal micronodular pneumocyte hyperplasia (MMPH) is another interesting abnormality that usually occurs in TS patients.On histological evaluation of MMPH, multicentric nodular hyparplastic changes of type 2 pneumocytes are seen with variable degrees of cellular atypia. The alveolar septa show fibrous thickening and the alveolar spaces are infiltrated by macrophages. No smooth muscle proliferation is seen, in contrast to LAM. In addition, oestrogen receptors, progesterone receptors and HMB-45 smooth muscle staining is negative. In contrast to atypical adenomatous hyperplasia (AAH), the nuclear-to-cytoplasmic ratio is not high, the degree of macrophages infiltration is more pronounced and no CEA or p53 immunoreactivity is seen.MMPH occurs in both the TS and LAM populations. However, it is more commonly seen in the former group. The awareness of this entity is increasing due to the increased number of CT examination obtained in such patients. This entity is believed now to be far more common that what was previously reported. In fact, an incidence as high as 28-43% has been documented in TS patients. In addition, a few proven cases of MMPH in non-TS and non-LAM patients have been reported.The entity of MMPH is usually asymptomatic. The discovery of the abnormality is usually made on chest radiographs or CT studies performed for LAM- or TS-related presentations. A few cases primarily presenting with mild dyspnoea, cough or mild hypoxemia have been reported. One case of mortality has also been documented.The chest radiograph is usually normal, but small nodular scattered opacities could be seen. CT images show a typical appearance of randomly-distributed 1-8mm ground-glass nodules. The distribution is usually diffuse, but a slight upper lobar and peripheral predominance has been seen. The findings may or may not be associated with parenchymal cysts of LAM.MMPH is a benign entity with no known malignant potential. The MMPH imaging findings do not show progression over time. No treatment is usually needed in such cases. It is important to recognize this entity, especially when facing TS or LAM patients. Confusion with other more sinister diseases such as AAH or multicentric bronchoalveolar carcinoma should be avoided. In non-TS or non-LAM patients, this distinction might be difficult. In theses instances, trans-bronchial or video assisted thoracoscopic surgical biopsies might be helpful. Imaging follow-up could also be an alternative way of managing these patients.",
    "differential_diagnosis": "Multifocal, Micronodular, Pneumocyte, Hyperplasia, (MMPH), in, Tuberous, Sclerosis, (TS).",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007878/000001.jpg?itok=3yP9Teeg",
            "caption": "Multiple small randomly-distributed ground-glass lung nodules are seen."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007878/000002.jpg?itok=dbuyfqTK",
            "caption": "Multiple small randomly-distributed ground-glass lung nodules are seen."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007878/000003.jpg?itok=R68FiNjG",
            "caption": "Multiple small randomly-distributed ground-glass lung nodules are seen."
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007878/000004.jpg?itok=ADfWbKhn",
            "caption": "Multiple small randomly-distributed ground-glass lung nodules are seen."
          },
          {
            "number": "Figure 1e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007878/000005.jpg?itok=-ZOLi2AV",
            "caption": "Multiple small randomly-distributed ground-glass lung nodules are seen."
          },
          {
            "number": "Figure 1f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007878/000006.jpg?itok=_aa5J-E8",
            "caption": "Multiple small randomly-distributed ground-glass lung nodules are seen."
          },
          {
            "number": "Figure 1g",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007878/000007.jpg?itok=hyLalT16",
            "caption": "Multiple small randomly-distributed ground-glass lung nodules are seen."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/7878",
    "time": "25.10.2009"
  },
  "7903": {
    "case_id": 7903,
    "title": "A brain Stimulating Case",
    "section": "Chest imaging",
    "age": "74",
    "gender": "male",
    "diagnosis": "Pergolide from parkinsons treatment causing rounded atelectasis",
    "history": "A 74 year old male being treated for M. Parkinson presented with worsening shortness of breath. No asbestos exposure and negative tests for TB.",
    "image_finding": "A 74 year old male patient, who had been diagnosed with Parkinson\u2019s disease 16 years ago, presented to a respiratory clinic with progressively worsening shortness of breath over the preceding year. He had no history of weight loss, increased temperature or haemoptysis. He was an ex-smoker, who had given up 20 years ago. The man had no previous exposure to asbestos or tuberculosis (mantoux test negative). There was no past surgical or other medical history of note. Medications included:  Sinemet plus 125mg q.i.d. (active ingredients levodopa and carbidopa); Pergolide 3 mg o.d.; Madopar 125mg b.d. (active ingredients levodopa, benserazide hydrochloride); Dothiepin 75mg o.d.; Apomorphine; and oxibutynin 2.5mg b.d.On examination his oxygen saturations were 95% SpO2, with all of his other vitals being within normal limits. On examination his chest was clear to auscultation; there was no evidence of cardiac failure, no palpable lymph nodes, and no clubbing, the only finding being an incidental metallic object which was palpated superficially over his anterior chest wall. Neurological examination revealed a bad tremor, some rigidity, slowed movements, and a shuffling gait. His baseline blood tests were normal. A chest radiograph (Fig 1) was ordered from the clinic. The respiratory team reviewed his chest radiograph in the clinic, saw a right hilar mass and so undertook a bronchoscopy, which was normal. This was followed by a CT chest (Fig 2-4), and a CT guided percutaneous biopsy of the easily accessible right upper lobe mass. This biopsy showed normal lung tissue.",
    "discussion": "This is a case of pergolide lung, a condition of rounded atelectasis induced by pergolide, which is a drug used to treat the patients Parkinson\u2019s disease. The chest radiograph (Fig 1) shows a deep brain stimulator device which obscures some of the lung field in the left mid zone; note that the leads of this device are directed cranially. There is a rounded shadow overlying the right hilar region. In the CT thorax (Fig 2-4) there are bilateral upper lobe masses anteriorly, both of which have \u201ccomet tail\u201d converging bronchovascular markings adjacent to thickened pleurae, which are typical features of rounded atelectasis. Note is again made of the neurostimulator device in the soft tissue of the anterior chest wall. Rounded atelectasis is an area of non-segmental peripheral pulmonary collapse, which often mimics a primary lung tumour. It was first described by Blesovsky in 1966 [1], which is why it is also called Blesovsky\u2019s syndrome. Other names include folded lung, atelectatic pseudo tumour, shrinking pleuritis, pulmonary pseudotumour, helical atelectasis, and pleuroma [2-6]. Its aetiology is an inflammatory reaction at the visceral pleura leading to fibrosis. As the scar then matures it causes the pleural to \u201cfold\u201d into the lung. Another theory suggested that in the presence of a pleural effusion, the lung is folded into a cleft that formed in a focal area of volume loss. This cleft then became fibrosed maintaining the volume loss and the effusion later resolves [7]. It can affect any lobe, but most commonly the lingula followed by the, middle, upper and lower lobes. On the chest radiograph there may be several fibrous bands close to the area of atelectasis, which give the appearance of \u201ccrow\u2019s feet\u201d. The classical triad of CT findings is a rounded mass abutting the pleura, converging curving bronchovascular markings (\u201ccomet tail sign\u201d), and thickening of the pleura adjacent to the mass [5,8]. The other CT findings are that the mass is densest at its periphery, has associated air bronchograms, forms an acute angle with the pleura, and has a blurred centrally directed edge [9]. All these findings are demonstrated in figures 2-4. Various causes have been reported including asbestos exposure (associated with calcified pleural plaques), tuberculosis, trauma, pulmonary infarction, cardiac failure, uraemia, Dressler\u2019s syndrome, aortopulmonary bypass surgery, therapeutic pneumothorax, mesothelioma, and pergolide drug treatment [10-14].  Pergolide is an ergot alkaloid, a long acting dopamine receptor agonist. Some documented side effects of pergolide include retroperitoneal, pulmonary and pleural fibrosis, which occurs in 5% of patients [12, 15]. The effect when it does occur appears to be dose related [13]. The hypothesis is that the fibrotic changes are due to increased serotonin levels, which causes an increase in fibroblastic activity [14]. \tThe deep brain stimulator is a device used to treat the debilitating symptoms of Parkinson\u2019s disease and is used in patients whose symptoms are not adequately controlled by medication. It is important to realise that not all battery operated devices in the chest are cardiac pacemakers.",
    "differential_diagnosis": "Pergolide, from, parkinsons, treatment, causing, rounded, atelectasis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007903/000001.jpg?itok=uZTQukmX",
            "caption": "shows a deep brain stimulator device which obscures some of the lung field in the left mid zone; note that the leads of this device are directed cranially"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007903/000002.jpg?itok=lt2gYLA9",
            "caption": "CT thorax (lung windows) - there are bilateral upper lobe masses anteriorly, both of which have \u201ccomet tail\u201d converging bronchovascular markings adjacent to thickened pleurae, which are typical features of rounded atelectasis."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007903/000003.jpg?itok=av46jL9F",
            "caption": "In the CT thorax -(lung windows)  there are bilateral upper lobe masses anteriorly, both of which have \u201ccomet tail\u201d converging bronchovascular markings adjacent to thickened pleurae, which are typical features of rounded atelectasis."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007903/000004.jpg?itok=mvGXAAA0",
            "caption": "mediastinal windows - Mass in right upper lobe. Note is again made of the neurostimulator device in the soft tissue of the anterior chest wall."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/7903",
    "time": "27.12.2009"
  },
  "7913": {
    "case_id": 7913,
    "title": "Radiological imaging of pleuropulmonary synovial sarcom",
    "section": "Chest imaging",
    "age": "40",
    "gender": "male",
    "diagnosis": "Pleuropulmonary synovial sarcoma (PPSS)",
    "history": "Pleuropulmonary synovial sarcoma (PPSS) represents a rare subtype of lung sarcomas. Pulmonary sarcomas constitute only 0.1-0.5 % of all primary lung malignancies and synovial sarcoma accounts for 7-10% of all soft tissue sarcomas.  In unusual cases, synovial sarcoma may arise from the chest wall, mediastinum, heart, lung, or pleura.",
    "image_finding": "A 40 year old man was referred to the pulmonary clinic of our hospital with a history of cough and dyspnoea, at least for a month. On the chest radiograph, a large sharply marginated mass with uniform opacity was demonstrated projected over the right upper lung. CT and MR imaging was recommended for confirming the localization of the mass to either the lung or the pleura and for more details of the tumour appearance. CT images showed a well-circumscribed homogeneously non-enhancing lung lesion without associated involvement of bone and without calcification.MRI provided superior demonstration. T1- and T2-wighted images showed a well-circumscribed mass without evidence of spiculation or satellite nodules. A peripheral rim of enhancement in the lesion was demonstrated after the administration of gadolinium.Differential diagnosis included bronchogenic carcinoma, various metastatic lesions, mesothelioma, lymphoma, Wegener's granulomatosis, pyogenic abscess, intrapulmonary haematoma, rheumatoid nodules, histoplasmosis, and coccidiomycosisA fine needle guided biopsy (FNB) was performed. The histological and immunochemical (Ki-67 pos.>60%, vimentin, CD99, Bcl-2, CK7, EMA, CK19 positive) examination confirmed the diagnosis of PPSS.",
    "discussion": "Pleuropulmonary synovial sarcoma (PPSS) is increasingly recognized as a subtype of sarcoma because of the recent identification of a distinctive chromosomal translocation specific to synovial sarcoma t(X;18)(p11.2;q11.2). PPSS is a mesenchymal spindle-cell tumour characterized by variable epithelial differentiation and can arise in the chest wall, heart, mediastinum, pleura, or lung. It chiefly affects young and middle-aged adultsOn chest radiographs PPSS might be depicted as a pulmonary parenchymal consolidation or mass (with sharp or ill-defined margins), a pleural-based mass, focal pleural thickening with or without a central mass, or near-complete opacification of a hemithorax. The lesion is typically uniform, with well-circumscribed rounded or lobulated borders, with mediastinal shift in some patients The contralateral lung appears normal, although mediastinal shift might occur in the presence of a large mass. An ipsilateral pleural effusion is often evident. Rarely, chest radiographs reveal pneumothorax. Primary lung cancer typically is indistinguishable from PPSS on chest radiography, CT, and magnetic resonance imaging (MRI). However, the presence of significant adenopathy on images obtained with any of these modalities militates against a diagnosis of PPSS and favours that of lung cancer. Metastatic disease of the lung and pleura is common, and it is rarely manifested as a large solitary mass; nevertheless, the exclusion of extrathoracic synovial sarcoma is essential for determining a pulmonary origin of PPSS. On CT, PPSS typically is manifested as a well-defined, heterogeneously enhanced mass that contains areas of fluid attenuation compatible with necrosis or hemorrhage. Although a lesion might appear to be located primarily within the lung or the pleura, the site of origin is often unclear. An ipsilateral pleural effusion is often present and might represent acute or recurrent haemothorax. A rim of ground-glass opacity surrounding the mass has been reported.Synovial sarcomas that arise in the chest wall demonstrate well-defined margins and heterogeneous enhancement as well as cortical bone destruction, tumour calcifications, and tumour infiltration of the chest wall musculature on CT. Radiologically, compared with soft-tissue synovial sarcoma, primary pulmonary and mediastinal synovial sarcoma shows less vascularity. Sarcomas arising in the chest wall closely match the imaging characteristics of soft tissue synovial sarcoma with cortical bone destruction, tumour calcification and/or invasion into chest wall musculature. MRI is more revealing regarding heterogeneity within tumours. The T2-weighted images on MRI demonstrate the so-called \u201ctriple sign\u201d (bright, dark, and gray) representing tumour, haemorrhage, and necrosis on MRI. Soft-tissue synovial sarcoma tends to be intermuscular and have vessels in one third (representing the hemangiopericytoma-like pattern), which were only rarely observed on chest imaging in the current series. Magnetic resonance imaging often allows more accurate delineation and localization of the tumour and is helpful for determining the presence and extent of tumour invasion and for tissue characterization. Because the morphologic features of primary and metastatic synovial sarcomas are similar, clinical and radiologic evaluation is essential to exclude the presence of a primary tumour outside the thorax. Extrathoracic primary synovial sarcoma must be excluded before a diagnosis of PPSS can be confirmed.",
    "differential_diagnosis": "Pleuropulmonary, synovial, sarcoma, (PPSS)",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007913/000001.jpg?itok=xHclD49y",
            "caption": "Right upper lobe mass and elevated right diaphragm suggesting right diaphragmatic nerve invasion"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007913/000002.jpg?itok=nB36GHZB",
            "caption": "Well circumscribed homogenous solid lesion"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007913/000004.jpg?itok=z_syPJbS",
            "caption": "Mildly heterogeneous mass with no invasion of the adjacent vessel"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007913/000005.jpg?itok=-GaSqELf",
            "caption": "Mildly heterogeneous mass with no invasion of the adjacent vessel"
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007913/000006.jpg?itok=ArhRsk_l",
            "caption": "Subtle enhancement after  intravenous administration of gadolinium"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/7913",
    "time": "12.12.2009"
  },
  "7920": {
    "case_id": 7920,
    "title": "Bronchogenic cyst:chest x-ray and CT Findings",
    "section": "Chest imaging",
    "age": "52",
    "gender": "male",
    "diagnosis": "Bronchogenic cyst",
    "history": "A 52 year old man came to our hospital with shortness of breath. The patient did not mention any prior disease of the lungs. No prior radiologic examinations were available.",
    "image_finding": "A 52 year old man came to our hospital with shortness of breath. The first step was to obtain a chest x-ray. The patient did not mention any prior disease of the lungs. The PA chest radiograph showed a right paratracheal soft tissue density of unclear aetiology. The lungs were clear.As the next step, a CT of the lungs and mediastinum was performed. The axial CT of the chest shown at mediastinal window demonstrated a right paratracheal mass, with fluid attenuation (9 HU). The mass had well defined margins, without compression of the surrounding structures and without surrounding fat infiltration. The lung parenchyma was clear. The findings were consistent with a bronchogenic cyst.",
    "discussion": "Bronchogenic cysts (BCs) are developmental mediastinal cysts that belong to the category of bronchopulmonary foregut malformations. Other cysts in this category are oesophageal duplication cysts and neurenteric cysts, both of which are located predominantly in the posterior mediastinum. Oesophageal duplication cyst may show proximity to, or communication with, the oesophagus. Neurenteric cysts are often associated with additional anomalies. Pericardial cysts, another type of mediastinal cyst in the differential diagnosis, are generally seen in the right cardiophrenic angle. Definitive differentiation requires pathologic analysis of the cyst wall. BCs have a fibrous capsule, often contain cartilage, and are filled with fluid attenuation serous,or less oftenly mucoid, material. On plain radiographs they may have the appearance of a solitary mediastinal or hilar mass adjacent to the major airways. Most of them are found in the mediastinum, although they also occur within the pulmonary parenchyma of the lower lobes. Most often they are found around the carina (52%) or the paratracheal region (19%) as in this case.On CT imaging, a BC appears as a fluid-filled structure with a well-circumscribed margin.  It does not have significant mass effect on surrounding structures, and generally conforms in shape to the adjacent mediastinal structures. Systemic vessels may be seen supplying the wall of the cyst. As predominantly fluid structures, they are typically bright on T2-weighted MR sequences. Due to their wide range of protein content, the appearance of these cysts on T1-weighted sequences is highly variable. They do not enhance with gadolinium injection.BCs often remain asymptomatic and may be detected on imaging performed for another reason. Interval increase in size often indicates haemorrhage or infection, while development of an air-fluid level signifies a gas forming organism or connection with the airway. Post-haemorrhage or post-infectious calcification of the cyst wall, or formation of milk of calcium, may also occur.",
    "differential_diagnosis": "Bronchogenic, cyst",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007920/000001.jpg?itok=vTHp8Rz1",
            "caption": "A right paratracheal soft tissue mass is shown.The lungs are clear"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007920/000002.jpg?itok=AxSzMIRu",
            "caption": "A right paratracheal mass,which appears to have fluid attenuation(9 HU).The mass has well defined margins,without compressing the surrounding structures and without surrounding fat infiltration."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007920/000003.jpg?itok=TM-9Mdqr",
            "caption": "The lung parenchyma is clear"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/7920",
    "time": "16.11.2009"
  },
  "7923": {
    "case_id": 7923,
    "title": "Broncholithiasis",
    "section": "Chest imaging",
    "age": "65",
    "gender": "male",
    "diagnosis": "Broncholithiasis of the left lower lobe",
    "history": "A 65 years old man presented at the emergency department with persistent cough and hemoptysis. The patient mentioned no significant medical history.",
    "image_finding": "A 65 years old man presented at the emergency department with persistent cough and hemoptysis. A PA chest x-ray was performed(unfortunately not shown here) and showed opacity in the left lower lobe.The next step was a CT follow-up. Axial CT images of the chest shown as soft tissue and lung windows (figure 1 and 2) revealed broncholith in a left lower lobe bronchus.The patient also underwent bronchoscopy. The bronchoscopy showed a small amount of pus but did not isolate a broncholith in the left lower lobe.",
    "discussion": "Broncholithiasis is an entity defined as the presence of calcified material within the lumen of a bronchus. It is most commonly caused by the erosion and extrusion of a calcified lymph node into the lumen of an adjacent bronchus, which is generally associated with long-standing necrotizing granulomatous lymphadenitis. Causative organisms include Mycobacterium tuberculosis, Histoplasma capsulatum, along with a variety of others. Rare cases of silicosis with lymph node involvement complicated by broncholithiasis have also been reported.  Other potential causes of broncholithiasis are aspiration of bony tissue or in situ calcification of a foreign body, and the erosion by and extrusion of calcified bronchial cartilage into the lumen of a bronchus. Cough is the most common symptom associated with broncholithiasis, often accompanied by hemoptysis.  Lithoptysis (the expectoration of calcified material) and signs of secondary infection (pain, chills, and fever) are less common symptoms.Radiographic appearances associated with broncholithiasis include the movement or disappearance of a calcified body on serial images or the development of airway obstruction, evidenced by segmental atelectasis, expiratory air-trapping, or mucoid impaction.However,radiographs are rarely diagnostic,and broncholithiasis is often missed.  Broncholithiasis is strongly suggested on CT by the presence of an endobronchial calcified nodule with secondary suggestion of airway obstruction, such as bronchiectasis, atelectasis, and obstructive pneumonitis. Additionally, calcified hilar or mediastinal lymph nodes are almost always seen in patients with broncholithiasis.  Helical CT (with less than 3 mm sections) is the preferred method for determining the endobronchial location of a broncholith because thicker sections used in conventional CT (5mm to 10mm) often results in volume-averaging of the broncholith, bronchus, and surrounding tissues.  Multiplanar reformatting is also helpful in determining the location of a broncholith by helical CT.  Because a broncholith is not commonly identified by bronchoscopy (only in 5 out of 15 patients in one study),as in this case,CT is an extremely valuable tool in the diagnosis of this entity (as seen in our case).The reason for having a negative bronchoscopy is that the wide defintition of broncholith includes the calcifications that are impinging the bronchial wall.Some diseases that may mimic broncholithiasis include primary endobronchial infection (i.e. fungus ball or Actinomyces),or tracheobronchial amyloidosis with calcification.Lung cancer or endobronchial tumors(i.e. carcinoid or hamartoma)are mainly included in differential diagnosis.The key in the diagnosis is that in broncholith there is no mass present.",
    "differential_diagnosis": "Broncholithiasis, of, the, left, lower, lobe",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007923/000002.jpg?itok=ZGuTa4M0",
            "caption": "Broncholith in a left lower lobe bronchus"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007923/000003.jpg?itok=bXBwH1pz",
            "caption": "Broncholith in a left lower lobe bronchus with segmental atelectasis of left lower lobe"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/7923",
    "time": "12.12.2009"
  },
  "7978": {
    "case_id": 7978,
    "title": "CT findings in pulmonary Asbestosis, two cases in different stages.",
    "section": "Chest imaging",
    "age": "50",
    "gender": "female",
    "diagnosis": "Pulmonary Asbestosis",
    "history": "Two women, mother(50-years-old) and daughter(30-years-old), living near an asbestos related factory, underwent chest radiographs and HRCT in the context of periodical screening, recommended by the local attendant doctor due to the high incidence of lung cancer and mesotelioma in the local population. No other prior medical problems were reported.",
    "image_finding": "Mother and daughter were living for a period of about 40 and 20 years, respectively, in the proximity of an asbestos related factory. Both women were asymptomatic.According to the information provided on the referral letter by the local attendant doctor, the chest radiographs demostrated findings of asbestosis  and  so a HRCT scan was ordered. The daughter\u2019s HRCT revealed non calcified pleural thickening along with normal imaging of the pulmonary parenchyma, whereas calcified plaques were shown in the mother\u2019s HRCT. Lesions of pulmonary fibrosis were also present in the older woman\u2019s imaging, such as subpleural curvilinear lines and thickening of the interlobular septa in subpleural and basal zones.",
    "discussion": "Asbestos is the name given to a group of naturally occurring silicate minerals. It is not combustible, has great tensile strength, and has good frictional properties. These properties have led to its use in many commercial and domestic settings. Exposure to asbestos arises from mining and processing of asbestos and manufacture of asbestos products. The main asbestos-related conditions and diseases include pleural effusion, pleural plaques, diffuse pleural thickening, asbestosis, malignant mesothelioma, and bronchogenic carcinoma.Benign pleural manifestations of asbestos exposure include circumscribed pleural plaques, round atelectasis, benign exudative effusions and diffuse pleural fibrosis. Pleural plaques, usually asymptomatic, are the most common benign manifestations of asbestos exposure. There is a latency period of 20 and 40 years. They appear on CT as discrete areas of fibrosis that usually arise from the parietal pleura but may arise from visceral pleura. Visceral pleural plaques are associated with abnormality in the adjacent lung parenchyma. Plaques are usually found postero-laterally as well as along the diaphragm. Calcifications occur in approximately 10-15% of plaques. Asbestosis is defined as interstitial fibrosis caused by inhalation of asbestos fibers. It occurs 15 to 20 years after exposure, with disease progressing even after exposure has ceased. Initially, asbestosis affects respiratory bronchioles with development of peribronchial fibrosis. Progressively, the alveolar walls are involved and eventually the interlobular septa. The fibrosis tends to be patchy and is usually more severe in the subpleural regions of the lower lobes and posterior lungs. Clinico-laboratory findings suggesting the disease are: the restrictive lung disease on pulmonary function testing as well as a diffusion abnormality, the presence of rales at auscultation and abnormal chest radiograph (ILO score). HRCT is more sensitive than the radiograph in the detection of asbestosis. The diagnosis of asbestosis on HRCT is based on clinical history of exposure, findings indicative bilateral pulmonary fibrosis and bilateral pleural plaques or diffuse pleural thickening. It is recommended that in patients being assessed for asbestosis, HRCT scans be obtained in both supine and prone positions because in many cases the fibrosis is mild and limited to the dependent regions of the lower lung zones. The earliest pulmonary abnormalities, although nonspecific, consist of subpleural nodules or dotlike opacities 1mm or less in diameter. They are situated a few millimetres away from the pleura and may appear as fine branching structures. Confluence of nodules leads to pleura-based nodular irregularities and subpleural curvilinear lines. As the fibrosis progresses, intralobular lines and irregular thickening of the interlobular septa are seen on HRCT as well as parenchymal bands. With further progression, architectural distortion, traction bronchiectasis and honeycombing are seen. The HRCT findings of asbestosis resemble those of interstitial pulmonary fibrosis (IPF). Nevertheless, in asbestosis there is great prevalence of subpleural dotlike or branching opacities, parenchymal bands, and subpleural lines as well as more-marked distribution of the disease in subpleural and basal zones. On the other hand, honeycombing and traction bonchiectasis are more prevalent in IPF. Furthermore, ground-glass opacities are relatively uncommon in asbestosis.",
    "differential_diagnosis": "Pulmonary, Asbestosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007978/000001.jpg?itok=-eijuole",
            "caption": "There are some pleural plaques not yet calcified suggesting findings of asbestosis at an earlier stage. An important aspect of asbestosis is the high risk of development of lung malignancies and mesotelioma which may also present with non- calcified pleural thickening."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007978/000002.jpg?itok=zJJyPlz9",
            "caption": "There are some pleural plaques not yet calcified suggesting findings of asbestosis at an earlier stage. An important aspect of asbestosis is the high risk of development of lung malignancies and mesotelioma which may also present with non- calcified pleural thickening."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007978/000012.jpg?itok=ziT5V42G",
            "caption": "Normal lung parenchyma."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007978/000006.jpg?itok=ufrrXGnh",
            "caption": "Subpleural curvilinear lines."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007978/000007.jpg?itok=f3ETYVXG",
            "caption": "Subpleural curvilinear lines."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007978/000009.jpg?itok=oH4IVwJm",
            "caption": "Subpleural curvilinear lines."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007978/000008.jpg?itok=Gzn5xXIh",
            "caption": "Interlobar septal thickening"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007978/000010.jpg?itok=UQI2iM5N",
            "caption": "There are several partially calcified pleural plaques(arrows)."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007978/000011.jpg?itok=Z0BpzeGP",
            "caption": "There are several partially calcified pleural plaques(arrows)."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/7978",
    "time": "27.12.2009"
  },
  "7982": {
    "case_id": 7982,
    "title": "Scroful",
    "section": "Chest imaging",
    "age": "27",
    "gender": "female",
    "diagnosis": "Scrofula (Tuberculous lymphadenitis).",
    "history": "A 27-year-old female was referred to the radiology department for evaluation of right cervical and axillary painless mass.",
    "image_finding": "A 27-year-old female was referred to the radiology department for evaluation of a painless right neck mass and a right axilla mass. She has a known history of rheumatoid arthritis. She has received a TNF (tumour necrosis factor) therapy.A pre and post-contrast cervical and chest CT examination were performed. Cervical CT examination revealed: bilateral enlarged cervical lymph nodes, especially at the right side, with low-density centre (necrosis) and peripheral rim of enhancement (Fig. 1). Also supraclavicular enlarged lymph nodes were observed, at the right cervical area with the same characteristics (Fig. 2). Chest CT examination revealed: enlarged right axillary lymph nodes with low density centre and a rim of enhancement (Fig. 3), a bilateral pleural effusion (Fig. 4), airspace opacities at the right upper and left lower lobe and bilateral fibrotic disease at the lower lobes (Fig. 5).A right cervical node aspirate was positive for pansensitive Mycobacterium tuberculosis.",
    "discussion": "Tuberculosis is an airborne communicable disease caused by Mycobacterium tuberculosis, which is an obligate, aerobic, nonspore-forming rod. Patient-to-patient transmission typically occurs via inhalation of small aerosols and, in most cases, the disease is confined to the respiratory system. Although the thorax is most frequently involved, tuberculosis may involve any of a numberof organ systems, especially in immunocompromised patients, like respiratory, cardiac, central nervous, musculoskeletal, gastrointestinal and genitourinary systems. Immunocompromised patients (as the patients who were having TNF therapy) have a significantly higher prevalence of extrapulmonary tuberculosis than the general population.Cervical tuberculous adenitis is a manifestation of a systemic disease process. It represents about 15% of cases of extrapulmonary tuberculosis. About one half of these have a history of previous tuberculosis or chest radiographic evidence of past disease. This condition is most prevalent in the 20 to 30 year age group, but can occur at any age. The most common location is within neck nodes, often manifesting as bilateral painless cervical lymphadenitis, also known as scrofula. Four CT patterns of nodal disease have been observed:1. Multichambered nodal mass with ring \u2013like areas of enhancement both within and around the mass. The enhanced walls of these multichambered masses are thicker than those usually defined as rim enhancement of necrotic nodes secondary to metastatic carcinomatous disease. 2. A large, low density mass with a thick sometimes corrugated rim of enhancement about the periphery. This CT pattern is encountered when the walls of individual lymph nodes have been totally destroyed and the nodes coalesce to form a single large necrotic mass. This is commonly referred as a \u201ccold abscess\u201d.3. A homogenous soft-tissue mass in a lymph-node-bearing area with or without enhancement. Normal fascial planes are preserved adjacent to the mass.4. A soft-tissue mass in a lymph-node-bearing area with a thin rim of enhancement and normal fascial planes. This appearance by itself is not distinctive for tuberculosis and mimics neoplastic nodal disease.Nodal calcification often develops late in tuberculosis, which helps differentiate tuberculous nodes from malignancy. Metastatic disease from head and neck squamous cell carcinomas, treated lymphoma, and non-nodal lesions (such as an infected branchial cleft cyst) should be considered for the differential diagnosis.Fine-needle aspiration with CT guidance or, most often, ultrasonographic guidance is usually the first diagnostic investigation performed, with a reported sensitivity of 77% and a specificity of 93%. Biopsies are not usually recommended, as they may result in spread of the disease and sinus formation.With proper treatment, patient recovery is usually complete. Antibiotic regimens used for treating pulmonary infection are also applied to tuberculous lymphadenitis. Just as the disease is slow to develop, it is also slow to respond to medical therapy. Antibiotics must be taken for at least a 6-month period, although a longer course may be necessary.In conclusion, we should include cervical tuberculous adenitis in the differential diagnosis of an asymptomatic neck mass.",
    "differential_diagnosis": "Scrofula, (Tuberculous, lymphadenitis).",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007982/000001.jpg?itok=2zEU_zQG",
            "caption": "Enlarged cervical lymph nodes with low-density centre (sign of necrosis) and peripheral rim of enhancement."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007982/000002.jpg?itok=O_tqTNB8",
            "caption": "Enlarged right supraclavicular lymph nodes with the same characteristics as Figure 1."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007982/000003.jpg?itok=wkxk_7Vg",
            "caption": "Enlarged axillary lymph nodes with low density centre and peripheral rim enhancement"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007982/000004.jpg?itok=-W7llthC",
            "caption": "Bilateral pleural effusion."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007982/000005.jpg?itok=HCBCxtRl",
            "caption": "Airspace opacities at the right upper lobe."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007982/000006.jpg?itok=n5ysdE2V",
            "caption": "Airspace opacities left lower lobe."
          }
        ]
      },
      {
        "number": "Figure 7",
        "subfigures": [
          {
            "number": "Figure 7",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000007982/000007.jpg?itok=Vhy0nhJI",
            "caption": "Bilateral fibrotic disease at the lower lobes."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/7982",
    "time": "27.12.2009"
  },
  "8005": {
    "case_id": 8005,
    "title": "CT findings in idiopathic pulmonary alveolar proteinosis before and after whole lung lavage",
    "section": "Chest imaging",
    "age": "51",
    "gender": "female",
    "diagnosis": "idiopathic pulmonary alveolar proteinosis",
    "history": "A 51 year old female presented with dry cough and progressive dyspnoea.",
    "image_finding": "A 51 year old female was referred to our department with a 4 month history of dry cough and progressive dyspnoea. The patient was a smoker of 10 cigarettes/day. Physical examination by her primary care physician revealed fine end-respiratory crackles. A chest X-ray was ordered and revealed patchy perihilar consolidations with associated reticular pattern. CT revealed diffused ground glass opacities with superimposed thickening of the interlobular septae and intralobular lines (\"crazy paving\"). The opacities seemed to involve mainly the perihilar regions and pulmonary bases. There is a sharp demarcation between the areas of \"crazy paving\" and unaffected lung. No mediastinal or hilar adenopathy was noticed (Fig 1). Then, a brochoalveolar lavage was performed. The specimens of fluid contained large amounts of granular acellular eosinophilic proteinaceous material with morphologically abnormal \"foamy\" macrophages engorged with diastase-resistant PAS-positive intracellular inclusions, findings compatible with PAP. The patient sustained a whole lung lavage. A CT was performed 3 days after the lung lavage. It showed marked decrease in the extent of the opacities noticed in the previous study (Fig 2).",
    "discussion": "Pulmonary alveolar proteinosis (PAP) is a rare lung disorder of unknown aetiology characterized by alveolar filling with surfactant-like material. PAP was first described in 1958. [1]Three distinct subgroups of PAP are currently recognized: idiopathic, secondary, and congenital. Idiopathic PAP (also termed \u201cacquired\u201d or \u201cadult-type\u201d PAP) accounts for the great majority of cases (90%). This form occurs worldwide, with an incidence of 0.36 new cases per 1 million persons each year and a prevalence of 3.7 cases per 1 million persons. [2]Secondary PAP (5\u201310% of cases) is recognized in patients with industrial inhalational exposure to materials such as silica particles, cement or aluminium dust; underlying hematologic malignancy; or immunodeficiency disorders (including cytotoxic or immunosuppressive therapy and human immunodeficiency virus infection). Congenital PAP is quite rare (2% of cases) and manifests in the neonatal period with severe hypoxia. \u201cCongenital PAP\u201d is not universally regarded as a true form of PAP, but may instead represent the disease entity termed \u201cchronic pneumonitis of infancy\u201d [3].Patients with idiopathic or secondary PAP experience nonspecific, moderate respiratory symptoms including progressive dyspnoea (mean duration 7 months; however, onset may last for years) and dry or minimally productive cough. Less common signs and symptoms include fatigue, weight loss, low-grade fever, chest pain, and haemoptysis [2,3]. Physical examination may reveal crackles, clubbing, or cyanosis [3]. The mean patient age at diagnosis is 40 years.There is a strong association with tobacco use, about three-quarters of PAP patients are smokers, and in this subgroup, men are three times more frequently affected than women. In non-smokers, there is no gender predilection [2,3,4].Chest X-ray in PAP shows bilateral perihilar opacities in a \"bat-wing\" configuration, which may mimic pulmonary oedema, although with a typical absence of cardiomegaly or pleural effusion. Unilateral involvement occurs occasionally, and lymphadenopathy is rarely present. Typically, changes progress over weeks to months into a diffuse reticulonodular pattern. High-resolution computed tomography (HRCT) scan of the chest demonstrates areas of patchy ground-glass opacification with smooth interlobular septal thickening and intralobular interstitial thickening, which produces a polygonal pattern referred to as \"crazy paving.\" The crazy-paving pattern also can be observed in other conditions such as lipoid pneumonia, sarcoidosis, mucinous bronchoalveolar cell carcinoma, acute respiratory distress syndrome (ARDS). Up to 25% of the cases demonstrate only ground glass opacities. Unusual cases of PAP demonstrate CT findings of mild traction bronchiectasis and focal fissural distortion. In this setting, crazy paving is absent or less distinct and there is an increase in the overall apparent density of the lung.Flexible bronchoscopy with bronchoalveolar lavage (BAL) remains the standard criterion for definitive diagnosis. Diagnosis can also be made with more invasive procedures such as transbronchial lung biopsies.The standard of care is mechanical removal of the lipoproteinaceous material by whole-lung lavage. Historically, patients have been treated with systemic steroids, mucolytics (aerosol), and proteinase (aerosol) without much success. In secondary PAP, appropriate treatment of the underlying cause also is warranted. GM-CSF has been shown to improve PAP in several patients and is being investigated.",
    "differential_diagnosis": "idiopathic, pulmonary, alveolar, proteinosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008005/000001.jpg?itok=HSuHb83x",
            "caption": "Geographic ground glass opacities, thickening of the interlobular and intralobular  septa. The opacities involve the perihilar regions and pulmonary bases. Note the sharp demarcation between affected and normal lung parenchyma."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008005/000002.jpg?itok=-f6ahRoI",
            "caption": "Geographic ground glass opacities, thickening of the interlobular and intralobular  septa. The opacities involve the perihilar regions and pulmonary bases. Note the sharp demarcation between affected and normal lung parenchyma."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008005/000003.jpg?itok=sOxOYqaD",
            "caption": "Geographic ground glass opacities, thickening of the interlobular and intralobular  septa. The opacities involve the perihilar regions and pulmonary bases. Note the sharp demarcation between affected and normal lung parenchyma."
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008005/000004.jpg?itok=iV9i_PmD",
            "caption": "Geographic ground glass opacities, thickening of the interlobular and intralobular  septa. The opacities involve the perihilar regions and pulmonary bases. Note the sharp demarcation between affected and normal lung parenchyma."
          },
          {
            "number": "Figure 1e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008005/000005.jpg?itok=SSWUlAme",
            "caption": "Geographic ground glass opacities, thickening of the interlobular and intralobular  septa. The opacities involve the perihilar regions and pulmonary bases. Note the sharp demarcation between affected and normal lung parenchyma."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008005/000006.jpg?itok=-9L_TVEY",
            "caption": "Marked decrease in the extent of the opacities."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008005/000010.jpg?itok=GrFLIcVZ",
            "caption": "Marked decrease in the extent of the opacities."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008005/000007.jpg?itok=Y5dU_cke",
            "caption": "Marked decrease in the extent of the opacities."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008005/000008.jpg?itok=lv2OaDdT",
            "caption": "Marked decrease in the extent of the opacities."
          },
          {
            "number": "Figure 2e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008005/000009.jpg?itok=0skG2R4N",
            "caption": "Marked decrease in the extent of the opacities."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/8005",
    "time": "09.01.2010"
  },
  "8031": {
    "case_id": 8031,
    "title": "Pneumomediastinum after thyroidectomy.",
    "section": "Chest imaging",
    "age": "85",
    "gender": "male",
    "diagnosis": "Severe subcutaneous emphysema of neck and pneumomediastinum after thyroidectomy.",
    "history": "An 85-year-old male patient who developed extensive subcutaneous emphysema, and severe pneumomediastinum after total thyroidectomy.",
    "image_finding": "An 85-years-old male patient developed severe subcutaneous emphysema and pneumomediastinum after total thyroidectomy. The patient arrived to our attention with dysphonia and dyspnea. Computed tomography (CT) of the neck was performed, showing a huge disomogeneous tumefaction (7 cm) in the left thyroid lobe. Laterocervical and sovraclavear lymph nodes involvement was also demonstrated.Biopsy confirmed the diagnosis of papillary thyroid cancer, and total thyroidectomy was performed with central neck dissection and tracheostomy. Two days later the patient developed dyspnea and clinical signs of subcutaneous emphysema. So another neck CT was performed, confirming the presence of subcutaneous emphysema and showing pneumomediastinum and pneumothorax due to a tracheal perforation (Fig.1). A following surgery was done in order to repair the tracheal perforation, and seven days later a CT examination showed that all previous findings had almost disappeared (Fig. 2).",
    "discussion": "Pneumomediastinum, pneumothorax and subcutaneous emphysema are defined as the presence of air in the mediastinum, thoracic cavity and between cutaneous layers.Air may gain access to these areas through several anatomic routes: directly, through a perforation of the trachea, bronchi, or esophagus; by dissection along the fascial planes of the neck; from the interstitial tissue of the lung; from the retroperitoneal space. In most cases of pneumomediastinum, air ascends along the mediastinum toward the subcutaneous space of the neck after rupture of marginal pulmonary alveoli. In contrast, pneumothorax and pneumomediastinum following cervical emphysema are very rare.In thyroid surgery, tracheal perforation with subcutaneous emphysema, pneumothorax and pneumomediastinum are usually associated with a difficult dissection of thyroid. Generally the perforation occurs in the posterolateral trachea, either following attempted suture ligation of vessels in the region of the ligament of Berry or with the use of diathermy adjacent to the trachea. As a result, postoperative pneumothorax can be encountered. Most perforations are recognized as they occur, but smaller inadvertent injuries are identified at the conclusion of the procedure by filling the wound with saline and observing for small air leaks in the trachea.Pneumothorax or pneumomediastinum are usually of little clinical importance. Nevertheless in rare cases they can be associated with several serious complications including cardiac tamponade, tension pneumomediastinum, air embolism, mediastinitis and neck abscess.Initially, dyspnea is considered as a consequence of airway compression due to postoperative haematoma, but after a few days the patient with tracheal perforation develops pneumomediastinum and pneumothorax.The mechanisms of pneumothorax may be as follows. First, postoperative haematoma and narrowed airway from medially fixed unilateral vocal fold aggravate dyspnea. Second, a high-pressure air leak occurs through the perforated trachea due to deep breathing and vigorous coughing. Finally, along the fascial planes of the neck, pneumomediastinum and bilateral tension pneumothorax occur before neck exploration. Consistent with this route, air leak can be aggravated by tracheal injury during intubation and by positive-pressure ventilation anaesthesia during a subsequent operation.The defect is repaired by reapproximating the tracheal edges, either with a single absorbable suture or with a catgut suture and sometimes reinforced by adjacent strap muscle flaps using fibrin glue.All patients with inadvertent tracheal perforation have a prolonged hospital stay, but long-term outcome is good and there are no deaths.",
    "differential_diagnosis": "Severe, subcutaneous, emphysema, of, neck, and, pneumomediastinum, after, thyroidectomy.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008031/000001.jpg?itok=gHgLlIpY",
            "caption": "Neck CT scans shows the presence of subcutaneous emphysema and..."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008031/000003.jpg?itok=EW0mtM62",
            "caption": "...pneumomediastinum."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008031/000004.jpg?itok=gmxZ3aAl",
            "caption": "MPR reconstruction shows subcutaneous emphysema."
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008031/000005.jpg?itok=uf-ACsiO",
            "caption": "Subcutaneous emphysema in axial chest CT scans."
          },
          {
            "number": "Figure 1e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008031/000006.jpg?itok=bC3z0ncc",
            "caption": "Pneumothorax and pneumomediastiunum in axial chest CT scans."
          },
          {
            "number": "Figure 1f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008031/000007.jpg?itok=3-s1TboG",
            "caption": "MPR shows the tracheostomy."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008031/000008.jpg?itok=hejBmVz-",
            "caption": "CT exam showed the nearly disappearance of all previous findings."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008031/000009.jpg?itok=XmywZQcS",
            "caption": "CT exam showed the nearly disappearance of all previous findings."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008031/000011.jpg?itok=-QokBiLy",
            "caption": "MPR shows the reduction of pneumomediastinum."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008031/000012.jpg?itok=sHMqhzAZ",
            "caption": "MPR shows the reduction of subcutaneous emphysema."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/8031",
    "time": "24.01.2010"
  },
  "8043": {
    "case_id": 8043,
    "title": "Rituximab induced pneumonitis",
    "section": "Chest imaging",
    "age": "63",
    "gender": "male",
    "diagnosis": "Rituximab induced pneumonitis.",
    "history": "A 63-year-old patient presented at the emergency department with progressive dyspnea over the last week and fever (38.5 o C). There was also mild non-productive cough. The patient was under treatment of a follicular B-cell lymphoma, receiving chemotherapy according to the CHOP scheme including rituximab (CHOP-R).",
    "image_finding": "A 63-year-old man presented at the emergency department with progressive dyspnoea over the last week and fever (38.5 o C). There was also mild non-productive cough. The patient was under treatment of a follicular B-cell lymphoma, having been diagnosed 5 months prior to the admission. He actually received chemotherapy with CHOP-R, the last time about three weeks before admission. The patient showed elevated C-reactive protein and an elevated white cell count. On admission an ECG was recorded, which showed signs of right heart dysfunction and sinus tachycardia. A standard chest radiograph showed diffuse reticular densities with an area of beginning consolidation in the right upper lobe (Figure 1). In a chest CT scan pulmonary embolism could be ruled out, but an interstitial disease pattern with patchy areas with ground glass attenuation and reticular densities and some areas of consolidation was found. There were no signs of pulmonary fibrosis and no pleural effusions (Fig. 2). Given the clinical picture the diagnosis of an atypical pneumonia was made and a therapy with antibiotics and corticosteroids was initiated. Bronchoalveolar lavage was performed, but all bacterial, viral and fungal cultures were negative. Because of the negative microbiological cultures the observed good response to the applied corticosteroids the diagnosis of a rituximab induced pneumonitis was made. The control scan two weeks after the initiation of therapy showed a marked improvement and the patient could leave the hospital soon thereafter (Fig. 3).",
    "discussion": "Rituximab is a chimeric antibody, directed against the CD20-antigen of lymhocytes. It has been first approved in 1997 and is now part of the standard therapy of CD20+  non- Hodgkin\u2019s lymphomas and is also used in a wide variety of autoimmune diseases, for example rheumatoid arthritis or idiopathic thrombocytopenic purpura [1]. Common side effects are fever, chills, headache and vomiting at the time of application. These infusion related reaction can be diminished with the use of paracetamol and antihistaminergics.  Rituximab is considered to be a safe treatment and pulmonary drug reactions after rituximab have been considered a rare event [2]. About 10 years after the approval of rituximab Heresi et al. reported about 21 cases in the literature [3]. In contrast, pulmonary drug reactions have been reported in 9% of patients in a recently published series of 108 patients undergoing treatment with rituximab [4]. This data warrants confirmation, but it could be that rituximab induced lung damage is more common than previously reported. Pathogenesis is unclear, however a dysregulation of the immune system is proposed. In most cases bilateral areas of alveolar or interstitial infiltrations with a patchy appearance on imaging is reported, but also the picture of cryptogen organizing pneumonia has been reported [1, 3]. The clinical picture is not uniform and lethal cases due to ARDS are reported [1]. Diagnosis is not straight forward because a wide range of differential diagnosis has to be considered, specifically opportunistic infections. In clinical practice the diagnosis is usually made using exclusion. Therapy consists of corticosteroids and the response to them is prognostically important [1, 3]. In conclusion, pulmonary drug reactions following the use of rituximab are a rare entity in clinical practice. But as its prevalence may be underestimated and its use increases, radiologists should be aware of this side effect and consider it in their differential diagnosis in the proper clinical context.",
    "differential_diagnosis": "Rituximab, induced, pneumonitis.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008043/000001.jpg?itok=MhqIUYtH",
            "caption": "Standard chest radiograph of a 63-year-old patient with progressive dyspnea, fever and non-productive cough being under chemotherapeutic treatment because of a lymphoma, receiving chemotherapy with CHOP- R. There are diffuse reticular densities with an area of beginning consolidation in the right upper lobe. Note there is also a dislocation of the port system."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008043/000002.jpg?itok=lHYARU8J",
            "caption": "The chest CT scan of the same patient shows an interstitial disease pattern with patchy areas with ground glass attenuation and reticular densities and some areas of consolidation."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008043/000003.jpg?itok=qdpzU4aE",
            "caption": "The control CT scan of the patient shows marked  improvement after a two week treatment with corticosteroids."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/8043",
    "time": "12.12.2009"
  },
  "8092": {
    "case_id": 8092,
    "title": "Pulmonary lymphangitic carcinomatosis",
    "section": "Chest imaging",
    "age": "67",
    "gender": "male",
    "diagnosis": "Non small cell lung carcinoma with pulmonary lymphangitic carcinomatosis.",
    "history": "A 67 year old male patient with shortness of breath underwent a CT examination.",
    "image_finding": "A 67-year-old male patient with shortness of breath underwent a chest radiograph and CT examination. No other symptoms were present and the laboratory exams were within the normal limits.Diffuse reticulonodular opacities and a mass at the right middle lung were depicted at the chest radiograph (not shown). Further investigation with CT and HRCT of the lungs was performed.CT-HRCT revealed: (1) bilateral pleural effusion, (2) mediastinal lymphadenopathy, (3) nodule with spiculated margins in the right lower lobe, (4)  smooth and nodular thickening of the interlobular septa, (5) nodular thickening of the peribronchovascular interstitium,in the right middle and lower lobe, (6) nodular thickening of the right major fissure and (7) subpleural nodules. Imaging findings were compatible with pulmonary lymphangitic carcinomatosis. The nodule in RLL was considered to be the possible cause. Bronchoscopy confirmed the diagnosis of pulmonary lymphangitic carcinomatosis (PLC). Transbronchial biopsy of the nodule in the RLL revealed primary lung carcinoma (non-small cell lung carcinoma) which caused PLC.",
    "discussion": "Pulmonary lymphangitic carcinomatosis is a term that refers to tumour growth in the lymphatic system of the lung. The most common malignancies to produce lymphangitic carcinomatosis (LC) are breast carcinoma, lung, stomach, pancreas, prostate, cervix, or thyroid and metastatic adenocarcinoma from an unknown primary site. The most common clinical manifestation is dyspnoea. It is typically insidious in onset but progresses rapidly and within a few weeks can cause severe disability. Pathologically there is haematogenous spread of tumour to the lungs, followed by embolisation of small peripheral vessels by cancer cells, consequent growth of small parenchymal nodules, extension through vessel walls and invasion of the interstitium and finally centripetal spread by permeation of peribronchial lymphatics.The chest radiograph is normal in approximately 50% of cases of proven LC. Radiographic manifestations of LC include: i) reticular or reticulonodular opacities, ii) septal lines, iii) hilar and mediastinal lymphadenopathy, iv) pleural effusion.HRCT is the imaging method of choice for diagnosing LC. HRCT findings of LC include: 1) smooth or nodular peribronchovascular interstitial thickening, 2) smooth or nodular interlobular septal thickening, 3) smooth or nodular thickening of fissures, 4) smooth or nodular subpleural interstitial thickening, 5) thickening of the peribronchovascular interstitium (peribronchial cuffing), 6) preservation of normal lung architecture at the lobular level despite the presence of these findings, 7) lymph node enlargement and 8) pleural effusion.Although the findings of LC are characteristic, they can also be seen in other conditions like pulmonary oedema, sarcoidosis, CWP (Coal Worker\u2019s Pneumoconiosis) or silicosis, lymphocytic interstitial pneumonia, amyloidosis. The following clues to differential diagnosis should be considered: a) in sarcoidosis and CWP septal nodules are commonly seen but septal thickening is usually less extensive than that seen in patients with lymphangitic spread of tumour, b) in sarcoidosis and CWP distortion of lung architecture may be present, a finding that is not seen in patients with LC, c) pleural effusion is rare in sarcoidosis or silicosis and finally d) in pulmonary oedema interstitial thickeninig is smooth and there are no peribronchovascular and subpleural nodules.",
    "differential_diagnosis": "Non, small, cell, lung, carcinoma, with, pulmonary, lymphangitic, carcinomatosis.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008092/000001.png?itok=cDru08GK",
            "caption": "Topogram showing diffuse reticulonodular opacities more prominent on the right"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008092/000002.png?itok=Q6qfcLze",
            "caption": "Pleural effusion, interlobular septal thickening, nodular thickening of the right major fissure"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008092/000003.png?itok=TrJAJ4cv",
            "caption": "Mediastinal lymphadenopathy with cuffing of the right central bronchi"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008092/000004.png?itok=_fr0gE0-",
            "caption": "Nodule with spiculated margins in RLL. Transbronchial biopsy revealed lung carcinoma."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008092/000005.png?itok=VF13jeNo",
            "caption": "Nodular peribronchovascular thickening in RLL and RML"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/8092",
    "time": "02.07.2010"
  },
  "8129": {
    "case_id": 8129,
    "title": "pidural Pneumorrhachis : Sequalae Of Spontaneous Pneumomediastinum",
    "section": "Chest imaging",
    "age": "5",
    "gender": "female",
    "diagnosis": "Epidural Pneumorrhachis/Aerorrhachis",
    "history": "A 5 year old child presented with sudden respiratory distress and soft tissue oedema with crepitus over the chest and neck.",
    "image_finding": "A 5 year old female patient was admitted with sudden onset of dyspnea at rest with soft tissue oedema in the chest and neck regions. The patient was having mild cough and occasional wheezing chest. The patient was afebrile and vital signs were normal.The initial chest radiograph showed subcutaneous emphysema in the cervical, thoracic, and axillary regions with no evidence of rib fracture [Fig. 1].To better define the extent of air dissection into the neck and mediastinum, the patient underwent computed tomography (Philips Brilliance six slice scanner). CT examination confirmed the extent of the stripping, which showed air in the subcutaneous, visceral and carotid spaces of the neck, extending along the anterior mediastinal space down to the aortic arch [Fig. 2].CT sections of the lung showed significant amount of pneumothorax. Air was seen dissecting the intrapulmonary perivascular interstitium and causing pneumomediastinum. Few small patches of consolidation were seen in both lungs. There was no evidence of pulmonary interstitial emphysema or any bullae. A small amount of air in the spinal epidural space at cervicothoracic region was found [Figs. 3 a, b].",
    "discussion": "Epidural pneumorrhachis due to spontaneous pneumomedistinum is an uncommon clinical condition and should be a diagnosis of exclusion. It was first described in 1617 by Louise Bourgeois whilst Hamman in 1939 named \u201cHamman\u2019s sign\u201d which is presence of an audible crepitis occurring with the heart beat due to the presence of mediastinal air [1, 4].It has an incidence of 1 in 33,000 in general population, is usually seen in healthy young patients resulting from the rupture of peripheral pulmonary alveoli due to sudden increase of intra-alveolar pressure after exaggerated Valsalva manoeuvres [1]. The most common cause in children is asthma [2, 3]. It may also complicate obstructive airway processes such as asthma or foreign bodies. Inhalational drug use has been reported as the most common associated activity, accounting for about 76% of cases [5]. This condition is usually self-limited due to the transient nature of the clinical course e.g. cough, asthma, and bronchiolitis [3]. However, in the presence of a foreign body, persistence of expiratory outflow resistance and associated coughing leads to uninterrupted air leak and progressive emphysema. A possible explanatory mechanism for pneumomediastinum is high bronchoalveolar pressure during cough resulting in air leakage into pulmonary perivascular interstitium. The air dissects the paths of least resistance into the mediastinum to the fascial planes of the neck. There are no fascial barriers to prevent communication of the posterior mediastinum or retropharyngeal space with the epidural space. Air can thus communicate freely via the neural foramina [7]. The causes of pneumorrhachis have broadly been classified into iatrogenic, non-traumatic and traumatic. Iatrogenic causes are the most common, following epidural analgesia. Non-traumatic causes are related to pneumomediastinum or pneumothorax [6]. The combination of pneumomediastinum with epidural pneumorrachis without thoracic trauma has rarely been reported in the medical literature. Although recognised in the adult population, pneumorrhachis is very rare in children. Detailed imaging allows the distinction between air within the epidural space and subarachnoid air which, due to breach of the dura, has further clinical implications. Awareness of the mechanism by which air reaches the epidural space secondary to pneumothorax and pneumomediastinum is reassuring, and allows a conservative approach to be taken, as treatment of the underlying cause will lead to spontaneous resorption of the pneumorrhachis [5, 7]. The treatment is conservative and consists of bed rest, analgesics, and avoidance of the Valsalva manoeuvre [5, 8]. In conclusion, epidural pneumorrhachis associated with Spontaneous pneumomediastinum usually has a benign character, therefore, does not need a special treatment. However, follow-up of this rarely seen entity still remains significant, because in some cases serious neurologic symptoms may occur. To our opinion, while the chest X-ray is able to define the presence of a pneumomediastinum and subcutaneous emphysema, only CT can make the diagnosis of epidural pneumorrhachis.",
    "differential_diagnosis": "Epidural, Pneumorrhachis/Aerorrhachis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008129/000001.jpg?itok=HSpkLT5x",
            "caption": "Showing extensive subcutaneous emphysema and pneumomediastinum"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008129/000002.jpg?itok=D4ieomEC",
            "caption": "Extensive soft tissue emphysema with pneumomediastinum and posterior epidural pneumorrhachis"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008129/000003.jpg?itok=XjLyArhu",
            "caption": "Subcutaneous emphysema with pneumomediastinum,air in perivascular interstitium(arrow) with posterior pneumorrhachis"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008129/000004.jpg?itok=nbbebuFE",
            "caption": "Posterior Epidural Pneumorrhachis(arrow) with pneumomediastinum and air in soft tissues of neck"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/8129",
    "time": "08.02.2010"
  },
  "8153": {
    "case_id": 8153,
    "title": "Intralobar Pulmonary Sequestration",
    "section": "Chest imaging",
    "age": "25",
    "gender": "male",
    "diagnosis": "Intralobar pulmonary sequestration left lung with dual venous drainage.",
    "history": "A 25 year old male had recurrent episodes of fever, cough and chest pain for past 3 years. The symptoms were persistent in spite of repeated antibiotic course.",
    "image_finding": "A 25 year old male was investigated by CECT thorax for recurrent episodes of fever, cough and chest pain. CT scan revealed, a well defined wedge shaped radio opacity in left lower lung zone. The lesion does not obliterate the left cardiac border as well as the diaphragmatic contour (Fig 1). The right lung fields and hila were normal. CT angiography was done according to standard protocols and arterial, venous and delayed phases were obtained. Scans were reviewed using MIP (maximum intensity projections) in orthogonal views.A well defined multi-loculated cystic lesion with air \u2013 fluid levels along with irregular enhancing margins and internal septae was noted in basal pulmonary segments of left lower lobe (Fig 2). Lung window showed adjoining areas of consolidation, ground glass opacities and bronchial wall thickening (Fig 3a). Communication with bronchial tree was also noted (Fig 3b)MIP reformats of arterial phase revealed an anomalous artery originating from the descending thoracic aorta coursing to the lung mass (Fig 4). Venous drainage was by both pulmonary and systemic venous system. Drainage into pulmonary venous system was via left inferior pulmonary vein (Fig 5) and into systemic venous system was via hemiazygous vein (Fig 6).A diagnosis of \u201cintralobar pulmonary sequestration\u201d was made. The uniqueness is this case is the presence of both pulmonary and systemic venous drainage.",
    "discussion": "Pulmonary sequestration is a congenital cystic or solid mass composed of non-functioning primitive lung tissue that usually does not communicate with the tracheo-bronchial tree and has anomalous systemic blood supply. The sequestration can be intralobar or extralobar. Pulmonary sequestration accounts for 6.4% of all congenital pulmonary malformations out of which 75-86% are intralobar and 14-25% are extralobar.The most frequently supported theory of sequestration formation involves an accessory lung bud that develops from primitive foregut. This additional lung bud migrates in a caudal direction with the normally developing lung. It receives its blood supply from vessels that cover the primitive foregut. These attachments to the aorta remain to form the systemic arterial supply of the sequestration.  If the additional lung bud is encased within the same pleural covering, the intralobar variant results. In contrast, later development of the accessory lung bud results in the extralobar type which has a separate visceral pleural covering. However, the current widely held theory is that intralobar sequestration is acquired after one or more episodes of necrotizing pneumonia, resulting in obliterative bronchitis and obstruction of a lower lobe bronchus.Findings common to both types are: 1. Systemic arterial supply, 2. usually no communication with bronchial tree. The major differences include the presentation, venous drainage and pleural covering. Very rarely both intra and extralobar sequestration can occur in same lung. The differences between both are summarized in table 1.Intralobar sequestrations are encountered in young adults, usually by the age of 20 years with pneumonic presentations. The arterial supply is systemic in origin and arrives via the descending thoracic aorta (73%), the abdominal aorta or celiac axis artery (21%), and the intercostal arteries (4%). In 95% of patients, venous drainage occurs via the pulmonary veins; in 5% of patients, venous drainage occurs via the IVC, SVC, the azygos systems, or the intercostal veins.Infection is the major complication of pulmonary sequestration.Imaging modalities: - Chest radiographs can provide a diagnostic clue.  A mass in the postero-basal segment in young patients with recurrent localized pulmonary infections and incomplete resolution with therapy is suggestive.  - CT scans have 90% accuracy in the diagnosis of pulmonary sequestration. The vascular supply can be clearly delineated with CT angiography. It can also enable diagnosis of extralobar type due to presence of separate pleura seen as  a linear avascular area.- Magnetic resonance imaging (MRI) and MR angiography (MRA) can provide information similar to CT.- Ultrasonography along with color doppler  is noninvasive and safe, making its use ideal in prenatal (second trimester) and postnatal settings and especially useful in extralobar cases.  - Arteriography and radionuclide angiography are helpful in delineating the vascular supply. Differential diagnosis includes Bochdalek hernia, abscess, cavitating lung neoplasms, bronchiectasis, bronchogenic cysts, cystic adenomatoid malformations and fungal / bacterial pneumonias. The standard treatment is resection of the segment or lobe that contains the sequestered tissue. Other options are ligation or embolization of the vascular pedicle.",
    "differential_diagnosis": "Intralobar, pulmonary, sequestration, left, lung, with, dual, venous, drainage.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008153/000001.jpg?itok=zkIIHx3F",
            "caption": "CT scanogram shows well defined wedge shaped opacity in left lower lung zone not obliterating the left cardiac border."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008153/000002.jpg?itok=-7UcLYH_",
            "caption": "Axial CECT thorax shows multiloculated cystic lesion with enhancing margins and septae in left lower basal segments."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008153/000003.jpg?itok=mbMpptxv",
            "caption": "Axial CT thorax  in lung window shows perilesional ground glassing ( long arrow) along with bronchial thickening (short arrow)."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008153/000004.jpg?itok=qOtBwveC",
            "caption": "Coronal reformat shoes communication of the lesion with left lower bronchial tree (arrow)."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008153/000005.jpg?itok=54oLGCxn",
            "caption": "CT angiography arterial phase shows anomalous vessel arising from descending aorta (arrow)..."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008153/000006.jpg?itok=GqKUzMie",
            "caption": "..and coursing towards the lesion (arrow)....."
          },
          {
            "number": "Figure 4c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008153/000007.jpg?itok=5nPg7AT1",
            "caption": "...and is  seen to ramify and supply the lung lesion(arrow)."
          },
          {
            "number": "Figure 4d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008153/000008.jpg?itok=_Adw0ixs",
            "caption": "Coronal MIP reformat shows the anomalous artery from aorta(yellow arrow). Red arrow indicates normal inferior phrenic branch which should not be confused for anomalous vessel."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008153/000009.jpg?itok=5vHICwsF",
            "caption": "Coronal MIP reformat shows drainage by left inferior pulmonary vein(yellow arrow), hemiazygous v (red arrow). Green dot  and red dot represent pulmonary artery and left atrium respectively."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/8153",
    "time": "24.01.2010"
  },
  "8167": {
    "case_id": 8167,
    "title": "Giant Thymolipom",
    "section": "Chest imaging",
    "age": "44",
    "gender": "male",
    "diagnosis": "Giant Thymolipoma",
    "history": "Thymolipoma is a rare benign thymic mass of the anterior mediastinum typically containing mature fat and strands of connective and thymic tissue. They are occasionally very large at presentation and may have characteristic CT appearances.",
    "image_finding": "A 44 year old patient presented with a history of mild chest discomfort. Initial frontal chest radiograph (Fig.1) demonstrated a large mass obscuring the right hemidiaphragm and right heart border imitating combined right middle and lower lobe collapse. A CT (Fig.2,3) revealed a mediastinal mass of predominantly fat attenuation containing a few strands of higher attenuation soft tissue. After surgical excision via an extended thoracotomy and sternotomy, histological examination revealed a mass of mature adipose tissue containing elements of atrophic thymic tissue with no features of atypia or malignancy.",
    "discussion": "Thymolipomas are rare benign mediastinal tumours. They are encapsulated tumours composed mainly of mature adipose tissue with thin swirling strands of residual thymic tissue [1,2,3]. Very rarely, thymolipomas have been found to contain foci of thymoma and thymic carcinoma at histological diagnosis [4]. Thymolipomas have an equal frequency in men and women [3]. They mainly occur in the lower anterior mediastinum, often filling the cardiophrenic angles [1]. Thymolipomas may be an incidental finding or present with chest pain and sometimes respiratory failure if they achieve a massive size [5]. Most are diagnosed in early adulthood but can become very large before detection and because of their size and position, thymolipomas may mimic cardiomegaly, lobar collapse, pleural effusion or a raised hemidiaphragm particularly on projectional chest radiographs [1,6]. On CT, thymolipomas are well-demarcated masses of fat attenuation containing higher attenuation strands of connective tissue septa draped over the mediastinal surface. The CT differential diagnosis includes mediastinal lipomatosis, liposarcoma and an eccentric overgrowth of a cardiophrenic fat pad. On MRI, thymolipomas have fat and soft tissue signal characteristics. Typically the adipose tissue within the tumours returns a high T1 signal and the thymic tissue component a more intermediate T1 signal [1,2]. Thymolipomas are associated with a range of different conditions including myasthenia gravis, aplastic anaemia, Grave\u2019s disease and hypo-gammaglobulinaemia [2].",
    "differential_diagnosis": "Giant, Thymolipoma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008167/000001.jpg?itok=kJGlU69e",
            "caption": "Initial frontal chest radiograph demonstrating a large mass obscuring the right hemidiaphragm and right heart border imitating combined right middle and lower lobe collapse."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008167/000002.jpg?itok=d1I5TAx3",
            "caption": "Axial CT image demonstrating a mediastinal mass of predominantly fat attenuation containing a few strands of higher attenuation soft tissue."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008167/000003.jpg?itok=mpAZuGKa",
            "caption": "Axial CT image demonstrating a mediastinal mass of predominantly fat attenuation containing a few strands of higher attenuation soft tissue."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/8167",
    "time": "31.01.2010"
  },
  "8203": {
    "case_id": 8203,
    "title": "Partial anomalous pulmonary venous connection to the superior vena cav",
    "section": "Chest imaging",
    "age": "64",
    "gender": "male",
    "diagnosis": "Partial anomalous pulmonary venous connection to the superior vena cava",
    "history": "A 64-year-old male with small-cell lung carcinoma was admitted to our hospital with complaints of dyspnoea, facial oedema and swelling of neck and arms.",
    "image_finding": "We present the case of a 64-year old male already diagnosed with small-cell lung carcinoma who was admitted to our hospital due to dyspnoea, facial oedema and swelling of neck and arms. A contrast CT was performed to evaluate the symptoms and the progression of the underlying disease. CT revealed enlarged, necrotic, anterior mediastinal lymph nodes which caused extrinsic compression to the Superior Vena Cava (SVC) causing SVC syndrome (Fig. 1). The patient was then transferred to the angiosuite for palliative endovascular treatment with stent implantation. SVC venogram showed a rather unusual finding, the direct opacification of the right superior pulmonary vein (Fig. 2). The patient was diagnosed with partial anomalous pulmonary venous connection (PAPVC) to the superior vena cava. PAPVC creates a left-to-right shunt. SVC syndrome creates high systemic vein pressure in the upper body and in the upper lobe anomalous pulmonary vein. This causes reflux of the contrast from the SVC to the anomalous pulmonary vein. After stent implantation the SVC pressure dropped and the anomalous vein was no longer opacified (Fig.3). The patient reported no symptoms apart from a slight limitation of physical exercise prior to the accession of the lung carcinoma.",
    "discussion": "Partial anomalous pulmonary venous connection (PAPVC) is present when one or more, but not all, of the pulmonary veins connect to a systemic vein, the right atrium, or the coronary sinus. The prevalence reported by ElBardissi is 0.4% to 0.7% of postmortem examinations. The veins of the right lung have two to ten times the number of anomalous connections as those from the left lung. When an anomalous vein exists, it usually connects to the nearest adjacent systemic vein. The left lung veins connect to the left innominate vein, the coronary sinus, the hemiazygous vein, or to an anomalous vertical vein that drains into the innominate vein. In the right lung, the right superior pulmonary vein may connect to the right superior vena cava or azygous vein. The right inferior vein may connect with either the inferior or superior vena cava, or hepatic vein, or the azygous vein. The right pulmonary veins may also connect directly to the right atrium. Less common variations include absence of the coronary sinus with pulmonary veins from either side connecting to multiple systemic sites or to the left atrium. Rarely, an anomalous pulmonary vein will connect to the portal vein. Many variations exist in the number, size, and connections of the four pulmonary veins. If an atrial septal defect is present, about 10% of patients will have a pulmonary venous abnormality. The chest radiograph is usually normal because the pulmonary-to-systemic flow ratio is generally less than two to one. Pulmonary venous anomalies may be identified with cross sectional imaging and obviate the need for further studies. CT will demonstrate the course and termination of the anomalous vein, the bronchial distribution, abnormal lobation, and mediastinal shift and confirm the distinction from other venous structures, such as a left superior vena cava, pulmonary varices, and pulmonary arteriovenous fistulas. Since the majority of patients with PAPVC are asymptomatic, further evaluation after positive identification with CT is usually unwarranted. Complications of PAPVC result from pulmonary infection, atrial septal defect or dilation of the right atrial septal defect, or dilation of the right atrium and ventricle. Other imaging modalities may be required in these circumstances. Pulmonary angiography remains the standard examination for locating all the pulmonary veins. Selective injection into the right and left pulmonary arteries will visualize all pulmonary veins during a prolonged filming sequence. Alternative methods of locating pulmonary veins at catheterization include exploring the right atrium and adjacent systemic veins and documenting the anomaly by the entrance of the catheter into the vein or by a small hand injection of contrast material. While most patients with PAPVC are asymptomatic, the natural history dictates that if a significant left-to-right shunt exists, patients may develop irreversible pulmonary hypertension, pulmonary vascular obstructive disease, or right ventricular failure. Definitive treatment for PAPVC is surgical repair either using internal patch or the Warden technique. Radiologic intervention has been used in limited occasions for treating stenosis in the anastomotic sites after surgical treatment.",
    "differential_diagnosis": "Partial, anomalous, pulmonary, venous, connection, to, the, superior, vena, cava",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008203/000001.jpg?itok=S_B0HsOB",
            "caption": "Direct opacification of the right upper lobe pulmonary vein."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008203/000002.jpg?itok=SiTQXulp",
            "caption": "Large, necrotic, anterior mediastinal lymph nodes which cause extrinsic compression to the SVC."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008203/000003.jpg?itok=2s-D14hC",
            "caption": "Large, necrotic, anterior mediastinal lymph nodes which cause extrinsic compression to the SVC."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008203/000004.jpg?itok=lVkhCMK0",
            "caption": "Large, necrotic, anterior mediastinal lymph nodes which cause extrinsic compression to the SVC."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008203/000005.jpg?itok=cgJ0GR_-",
            "caption": "After stent implantation the pressure in the SVC is relieved and the anomalous pulmonary vein is no longer opacified."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/8203",
    "time": "15.04.2010"
  },
  "8255": {
    "case_id": 8255,
    "title": "The \\&#039;miliary\\&#039; chest pattern",
    "section": "Chest imaging",
    "age": "74",
    "gender": "male",
    "diagnosis": "Pulmonary miliary metastases, primary follicular carcinoma of the thyroid",
    "history": "An elderly man presenting with non-specific symptoms and signs was found to have a miliary chest pattern on his plain chest radiograph. His general condition continued to deteriorate despite empirical treatment for presumed miliary tuberculosis. Further cross-sectional imaging revealed lesions in his thyroid gland and in his brain.",
    "image_finding": "An elderly man presented with a three month history of chest pain, anorexia and malaise. No findings were evident on physical examination, but the chest radiograph showed multiple nodular opacities 1-3 mm in diameter interspersed throughout both lungs (Fig. 1b). The patient had already presented with the same complaints two months prior to this episode and the chest radiography (Fig. 1a) was reported to be within normal limits. In retrospect, some of these nodules were already evident on the first chest radiograph. The findings were confirmed on a high resolution scan of the lungs (Fig. 2a-c). The non-calcified nodular opacities appeared to be randomly distributed, with no segmental predilection.A provisional diagnosis of miliary tuberculosis was made, and the patient was admitted in the infectious disease unit. His general condition continued to deteriorate despite empirical anti-tuberculous treatment. The possibility of disseminated malignancy from an unknown primary and of disseminated mycoses was raised, and the patient was referred for further cross sectional imaging.A thyroid ultrasound (Fig. 3) revealed an abnormal and irregular echotexture. Multiple vascularised lesions of heterogeneous echogenicity were seen in both thyroid lobes.A slightly hyperdense lesion was seen posterolateral to the fourth ventricle on unenhanced CT brain. This lesion showed homogeneous enhancement following administration of intravenous contrast. Two similar supratentorial lesions were also seen on the contrast enhanced CT. Note was also made of a longstanding right sided occipital infarct (Fig. 4a-c).",
    "discussion": "The patient was scheduled for a thyroid gland biopsy in view of the possibility of disseminated thyroid malignancy. He passed away before a tissue diagnosis could be obtained. The autopsy report revealed a metastatic follicular carcinoma of the thyroid.  Numerous nodules of varying sizes were seen through the pulmonary parenchyma.The word \u2018miliary\u2019 refers to the small-seeded millet group of cereal crops. A miliary pattern [1] in conventional chest radiography refers to the presence of innumerable 1-3 mm nodular opacities scattered randomly, and often symmetrically, throughout the lung parenchyma. This \u2018random\u2019 distribution refers to the random location of nodules in relation to the structures of the secondary pulmonary nodule, and is therefore mostly appreciated on HRCT. Nodules may be located near the centre of the lobule or near the interlobular septa. They may be also seen in relation to the pleural surfaces or to the pulmonary arterial branches. This randomness is usually attributed to a vascular route of spread of infectious or neoplastic disease and to lymphatic distribution in occupational lung disease and sarcoidosis. The differential diagnosis is usually limited to the following conditions:1. Infectious granulomatous disease: miliary tuberculosis [2]2. Disseminated fungal infections: histoplasmosis, blastomycosis, coccidioidomycosis [3], cryptococcosis 3. Non infectious granulomatous disease: sarcoidosis4. Acquired occupational lung diseases (pneumoconiosis), especially silicosis, coal worker\u2019s pneumoconiosis, berylliosis5. Bronchoalveolar carcinoma, a subtype of pulmonary adenocarcinoma.6. Metastatic lesions following haematogenous spread of certain tumoursThyroid carcinoma is the primary tumour most commonly associated with this pattern of pulmonary involvement [4, 5], followed by renal cell carcinoma. Other primary tumours which may show this pattern of metastases include pancreatic carcinoma, breast carcinoma, some sarcomas and melanoma.At HRCT, lymph node enlargement and both interlobular and peribronchovascular thickening are more commonly observed in miliary metastases than in miliary tuberculosis [6]. Lymphangitic carcinomatosis, is easily distinguished from random metastatic nodules by the presence of characteristically thickened interlobular septae, preferentially involving the lung bases, and usually associated with asymmetric hilar adenopathy and pleural effusions [7].",
    "differential_diagnosis": "Pulmonary, miliary, metastases,, primary, follicular, carcinoma, of, the, thyroid",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008255/000001.jpg?itok=hYJxi7JN",
            "caption": "The chest radiograph taken two months prior to admission was reported as normal. In retrospect, a small number of nodules can be seen in both lungs especially in the mid and lower zones."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008255/000002.jpg?itok=z_O5GxgM",
            "caption": "A significant interval change can be seen two months on. Innumerable nodular opacities measuring 1-3 mm in diameter can be seen in both lungs. The nodules do not appear to be calcified, and are of a soft tissue density. No other significant abnormality is seen."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008255/000003.jpg?itok=wgXh0D6J",
            "caption": "The findings were confirmed on a high resolution scan of the lungs. The non-calcified nodular opacities measure 1-4 mm in diameter, and are randomly distributed, with no segmental predilection."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008255/000004.jpg?itok=x1jhfVLm",
            "caption": "Axial and sagittal views through the thyroid (right lobe).\n\nThe thyroid gland proved to be of an abnormal and irregular echotexture on ultrasound. Multiple lesions of heterogenous echogenicity were seen in both thyroid lobes, and were more prominent on the right. Vascularity of these lesions was confirmed on colour Doppler."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008255/000005.jpg?itok=tCXKYgRK",
            "caption": "A single slightly hyperdense lesion measuring 4.2 cm in diameter, not surrounded by oedema, was seen posterolateral to the fourth ventricle on unenhanced CT brain. This lesion showed homogenous enhancement following administration of intravenous contrast."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008255/000006.jpg?itok=7BqGkRBx",
            "caption": "Two similar, albeit smaller, supratentorial lesions were also seen on the contrast enhanced CT. Note was also made of a longstanding right sided occipital infarct."
          },
          {
            "number": "Figure 4c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008255/000007.jpg?itok=CFScJuQu",
            "caption": "Two similar, albeit smaller, supratentorial lesions were also seen on the contrast enhanced CT. Note was also made of a longstanding right sided occipital infarct."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/8255",
    "time": "16.06.2010"
  },
  "8257": {
    "case_id": 8257,
    "title": "Swine-Origin Influenza A (H1N1) Viral Pneumoni",
    "section": "Chest imaging",
    "age": "26",
    "gender": "male",
    "diagnosis": "Swine-Origin Influenza A (H1N1) Viral Pneumonia",
    "history": "A 26-year-old male patient with acute myeloid leukemia and bone marrow transplant one year ago, presented with low-grade fever, dry cough and dyspnea for several days. He stated recent contact with several family members who had influenza-like illnesses.",
    "image_finding": "Figure 1: Frontal and lateral chest radiographs showing perihilar ground-glass opacities and consolidation. Peripheral faint ground glass opacities are also questioned.Figures 2: A few selected trans-axial CT images of the chest in lung window showing consolidative and ground-glass opacities in a peribronchovascular and subpleural distribution. A few scattered thickened interlobular septa are thought to be due a background of volume overload.Figure.3: A few selected trans-axial CT images of the chest in soft tissue window show the absence of lymphadenopathy. Small bilateral pleural effusions are seen secondary to volume overload.The patient had negative cultures for bacterial organisms and a real-time reverse-transcriptase-polymerase chain reaction (rRT-PCR) confirming the presence of swine-origin influenza A (H1N1) virus in a processed nasal swab. The patient improved with Tamiflu and supportive treatment.",
    "discussion": "Swine-origin influenza A (H1N1) virus (S-OIV) is a highly contagious respiratory infection which has been a recent worldwide concern. The disease presents with an influenza-like picture. There is no specific age or sex predilection. Most cases are self limited. However, a subset of high-risk patients may have a severe course. High-risk patients include: children less than 5 years old, adults aged 65 years or older, pregnant females, asthmatics, diabetics, immunosuppressed patients, or patients with other underlying chronic conditions.The laboratory findings may include:  lymphopenia, Thrombocytopenia, and elevated serum lactate dehydrogenase and serum creatine kinase levels. Respiratory samples can be processed by several means to evaluate for S-OIV; however, rRT-PCR is the gold standard method. It is important to note that most circulating influenza nowadays is of the S-OIV type.Most cases do not require specific treatment. However, the latest recommendation is to start anti-retroviral medications (Tamiflu or Relenza) empirically in severe and high-risk cases. In most regions of the world, the disease has shown decreasing activity after initiating an extensive global vaccination campaign.The chest radiographs may be normal. The typical findings are those of airspace disease. Ground-glass opacities are usually the earliest finding. As the disease progresses, consolidation superimposes the picture. The disease can be unifocal or multifocal, unilateral or bilateral and confined or diffuse. Any lung zone cane be involved, but basal disease is noted to be the most common. On CT, more extensive involvement is usually encountered. Again, airspace disease predominates, being more ground-glass than consolidative in nature. A peculiar commonly seen distribution is that of subpleural and peribronchovascular predominance. This appearance has been linked to that of organising pneumonia. The overall appearance can be complicated by superadded bacterial pneumonia, adult respiratory distress syndrome (ARDS), air leaking and pulmonary embolism. Pleural effusions and lymphadenopathy are usually absent. Another notable observation is the lack of septal thickening, bronchial wall thickening, centrilobular nodularity, tree-in-bud arrangement or mosaic attenuation. The pattern of small airway inflammation or interstitial thickening - which is usually expected in the cases of viral pneumonia - was not observed in most S-OIV cases. Tow recent studies reported an exception to this observation. The first is a study that dealt with children having mild forms of the disease, where bronchial wall thickening and hyperinflation were noted. However, severe cases in this study showed airspace involvement. The second study dealt with immunocompromised adults and showed predominance of centrilobular nodularity and bronchial wall thickening, a pattern supporting small airway inflammation. The reason for this different appearance in these two groups is theorised to be due to the lack of sensitisation in the former and inability to induce an immune response in the latter. Another potential explanation is that both groups are likely to seek medical attention earlier in the course of the disease, which may lead to earlier imaging investigations. Thus, it is possible that the imaging features described in those two groups are merely the earlier manifestations of the disease.",
    "differential_diagnosis": "Swine-Origin, Influenza, A, (H1N1), Viral, Pneumonia",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008257/000001.jpg?itok=BSowFEgE",
            "caption": "Perihilar ground-glass opacities and consolidation are noted. Peripheral faint ground glass opacities are also suspected."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008257/000002.jpg?itok=4QSm4XCP",
            "caption": "Perihilar airspace opacities are re-demonstrated."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008257/000003.jpg?itok=--61WUln",
            "caption": "Consolidative and ground-glass opacities are noted in a peribronchovascular and subpleural predominance. A few scattered thickened interlobular septa are thought to be due a background of volume overload."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008257/000004.jpg?itok=Ra9l61qH",
            "caption": "Consolidative and ground-glass opacities are noted in a peribronchovascular and subpleural predominance. A few scattered thickened interlobular septa are thought to be due a background of volume overload."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008257/000005.jpg?itok=GW-BCzVo",
            "caption": "Consolidative and ground-glass opacities are noted in a peribronchovascular and subpleural predominance. A few scattered thickened interlobular septa are thought to be due a background of volume overload."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008257/000006.jpg?itok=YWJnJZHf",
            "caption": "Consolidative and ground-glass opacities are noted in a peribronchovascular and subpleural predominance. A few scattered thickened interlobular septa are thought to be due a background of volume overload."
          },
          {
            "number": "Figure 2e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008257/000007.jpg?itok=SPgRM_ob",
            "caption": "Consolidative and ground-glass opacities are noted in a peribronchovascular and subpleural predominance. A few scattered thickened interlobular septa are thought to be due a background of volume overload."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008257/000008.jpg?itok=82df58t9",
            "caption": "These windows show the absence of lymphadenopathy. The volume overload-related small bilateral pleural effusions are also noted."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008257/000009.jpg?itok=gHaqZEMw",
            "caption": "These windows show the absence of lymphadenopathy. The volume overload-related small bilateral pleural effusions are also noted."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008257/000010.jpg?itok=iKhHRVFq",
            "caption": "These windows show the absence of lymphadenopathy. The volume overload-related small bilateral pleural effusions are also noted."
          },
          {
            "number": "Figure 3d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008257/000011.jpg?itok=A661jaHt",
            "caption": "These windows show the absence of lymphadenopathy. The volume overload-related small bilateral pleural effusions are also noted."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/8257",
    "time": "01.03.2010"
  },
  "8265": {
    "case_id": 8265,
    "title": "Pulmonary Langerhans\\&#039; cells histiocytosis: classic findings!",
    "section": "Chest imaging",
    "age": "54",
    "gender": "male",
    "diagnosis": "Pulmonary Langerhans' cells histiocytosis",
    "history": "A 54-year-old male patient presented with dry cough and dyspnoea on exertion. Chest radiograph revealed a reticulonodular pattern. HRCT showed a combination of nodules and cysts.",
    "image_finding": "A 54-years old male patient with no notable medical history presents with dry cough and dyspnoea on exertion. Physical examination was unremarkable. A standard chest radiograph revealed an extensive reticulonodular pattern, as well as small left pleural effusion. In order to better characterise those findings, HRCT was performed. It showed a combination of multiple small pulmonary nodules, some with cavitation, and thin-walled infracentimetric cysts, distributed bilaterally and diffusely throughout the lung, but more conspicuous in the upper and medium lung fields.",
    "discussion": "Langerhans cells histiocytosis (LCH) encompasses a spectrum of disorders of unknown aetiology. In adults, pulmonary involvement occurs mostly as a single-system pathology; if not, pulmonary involvement in patients with systemic manifestations is rarely at the forefront of the clinical scenario[1]. Pulmonary LCH, also know as pulmonary eosinophilic granuloma or histiocytosis X, is uncommon and occurs almost exclusively in smokers (95-90%). There is an incidence peak at 20-40 years of age and no sex predilection. Symptoms and physical examination can be unremarkable. Prognosis in patients with LCH of the lung is good compared with multisystem disease (only 25% will follow a progressive downhill course) [2].Imaging features reflect histopathologic changes: earlier stages are characterised by granulomatous nodules (containing Langerhans cells); in later stages, these granulomatous nodules are replaced by fibrosis and lung cysts [2, 3]. Standard chest radiograph is performed as a routine investigation and a reticular, nodular or reticulonodular (the most common) patterns can be found. These features are better characterised by HRCT, which is now mandatory when lung LCH is suspected. HCRT initially may show only small poorly limited nodules, predominately centrilobular, often cavitating later (cheerios pattern). As the disease evolves, cystic airspaces (first thick-walled, then thin-walled) become a predominant finding: most are <10mm of size, usually have bizarre shapes and can be confluent. Nodules and cavitated nodules can resolve whereas cysts usually remain or enlarge over time. These findings are symmetrical and bilateral, predominating in the upper and middle fields. Costophrenic angles and medial tip of lingula and middle lobe can be spared. Lung volumes are normal or increased. Other features may include ground-glass attenuation and emphysematous bullae (secondary to smoke). Both pleural effusion and hilar/mediastinal adenopathy are unusual (unless caused by other coexisting diseases). Also important is to use bone window to search for bone lytic lesions.Bronchoalveolar lavage is useful for excluding infections and other disorders but is rarely useful in the diagnosis of LCH. The final diagnosis is achieved by surgical lung biopsy at a site selected by HCRT. To date, there is no effective treatment [1-3].There are multiple cystic lung mimickers and diseases. In individuals over 75 years old cysts can be found as a normal variant \u2013 presbyteric lung [4]; the lack of distinct walls and the occasional presence of a central centrilobular artery suggest emphysema. Honeycombing refers to thick-walled, rounded cysts arranged in several layers with loss of lung volume**; thick-walled, clustered cysts with air-fluid levels should be recognised as cystic bronchiectasis. A short differential diagnosis for cyst lung pathology should be kept in mind: lymphangioleiomyomatosis (women of childbearing age; pneumotorax, unilateral pleural effusion or pulmonary venous hypertension; innumerable, round-shaped, thinned-walled and evenly-distributed cysts, not sparing the costophrenic angles); tuberous sclerous (CT lung features identical to lymphangioleiomyomatosis; seizures, mental retardation and adenoma sebaceum; no sex predilection); LIP/collagen-vascular disease, particularly Sj\u00f6gren disease (ground glass opacity; isolated or diffuse cysts admixed with nodules), as well as neurofibromatosis, DIP, subacute hypersensitivity pneumonitis, traumatic lacerations, Birt Hogg Dub\u00e9 syndrome, light chain disease and neoplastic lesions, like pulmonary metastases (squamous/adenocarcinoma).",
    "differential_diagnosis": "Pulmonary, Langerhans', cells, histiocytosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008265/000001.jpg?itok=jgXVkjoQ",
            "caption": "Chest radiograph PA -\nmarked reticulonodular pattern, mimicking honeycombing."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008265/000002.jpg?itok=w73i4mTL",
            "caption": "Small-sized nodules and cysts, diffuse and more evident in the upper and medium lung fields."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008265/000003.jpg?itok=5XdGWrLy",
            "caption": "Small-sized nodules and cysts, diffuse and more evident in the upper and medium lung fields."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008265/000004.jpg?itok=waetKWO2",
            "caption": "Small-sized nodules and cysts, diffuse and more evident in the upper and medium lung fields."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008265/000005.jpg?itok=_0KEdlsa",
            "caption": "A relative sparing of the medial tip of the right middle lobe is suggestive of LCH. Even tough not common, a pleural effusion was seen (due to coexisting left lower lobe pneumonia)."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/8265",
    "time": "09.03.2010"
  },
  "8275": {
    "case_id": 8275,
    "title": "Spontaneous oesophageal perforation",
    "section": "Chest imaging",
    "age": "52",
    "gender": "male",
    "diagnosis": "Spontaneal oesophageal perforation.",
    "history": "A 52-year-old male patient presented with severe back and abdominal pain after vomiting.",
    "image_finding": "A 52-year-old male patient presented to the emergency department with severe back and abdominal pain after vomiting. Laboratory tests revealed elevated leukocytes and an acid pH (7.06). The patient's general condition was good at the time of his arrival at the emergency department but soon afterwards he developed dyspnoea.A chest and abdominal radiography were performed with the patient in the supine position. The chest radiography showed hydropneumothorax, pneumomediastinum and significant displacement of mediastinal structures to the contralateral hemithorax (Fig. 1). The abdominal radiography did not show significant findings. The study was completed with a thoracoabdominal CT with intravenous contrast material, which confirmed the chest radiography findings (Fig. 2). In addition, distal oesophagus thickening surrounded by air was visualised in CT study (Fig. 3). We did not visualise oesophageal perforation (the study was performed without oral contrast administration) but radiological findings and clinical history (abdominal pain after vomiting) suggested this diagnosis.The patient underwent emergency surgery which confirmed distal left oesophagus perforation. The pleural fluid showed purulent appearance with plenty of leftovers. 11 days later the patient developed an oesophageal fistula as a complication and was re-operated. Two months after being hospitalised the patient was discharged.",
    "discussion": "\u201cBoerhaave\u2019s syndrome\u2019\u2019 is the spontaneous oesophageal perforation, originally described by Boerhaave in 1724 . The pathogenesis of Boerhaave perforation is a sudden, rapid increase in intra-abdominal pressure, most commonly caused by severe retching and vomiting. The history often includes drinking of large amounts of alcohol before vomiting. Incomplete cricopharyngeal relaxation during vomiting results in abruptly increased intraluminal pressure, which is sufficient to rupture the oesophagus. The distal left posterior wall is the most common site of spontaneous rupture.Pneumomediastinum and left pleural effusion are the most common radiological findings. Mediastinitis, pneumonia, empyema and lung abscess are among the most common complications. Tissue destruction due to mediastinal inflammation, infection, or both may result in the development of a fistula between the oesophagus and adjacent structures, including the tracheobronchial tree.The optimal treatment of oesophageal perforation depends on a host of considerations. Treatment methods range from nonsurgical management to oesophagectomy or surgical exclusion and diversion; however, with an early diagnosis of uncontained perforation, surgery remains the mainstay of therapy.Most of the mortality associated with oesophageal emergencies has been attributed to delays in the diagnosis and treatment of oesophageal perforation.CT evaluation of the oesophagus requires a high index of suspicion in appropriate clinical settings. An awareness of the CT findings associated with the spectrum of acute oesophageal disease improves the radiologist\u2019s ability in the early diagnosis of oesophageal perforation, reducing delays in diagnosis.",
    "differential_diagnosis": "Spontaneal, oesophageal, perforation.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008275/000001.jpg?itok=aNj5NqH1",
            "caption": "Extensive left hydropneumothorax, pneumomediastinum and significant mediastinum displacement to the right."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008275/000002.jpg?itok=nAHNIdjk",
            "caption": "Coronal CT shows oesophageal displacement to the right due to significant left hydropneumothorax."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008275/000003.jpg?itok=MT72kHYu",
            "caption": "Axial CT shows left hydropneumothorax, pneumomediastinum, right pleural effusion and oesophageal wall thickening."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/8275",
    "time": "11.03.2010"
  },
  "8300": {
    "case_id": 8300,
    "title": "Ball inside a lung cavity? Think of aspergilloma!",
    "section": "Chest imaging",
    "age": "78",
    "gender": "male",
    "diagnosis": "Lung aspergilloma (fungus ball)",
    "history": "A 78-year-old man presented with cough and moderate haemoptysis. Plain chest radiograph and CT examination were performed.",
    "image_finding": "A 78-year-old man presented with cough and moderate haemoptysis. He referred to previous history of lung tuberculosis. Plain chest radiograph and CT examination were performed (Fig. 1, 2), revealing a soft-tissue mass inside a cavity with an air crescent between them, in the upper right lung suggesting mycetoma.  Surgical resection was performed in order to control bleeding. Histology of the surgical specimen was consistent with aspergilloma (fungus ball) (Fig 3).",
    "discussion": "Aspergillosis is a spectrum of diseases caused by Aspergillus, a fungus that when inhaled is capable of causing considerable pulmonary pathogenesis[1-3]. It presents as 4 lung forms: ABPA (allergic bronchopulmonary), aspergilloma, semi-invasive and invasive aspergillosis, all dependent on both the fungus (quantity and virulence) and host\u2019s response[2-3]. Aspergilloma represents an infection without tissue invasion (saprophytic). It\u2019s the most common form of aspergillosis. Patients have a preexisting structural lung condition (cavitary, bullous or cystic disease, or an ectatic bronchus). Tuberculosis and sarcoidosis are the most frequent underlying causes (other: emphysema, bronchogenic cyst, pulmonary sequestration and pneumatoceles). Although patients may remain asymptomatic, they may have cough, weight loss and haemoptysis. Haemoptysis is due to erosion of a bronchial artery and may be life-threatening (\u201csize doesn\u2019t matter\u201d - the size of the mass will not predict the development of life-threatening bleeding). In these patients treatment options (surgical versus selective bronchial artery embolization) should be considered[2-4]. Pathologically, the fungus replicates within an air-filled cavity creating a ball of fungus hyphae, mucus and cellular debris (other organisms that might cause this fungus ball image include Candida, Pseudallescheria, Cocciodes, Nocardia and Actinomyces)[5]. Although CT clearly outlines imaging findings, chest radiographs (PA and decubitus films) are sometimes all that is required to establish the diagnosis. Imaging reveals the presence of a solid mass of soft-tissue attenuation within a lung cavity. Classically, the lesion is separated from the wall of the cavity by a crescent of air (air crescent sign), even though the fungus ball may occasionally completely fill the cavity and no air crescent will exist. Air crescent sign is not pathognomic and can be seen in angioinvasive aspergillosis, hydatic cyst and, rarely, tuberculosis, lung abscess, bronchogenic carcinoma and PPC. The fungus ball may show calcification. It is usually moveable when the patient changes position but lack of movement is not uncommon. Thickening of the cavity wall and adjacent pleura are frequent. In fact, pleural thickening may precede the development of aspergillomal by months to years and be the earliest radiographic sign. Aspergillomas are mostly located in the upper lobes or apical segments of the lower lobes and are usually single (but may be multiple or even bilateral)[2-4]. Other forms of Aspergillus should be kept in mind: semi-invasive (chronic necrotizing) occurs in mildly immunocompromised patients. Imaging findings include lobar or segmental areas of consolidation with or without cavitation or adjacent pleural thickening, as well as multiple nodules. Invasive (disseminated) occurs primarily in deeply immucompromised (and mainly neutropenic) patients. 3 subtypes are recognised: acute tracheobronchitis (5% - normal findings, wall thickening or high-density tracheal plaques), smaller airways (15-30% -bronchopneumonia and bronchiolitis) and angioinvasive aspergillosis (70-85% - haemorrhagic infarcts and nodules \u2013 halo sign, which may later cavitate and originate an air crescent sign). ABPA occurs in patients with long-standing or severe asthma (2%) or with cystic fibrosis (10%). Imaging findings include mucoid impaction and bronchiectasis involving the segmental or subsegmental bronchi of the upper lobes4. Familiarity with imaging findings is key to identifying the correct form of Aspergillosis.",
    "differential_diagnosis": "Lung, aspergilloma, (fungus, ball)",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008300/000001.jpg?itok=oZKz7fNi",
            "caption": "PA radiograph shows a fungus ball within a cavity in the right upper lobe in a 78-year-old man with residual tuberculosis. A mild air crescent sign is seen."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008300/000002.jpg?itok=wYZojqji",
            "caption": "CT examination (lung windows) shows a large fungus ball in the right upper lobe. Note the air crescent sign and the marked pleural thickening surrounding the cavity containing the aspergilloma."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008300/000003.jpg?itok=TnNZSIur",
            "caption": "8 cm-surgical specimen.\nSurgical resection is indicated for patients with severe haemoptysis, and selective bronchial artery embolisation can be performed in patients with poor lung function."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/8300",
    "time": "12.06.2010"
  },
  "8303": {
    "case_id": 8303,
    "title": "Primitive neuroectodermal tumor (PNET) of the ple",
    "section": "Chest imaging",
    "age": "43",
    "gender": "female",
    "diagnosis": "Primitive neuroectodermal tumor (PNET) of the chest wall.",
    "history": "A 43-year-old woman presented with left side chest pain, slowly progressing shortness of breath, decrease of appetite and weight loss.",
    "image_finding": "A 43-year-old woman with a known history of hypertension and diabetes presented with left side chest pain , slowly progressing shortness of breath, decrease of appetite and weight loss . On physical examination the patient showed mild respiratory distress. Left side absent breath sound, stony dull on percussion and increase tactile focal fremitus. Chest X-ray showed complete opacification of the lift hemithorax with mild displacement of the trachea to the right side (Fig. 1). CT examination of the chest was performed and showed large left pleural effusion with complete collapse of the left lung.  Pleural-based multiple variable-sized enhancing lesions in left hemithorax. The masses arised from the pleura without invasion of the chest wall or rib destruction (Fig. 2).The radiological differential diagnosis was :Pleural metastases.Pleural lymphomaSarcomatoid mesothelioma.Infection such as TB.Spindle cell tumors. The diagnosis was based on tissue analysis based on the positivity of certain markers in this case like V9 , CD99 and CD56 and negativity of others like desmin ( D33) and synaptophysin ( SY 38).Therefore on pathology and after immunochemistry the best possible diagnosis was Pleural PNET (Fig. 3).",
    "discussion": "In 1979, Askin et al. described a rare, malignant small-cell tumour (Askin tumour) that arises in the soft tissues of the chest wall, occasionally in bone, or rarely, in the periphery of the lung. This neoplasm is now recognized as a type of primitive neuroectodermal tumour (PNET). Askin tumours are seen predominantly in children and young adults and probably develop from embryonal migrating cells of the neural crest [1].Peripheral PNET arises outside the central and sympathetic nervous systems and differs from central PNET in that peripheral PNET typically expresses high amounts of the MIC2 antigen (CD99) and exhibits highly characteristic chromosomal translocation.Peripheral PNET is uncommon, and the overall incidence is 1% of all sarcomas. This tumour can occur at any age, although the peak age incidence is adolescence and young adulthood. The incidence in men is slightly higher than in women (ratio of 1.1 : 1). In general, PNET is a very aggressive neoplasm and it has a poor prognosis, with a 5-year disease-free survival rate of 45\u201355%. The most common locations of peripheral PNETs have been the thoracopulmonary region, the retroperitoneal paravertebral soft tissues, the soft tissues of the head and neck, and the intraabdominal and intrapelvic soft tissues and extremities [3].Traditionally, distinctions were made between classic Ewing sarcoma and PNET, it is now accepted that both are a spectrum of a single neoplastic entity .Lesions of PNET are typically painful, invasive thoracic tumours that may develop on and invade the chest wall, lung, or mediastinum. They are generally soft and fleshy, with areas of haemorrhage and necrosis [2].The diagnosis of PNET, which was earlier considered difficult, is now greatly facilitated by the availability of antibodies such as HBA-71 MIC2 (12E7) antigen and O13 that recognise the cell surface antigen defined by the clusters of CD99. Although not specific for PNET or Ewing sarcoma, CD99 is almost always present in these tumours. [2]",
    "differential_diagnosis": "Primitive, neuroectodermal, tumor, (PNET), of, the, chest, wall.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008303/000001.jpg?itok=DQATevXL",
            "caption": "Complete opacification of the left hemithorax with mild displacement of the trachea to the right side."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008303/000002.jpg?itok=21wK_LXH",
            "caption": "Large left pleural effusion with complete collapse of the left lung. Pleural-based multiple variable-sized enhancing lesions in left hemithorax."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008303/000003.jpg?itok=MjcF2Lel",
            "caption": "Large left pleural effusion with complete collapse of the left lung. Pleural-based multiple variable-sized enhancing lesions in left hemithorax."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008303/000004.jpg?itok=EkI02RXm",
            "caption": "Large left pleural effusion with complete collapse of the left lung. Pleural-based multiple variable-sized enhancing lesions in left hemithorax."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008303/000005.jpg?itok=NnQ4Hs3t",
            "caption": "Large left pleural effusion with complete collapse of the left lung. Pleural-based multiple variable-sized enhancing lesions in left hemithorax."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008303/000006.jpg?itok=skfaA865",
            "caption": "Malignant small round cell tumour. Neoplastic cells are positive for vimentin (V9) and CD99 (12E7)."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008303/000007.jpg?itok=DE9TsQgW",
            "caption": "(CD99)\nmalignant small round cell tumou. Neoplastic cells are positive for vimentin (V9) and CD99 (12E7)."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008303/000008.jpg?itok=RvJV8P1o",
            "caption": "(V9)\nmalignant small round cell tumour. Neoplastic cells are positive for vimentin (V9) and CD99 (12E7)."
          },
          {
            "number": "Figure 3d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008303/000009.jpg?itok=1ADw28ww",
            "caption": "(PAS)\nmalignant small round cell tumour. Neoplastic cells are positive for vimentin (V9) and CD99 (12E7)."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/8303",
    "time": "24.03.2010"
  },
  "8320": {
    "case_id": 8320,
    "title": "Organising pneumonia after radiation therapy for breast cance",
    "section": "Chest imaging",
    "age": "56",
    "gender": "female",
    "diagnosis": "Cryptogenic organising pneumonia",
    "history": "A 56-year-old female patient that underwent breast-conserving surgery and radiation therapy for breast cancer six months ago presented at our hospital with dry cough, mild dysponea and recent onset of fever.",
    "image_finding": "A 56-year-old female underwent breast-conserving surgery and radiation therapy because of an infiltrating ductal carcinoma (G2) of the left breast. Six months after completion of radiation therapy, the patient developed dry cough, mild dyspnoea and fever. A chest roentgenogram showed the presence of an airspace consolidation in the left lower lobe. Antibiotics were given for 10 days, without clinical improvement. Laboratory tests revealed elevated erythrocyte sedimentation (42mm) and serum C reactive protein (4,57 mg/dL) but normal blood cell count.  Broncho-alveolar lavage (BAL) cell count showed 53% macrophages, 22% lymphochytes, 11% neutrophils and 14% eosinophils. Investigation of infectious agents in blood, urine, and BAL fluid were negative. CT revealed an airspace consolidation with air bronchogram and ground glass attenuation in the left lower lobe (Fig. 1). Lung biopsy was not performed. Because clinical and imaging findings were suggestive of cryptogenic organising pneumonia (COP), prednisone (40 mg/day) was started with resolution of clinical symptoms. Two months later, while tapering oral steroid doses, a follow-up CT was made and showed complete resolution of the previous opacities but appearance of new pulmonary opacities (Fig. 2). Steroid oral dose was raised (60 mg/day) and one month later the thoracic CT showed no opacities or sequelae. After steroid withdrawal there was recurrence of symptoms and CT revealed a solitary consolidation in the right upper lobe (Fig. 3).",
    "discussion": "Classic radiation pneumonitis is characterised by alveolar areas of increased opacity confined to the treatment port. Radiological abnormalities are seldom seen beyond the portal margin, although bilateral alveolar lymphocytosis is seen in bronchoalveolar lavage specimens after strictly unilateral breast irradiation [1, 2]. These findings suggest that radiation therapy gives rise to a lymphocyte-mediated hypersensivity reaction. Organising pneumonia \u201cprimed\u201d by radiation therapy to the breast (tangential field radiotherapy) was first described in 1995 by Crestani et al. [3] and Bayle et al. [4], independently. Crestani et al. [5] in 1998 suggested the following criteria to diagnose COP in this context: (1) radiation therapy to the breast within 12 months, (2) general and/or respiratory symptoms lasting for at least 2 weeks, (3) lung infiltrates outside the radiation port, and (4) no specific cause. Organising pneumonia had an incidence of 2,4% and 2,5% in two different series of women that underwent radiotherapy after breast-conservative surgery [6, 7]. As in COP, the patients present with fever, nonproductive cough and mild dyspnoea. In BAL, a \"mixed pattern\" is present at differential cell count with a significant increase in the percentage of lymphocytes, neutrophils, eosinophils and mast cells [5, 8]. The most common appereance at chest radiography and CT is patchy, bilateral, multifocal areas of consolidation or ground-glass infiltration, frequently in subpleural or peribronchial locations. Often initially unilateral and located in the irradiated lung, these are migratory in many patients. The atypical imaging findings include irregular linear opacities, solitary focal lesions that resemble lung cancer, or multiple nodules that may cavitate. Corticosteroid treatment results in rapid clinical improvement with clearing of the pulmonary opacities on imaging without significant sequelae, in contrast with radiation pneumonitis resulting in retractile consolidation with traction bronchiectasis. However, as in COP, relapses are frequent upon reducing (to daily doses of 5\u201310 mg prednisone) or stopping corticosteroids, with opacities in the same or other locations.  Chronic eosinophilic pneumonia has similar clinical and radiologic manifestations and its occurrence was also described after radiation therapy for breast cancer [10]. The differential diagnosis between these two entities is based on the presence of marked peripheral blood and alveolar eosinophilia and history of asthma or atopic manifestations in chronic eosinophilic pneumonia. Histopathologic analysis can diagnose both entities but sometimes there is overlap between them [10].",
    "differential_diagnosis": "Cryptogenic, organising, pneumonia",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008320/000001.jpg?itok=fCFkjKuk",
            "caption": "High-resolution CT showed an airspace consolidation with air bronchogram associated with ground glass attenuation in the left lower lobe."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008320/000003.jpg?itok=kgv4SpOD",
            "caption": "After steroid withdrawal, high-resolution CT revealed an airspace consolidation associated with ground glass attenuation in the right upper lobe."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008320/000004.jpg?itok=cpvrwXFI",
            "caption": "After tapering oral steroid doses, high-resolution CT showed an  airspace consolidation with  mild cylindrical bronchial dilatation in the right lower lobe and complete resolution of the left lower lobe consolidation (a); and irregular linear opacities in the anterior segment of the right upper lobe (b)."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/8320",
    "time": "27.06.2010"
  },
  "8379": {
    "case_id": 8379,
    "title": "Churg-Strauss syndrome",
    "section": "Chest imaging",
    "age": "55",
    "gender": "female",
    "diagnosis": "Churg-Strauss Syndrome",
    "history": "A 55-year-old woman with a 20 year history of asthma, rhinitis and chronic sinusitis.",
    "image_finding": "A 55-year-old female patient was admitted to the medical department for cough, fever (37-38\u00b0C), recurrent episodes of rhinitis and sinusitis, bronchial asthma and dyspnoea.Antibiotics were administrated with no results. Complete blood count (CBC) showed eosinophilia (30%), increased IgE levels (820 UI/ml) and ANCA positivity. A chest radiograph showed a right hilar parenchymal consolidation (fig. 1). A HRCT scan (High Resolution Computed Tomography) showed subsegmental subpleural areas of consolidation and ground-glass opacity associated with centrilobular micronodules mainly in the right lung (Fig. 2).Because of the persistence of symptoms, after one month another chest radiograph was performed showing multiple and bilateral areas of consolidation mainly in the upper and lower lobe of the right lung, without signs of hilar consolidation (Fig. 3). A second HRCT was done and confirmed the above mentioned findings (Fig. 4). The patient underwent a CT of the paranasal sinuses  that revealed mucosal thickening of the right frontal sinus, ethmoid sinuses and left sphenoid sinus (Fig. 5).Migratory pulmonary consolidation, bronchial asthma, alteration of para-nasal sinuses, positivity to antibody p-ANCA and eosinophilia led to the diagnosis of Churg-Strauss syndrome.",
    "discussion": "Churg-Strauss Syndrome (CSS) is a systemic vasculitis characterised by the presence of asthma and hypereosinophilia. It is generally considered a disease of adults. The incidence of CSS is estimated at 2.4 per million per year.The classic histopathological findings are vasculitis, necrotising extra-vascular granulomas and eosinophilic infiltration, even if these three features rarely coexist in the same biopsy specimen. Clinical extra-pulmonary manifestations include weight loss, myalgia, arthralgia, skin lesions (nodules, purpura, or urticaria), neurological, renal, gastrointestinal and cardiac involvement. The diagnosis of CSS by the American College of Rheumatology (ACR), requires 4 or more of the following clinical criteria: 1) the presence of asthma; 2) peripheral eosinophilia (>10%); 3) mononeuropathy or polyneuropathy; 4) temporary or migratory pulmonary infiltration; 5) para-nasal sinus abnormality; and 6) a biopsy specimen containing a blood vessel with extra-vascular eosinophils. The presence of 4 of the 6 criteria is thought to have a diagnostic sensitivity of 85% and specificity of 99.7%.[1-2]The clinical evolution of CSS is divided into three stages: the prodromal phase, that involves allergic rhinitis and asthma and can be protracted for many years; the second phase includes peripheral eosinophilia and eosinophilic tissue infiltration; in the final phase, the hallmark is a systemic vasculitis, which can be fatal. The predominant causes of death include heart, renal and cerebral failure, and gastrointestinal perforation or haemorrhage. Cardiovascular disease occurs in approximately half of the patients with CSS.CSS is considered to be one of the antineutrophil cytoplasmic antibody (ANCA)-associated systemic vasculities (AASVs). The pathogenesis is not well understood: neutrophils, when activated by ANCA, release oxygen radicals, lytic enzymes and inflammatory cytokines and adhere to endothelial cells and this causes apoptosis and necrosis.Therapy consists of corticosteroids only or together with cyclophosphamide, or plasma exchanges. The long-term prognosis of CSS is good, although most patients need low doses of oral or inhaled corticosteroids for persistent asthma.[3]In chest radiograph, the Churg-Strauss syndrome usually appears as bilateral nonsegmental consolidation or reticulonodular opacities. The most common CT findings include sub-pleural ground-glass opacity or consolidation with a lobular distribution, bronchial wall thickening, and interlobular septal thickening.",
    "differential_diagnosis": "Churg-Strauss, Syndrome",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008379/000001.jpg?itok=16WgQ5i4",
            "caption": "There is right perihilar  consolidation and focal opacities mainly seen in the upper  zone of the right lung."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008379/000002.jpg?itok=2yvoyiqm",
            "caption": "Sequential HRCT images from lung apices to the level of the lower lobes. Subpleural subsegmental  consolidations and thickening of interlobular septae is seen in both lungs."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008379/000003.jpg?itok=V25wy0pF",
            "caption": "Bilateral small subpleural consolidations are seen. Note subsegmental area of ground glass opacity in the anterior segment of the right upper lobe. Thickening of interlobular septae and centrilobular micronules in both lungs are also demonstrated."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008379/000004.jpg?itok=PdoCU3Q9",
            "caption": "Subsegmental areas of ground glass opacity, bronchial wall thickening and centrilobular micronodules are noted."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008379/000005.jpg?itok=GxFHL92G",
            "caption": "Subpleural subsegmental areas of consolidation and ground-glass pattern are seen. Thickening of the interlobular septae and presence of centrilobular micronodules are also noted."
          },
          {
            "number": "Figure 2e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008379/000006.jpg?itok=FL9de-rh",
            "caption": "Nodular area of  consolidation and accompanying ground glass opacity is seen at the superior segment of the right lung."
          },
          {
            "number": "Figure 2f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008379/000007.jpg?itok=z3Q04m_I",
            "caption": "Patchy areas of subsegmental ground-glass attenuation are seen at the middle lobe and the superior segment of the right lower lobe associated with bronchial wall thickening and presence of centrilobular micronodules."
          },
          {
            "number": "Figure 2g",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008379/000008.jpg?itok=-rreS4i5",
            "caption": "Thickening of interlobular septae and peribronchovascular interstitium. Centrilobular micronodules are also noted."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008379/000009.jpg?itok=KzrZxCt5",
            "caption": "New bilateral focal opacities are seen at the bases of both lungs. The right perihilar consolidation has resolved. Notice the remarkable reticulonodular pattern in the base of right lung."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008379/000010.jpg?itok=FlyHXMxq",
            "caption": "Sequential HRCT images from the level of the lung apices to the level of the lower lobes. Bilateral subpleural focal consolidations and thickening of interlobular septae are seen, more prominent in the right lung."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008379/000011.jpg?itok=cK5WOXDG",
            "caption": "New subpleural focal consolidations are noted in the superior segment of the right lower lobe and in the apicoposterior segment of the left upper lobe. CT demonstrates thickening of  bronchial walls and centrilobular micronodules."
          },
          {
            "number": "Figure 4c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008379/000012.jpg?itok=ga8jtq_L",
            "caption": "New focal consolidation with air-bronchogram and ill-defined nodules in the middle lobe are noted. \nThe comparison of this CT with the previous one verifies the migratory character of the consolidations."
          },
          {
            "number": "Figure 4d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008379/000013.jpg?itok=g32SdYQ_",
            "caption": "Peripheral subsegmental nodular consolidations and GGO in both lower lobes are demonstrated. Centrilobular micronodules and thickening of bronchial walls in both lungs bases are seen."
          },
          {
            "number": "Figure 4e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008379/000014.jpg?itok=kHWY6nnT",
            "caption": "Bilateral subpleural areas of GGOand centrilobular micronodules are seen. CT demonstrates thickening of peribronchovascular interstitium and interlobular septae, which are remarkable at the bases."
          },
          {
            "number": "Figure 4f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008379/000015.png?itok=SpMF5HvH",
            "caption": "A focal  subpleural consolidation in the the right lower lobe is seen. Patchy areas of GGO are seen in both lower lobes, middle lobe and lingula. Centrilobular nodules and bronchial thickening are present."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008379/000016.jpg?itok=1WMhBEEN",
            "caption": "CT documented a bilateral chronic sinusitis of etmoidals cells."
          },
          {
            "number": "Figure 5b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008379/000017.jpg?itok=orIMlckD",
            "caption": "CT documented a chronic sinusitis of the right frontal sinus."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/8379",
    "time": "07.11.2010"
  },
  "8391": {
    "case_id": 8391,
    "title": "A case report of thoracic outlet syndrome (TOS)",
    "section": "Chest imaging",
    "age": "67",
    "gender": "female",
    "diagnosis": "Thoracic outlet syndrome (TOS)",
    "history": "A 67-year-old woman with left hemithorax paresthaesia with irradiation to her left arm.",
    "image_finding": "A 67-year-old woman presented at our medical department with left hemithorax paresthaesia with irradiation to her left arm. She had no history of trauma.She was admitted to the clinical department with rheumatologic disorder.A Chest RX was performed for evaluation of pulmonary involvement that has suggested the presence of an accessory left rib (Fig. 1).Computed Tomography was performed to characterize the parenchymal findings, demonstrating an anomalous origin of the first left rib, which began from the fusion of C7 and T1 (Fig.2).The combination of radiological and clinical findings suggested thoracic outlet syndrome (TOS).",
    "discussion": "The term thoracic outlet syndrome (TOS) indicates compression of one or several of the neurovascular structures crossing the thoracic outlet. Thoracic outlet is bounded by the first thoracic vertebra, the superior border of the manubrium sterni anteriorly, and the first rib and costal cartilage laterally. The structures passing through this area and into the upper limb are the subclavian artery and vein, and the nervous structures of the brachial plexus. The most common age range for this syndrome is 20\u201340 years, with a female-to-male ratio of 4:1. Potential causes of TOS are a cervical rib, abnormal ligamentous tissue and hypertrophy of the scalenus anterior muscle, as well as postural effects that interfere with the normal relationship between the first rib and those structures overlying it.Five syndromes involving the thoracic outlet are described:1. Arterial, due to a well formed cervical rib or to an abnormal first rib.2. Neurological, related to the fibrous band associated with a rudimentary cervical rib or a giant transverse process of C7.3. Venous\u2014\u2018effort thrombosis\u2019. 4. Late post-traumatic, secondary to a fracture of the clavicle.5. The syndrome previously called \u2018scalenus anticus syndrome\u2019, being due to either trauma, or hypotonic shoulder muscles.TOS can present with symptoms and signs of any of these. 90% of the patients present with neurological symptoms \u2014 pain, paraesthaesia, arm and hand weakness \u2014 and 10% also have vascular problems. The most frequent vascular presentation is Raynaud\u2019s phenomenon, or less clearly defined symptoms of coldness, cyanosis and swelling of the hands, possibly resulting from irritation of sympathetic fibres in the subclavian bundle. Diagnosis of TOS is clinically based. Imaging may be helpful in informing the clinician as to the anatomic structures undergoing compression, the location of that compression, and the anatomic structures responsible for it. Radiographs may demonstrate predisposing bone abnormalities (elongated C7 transverse process, cervical rib). In the case of neurogenic or neurovascular symptoms, MR imaging has proved useful, especially in demonstrating brachial plexus compression and the existence of fibrous bands. CT with contrast medium and postural maneuvers appears effective in demonstrating vascular compression by means of volume-rendered images, which allow analysis of the relations with bony structures. Colour duplex sonographic examination and B-mode scanning is a valuable supplementary imaging when the results of the latter prove negative.A conservative approach is the rule in the initial treatment of neurogenic TOS. Therapeutic efforts are focused on relaxing the scalene muscles and strengthening the postural muscles through physical therapy, hydrotherapy and massage. Pain medication, nonsteroidal anti-inflammatory agents, and muscle relaxants are often useful adjuncts in treatment. The initial treatment of arterial TOS is focused on revascularization in order to remedy acute ischemia if necessary. Treatment of effort thrombosis generally involves contrast venography and catheter-directed thrombolytic therapy. First rib resection via a supraclavicular approach represents the predominant surgical treatment strategy, but some teams have recently adopted a highly selective approach in which supraclavicular scalenectomy is the principal surgical strategy and first-rib resection is reserved solely for vascular forms of TOS.",
    "differential_diagnosis": "Thoracic, outlet, syndrome, (TOS)",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008391/000003.jpg?itok=6lE9k3QT",
            "caption": "3D reconstructions show the anomalous origin of the first rib, which begins from the fusion of C7-T1."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008391/000004.jpg?itok=ML3qxEVx",
            "caption": "3D reconstructions show the anomalous origin of the first rib, which begins from the fusion of C7-T1."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008391/000005.jpg?itok=s2NnMOZw",
            "caption": "3D reconstructions show the anomalous origin of the first rib, which begins from the fusion of C7-T1."
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008391/000006.jpg?itok=_0LSpVek",
            "caption": "3D reconstructions show the anomalous origin of the first rib, which begins from the fusion of C7-T1."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008391/000007.jpg?itok=FbxbduL8",
            "caption": "Chest RX suggested the presence of an accessory left rib."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/8391",
    "time": "08.06.2010"
  },
  "8392": {
    "case_id": 8392,
    "title": "Rib chondrosarcoma with neural foramina invasion",
    "section": "Chest imaging",
    "age": "32",
    "gender": "male",
    "diagnosis": "Rib chondrosarcoma",
    "history": "A 32-year-old man presented at the orthopaedics department because of a lump in his left back that progressively enlarged over a period of 5 months. His past medical history was unremarkable. Physical examination revealed a painless, immobile, soft tissue mass in the posterior thoracic wall at the T3-T4 spinal level.",
    "image_finding": "Initial posteroanterior chest radiograph revealed the presence of a left sided soft tissue mass located at the level of the aortic arch (Fig. 1). The lesion\u2019s margins and the absence of a positive \u201csilhouette\u201d sign with the mediastinal structures indicated an extrapulmonary and posterior position, a finding which was verified in the lateral chest radiograph (Fig. 2). A CT examination was subsequently performed upon request, which showed a predominantly soft tissue tumour with internal areas of mineralisation (Fig. 3). The mineralised elements where amorphous, scattered, ring-like and arcuate shaped. Rib destruction and infiltration was also noted. Furthermore, widening of the adjacent neural foramina was depicted and an MRI examination was done to clarify this finding. MRI verified neural foramina invasion as well as significant spinal cord compression and contralateral displacement. Despite that fact, the patient remained completely asymptomatic, which was attributed to an indolent and slow growth of the tumour. The mass showed low signal intensity in T1-w images and heterogeneous but predominantly high signal intensity in T2-w images (Fig 4, 5). An associated superficial component of the tumour, which corresponded to the palpable finding, was also better demonstrated on MRI (Fig. 4, 5). Mineralised areas that were depicted in the CT examination demonstrated low signal intensity in all pulse sequences. Gadolinium enhanced T1-w fat saturated images showed intense, heterogeneous tumour enhancement (Fig. 6). Correlation of all the imaging findings with the clinical presentation suggested the diagnosis of a low grade rib chondrosarcoma, which was verified post a CT guided biopsy (Fig. 7, 8).",
    "discussion": "Cartilaginous tumours of the thoracic cage include enchondromas, osteochondromas, chondroblastomas, and chondrosarcomas. Rib lesions outnumber sternal ones but a sternal location is more frequently associated with malignancy. Rib chondrosarcoma is usually a relatively low-grade lesion with a long-term survival rate. It can be either primary or secondary due to malignant transformation of a preexisting rib osteochondroma. Hereditary multiple exostoses syndromes are more frequently associated with malignant transformation of osteochondromas. In our case, survey of the appendicular and peripheral skeleton revealed no findings of a hereditary exostosis syndrome. Nonetheless, no previous X-ray studies were available to exclude a possible malignant transformation of a preexisting benign rib exostosis. MDCT with its inherent superior spatial resolution is the imaging modality of choice to demonstrate the characteristic \u201crings and arcs\u201d shaped cartilaginous matrix of the tumour. Although the CT examination was initially indicative of the final diagnosis, foraminal invasion needed further clarification in order to guide appropriate surgical planning. The calcified chondroid matrix was detected as areas of low signal intensity in all MRI pulse sequences. The non-mineralised portion of the tumour that had low attenuation on CT examination, showed low to intermediate signal intensity on T1-w MR images, and very high and heterogeneous signal intensity on T2-w images due to the high water content of hyaline cartilage. In addition, MRI showed in detail the superficial palpable portion of the tumour with very high signal intensity on T2-w images possibly due to tumour necrosis and associated liquefaction. The patient is scheduled for combined orthopaedic-thoracic surgery. Treatment of rib chondrosarcoma is en block surgical resection. Complete surgical removal is considered to be therapeutic but recurrence is reported to be high if inadequate excision is performed. Radiation therapy and chemotherapy may be used with high-grade and dedifferentiated chondrosarcomas with controversial and disappointing results. In conclusion, although thoracic cage malignancies are low in incidence compared to lung and mediastinal tumours, the thoracic radiologist should be familiar with them in order to substantially narrow the list of differential diagnostic possibilities and contribute to the appropriate patient management.",
    "differential_diagnosis": "Rib, chondrosarcoma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008392/000001.jpg?itok=l9viYmAd",
            "caption": "The posteroanterior chest radiograph shows a well defined radiopaque lesion (arrow)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008392/000002.jpg?itok=qhYi9GJh",
            "caption": "The lateral chest radiograph shows posterior location of the lesion (arrow)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008392/000003.jpg?itok=7YPFCnoa",
            "caption": "The axial MDCT image demonstrates a soft tissue mass (arrow) with amorphous \u201crings and arcs\u201d calcified matrix (thin arrow) and adjacent neural foramina widening (asterisk)."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008392/000004.jpg?itok=dwdVG_h6",
            "caption": "The sagittal T1-w (a) MR image shows a hypointense lobulated lesion (arrow). The mass demonstrates heterogeneous but predominantly high signal intensity in the sagittal  T2-w (b) MR image(arrow). Note the superficial palpable component of the tumour (asterisks)."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008392/000005.jpg?itok=IH5pN3oB",
            "caption": "The axial T2-w (a) and the axial fat saturated PD-w (b) MR images show a heterogeneous high intensity mass (thick arrows) with mineralized elements that demonstrate low signal intensity (thin arrow). Note the superficial (open arrows) as well as the neural foraminal extension (asterisks) of the tumour."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008392/000006.jpg?itok=ikoPe3UG",
            "caption": "The sagittal (a) and axial (b) contrast enhanced fat saturated T1-w MR images show intense heterogeneous enhancement of both the intrathoracic (arrows) and the superficial (open arrows) tumour components. Enhancement is also observed in the intra-foraminal component of the tumor (asterisk)."
          }
        ]
      },
      {
        "number": "Figure 7",
        "subfigures": [
          {
            "number": "Figure 7",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008392/000007.jpg?itok=axXwsxE5",
            "caption": "CT guided biopsy of the lesion with a 18G true-cut needle."
          }
        ]
      },
      {
        "number": "Figure 8",
        "subfigures": [
          {
            "number": "Figure 8a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008392/000008.jpg?itok=6zV2pPF_",
            "caption": "Microscopic view of the biopsy, showing cartilaginous tissue in a lobular pattern with low cellularity, minimal atypia with occasional presence of two chondrocytes in a single lacuna and no mitosis (H&amp;E, X200).\nThe features are compatible with a grade 1 chondrosarcoma BUT the d.d. from other benign conditions e.g. enchondroma is very difficult or impossible based only on histology. Correlation with imaging findings is mandatory."
          },
          {
            "number": "Figure 8b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008392/000009.jpg?itok=Ynq5H_lf",
            "caption": "Microscopic view of the biopsy, showing cartilaginous tissue in a lobular pattern with low cellularity, minimal atypia with occasional presence of two chondrocytes in a single lacuna and no mitosis (H&amp;E, X200).\nThe features are compatible with a grade 1 chondrosarcoma BUT the d.d. from other benign conditions e.g. enchondroma is very difficult or impossible based only on histology. Correlation with imaging findings is mandatory."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/8392",
    "time": "08.05.2010"
  },
  "8447": {
    "case_id": 8447,
    "title": "Oesophageal rupture: a rare complication of blunt traum",
    "section": "Chest imaging",
    "age": "12",
    "gender": "male",
    "diagnosis": "Esophageal rupture after a fall from height",
    "history": "A 12-year-old boy fell from the third floor of his school building.",
    "image_finding": "A 12-year-old boy was brought to the hospital following a fall from the third floor of his school building. Although he did not sustain any life threatening injuries, he was having mild respiratory distress. He also complained of severe pain in the chest and upper abdomen. No significant osseous injury was documented. His chest radiograph however revealed a pneumothorax on the left side, for which an intercostal drainage tube was inserted (Fig. 1). The tube continued to drain a significant amount of fluid even on the third day following his injury with worsening of the clinical symptoms. This raised the suspicion of a hollow visucus injury. A contrast oesophagography with dilute water soluble non-ionic contrast media confirmed an oesophageal perforation (Fig. 2). CT was performed subsequently which demonstrated bilateral pleuro-oesophgeal fistulae with extension of the orally administered contrast into the pleural spaces bilaterally (Fig. 3, 4). Associated bilateral pulmonary consolidation and left sided hydropneumothorax was present (Fig. 5). The patient was initially managed conservatively with intercostal tube drainage and broad spectrum antibiotics. As the patient continued to deteriorate, surgical repair of the esophgeal tear was performed. Inspite of a second revision surgery, the patient died of disseminated intravascular coagulation (DIC) secondary to overwhelming sepsis.",
    "discussion": "Oesophageal perforation secondary to blunt trauma to the chest is extremely rare, with limited case reports available in the medical literature (1-4). The most common segment to get involved is the cervical oesophagus. Thoracic oesophagus involvement is quite rare, and most of these injuries are encountered in adults following high speed road traffic accidents (2,3). In paediatric population these injuries are highly uncommon accounting for < 1% of all the oesophageal injuries. The more common causes of oesophageal injury in paediatric patients include penetrating or iatrogenic trauma. The mechanism of thoracic oesophageal rupture in blunt trauma remains unclear. The most commonly accepted theory, similar to the mechanism in Boerhaave syndrome, is a sudden elevation of intraluminal oesophageal pressure (1-3). It is proposed that air under pressure forces the crico-pharyngeal sphincter to give way, leading to rapid dilatation of the oesophagus, and with a closed gastro-oesophageal sphincter this high pressure results in oesophageal rupture. Raised intraluminal pressure and resultant oesophageal rupture can also be sequential to expulsion of gas from the stomach into the oesophagus through the gastro-oesophageal junction, against a closed glottis. It is the distal third thoracic oesophagus on the left side i.e. the weakest portion, which gets perforated most commonly. Other proposed mechanisms include compression of oesophagus between the sternum and vertebrae, or disruption of the oesophageal vasculature resulting in ischemic insult and late oesophageal perforation (2,3). These patients can present with non specific complaints and often a high degree of clinical suspicion is required for clinching the correct diagnosis (4). Clinical symptoms may range from chest pain, dysphagia, odynophagia, respiratory distress, pyrexia to extensive subcutaneous emphysema. Plain radiograph of chest may be non-contributory or at times may reveal vital findings such as pneumothorax, pleural effusion, hydro-pneumothorax, pneumomediastinum or subcutaneous emphysema (4). In co-operative and clinically stable patients the primary imaging evaluation includes oesophagography using water-soluble contrast medium (3). Since barium swallow has a greater sensitivity for the detection of small perforations, it may be used in patients where there is no leak demonstrable with water soluble contrast. CT is the procedure of choice to assess the sequelae of oesophageal rupture. It is especially useful in sick patients where contrast oesophagography is not feasible. CT can also be used to exclude associated thoracic, pulmonary and osseous injuries. CT findings of oesophageal injury include oesophageal wall thickening, perioesophageal haematoma or gas, contrast material extravasation, loculated fluid collections in the mediastinum, and mediastinal inflammation (3,5). Ancillary findings such as pneumo or hydro-pneumothorax, pneumomediastinum, pleural effusion and pulmonary consolidation may be present. There are no well defined guidelines for the management of these patients. Therapeutic management needs to be individualised depending upon the cause and site of rupture, associated injuries and overall condition of the patient (2,3). Treatment can be either conservative or surgical (1-4). Surgical options include primary oesophageal repair within 48 hours, oesophageal resection, exclusion, and chest drainage with or without oesophageal repair (1-3). In general, most cervical oesophageal perforations unlike intrathoracic perforations can be treated conservatively (2).",
    "differential_diagnosis": "Esophageal, rupture, after, a, fall, from, height",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008447/000001.jpg?itok=z1qb1QPf",
            "caption": "Chest radiograph shows hydro-pneumothorax on the left side. Intercostal drainage tube is seen insitu. No overt bony injuries are evident."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008447/000002.jpg?itok=Ey0bmrh-",
            "caption": "Contrast oesophagography demonstrates bilateral contrast extravasation suggestive of oesophageal rupture."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008447/000003.jpg?itok=mppjGQcw",
            "caption": "Left side hydropneumothorax and basal consolidation are well visualised on this lung window setting."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008447/000004.jpg?itok=I3jqYExP",
            "caption": "Axial CT thorax demonstrates peri-oesophageal air which is extending into the bilateral pleural spaces."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008447/000005.jpg?itok=66Bszlbx",
            "caption": "Axial CT thorax demonstrates peri-oesophageal air which is extending into the bilateral pleural spaces. Note is made of bilateral pleural effusion."
          },
          {
            "number": "Figure 4c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008447/000008.jpg?itok=iInU9f7_",
            "caption": "Lung window settings confirm peri-oesophageal air extension into bilateral pleural spaces."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008447/000006.jpg?itok=ojA8-rTT",
            "caption": "Orally administered diluted water soluble contrast delineates bilateral oesophago-pleural fistulae."
          },
          {
            "number": "Figure 5b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008447/000007.jpg?itok=afloOGx5",
            "caption": "Orally administered diluted water soluble contrast delineates bilateral oesophago-pleural fistula with pooling of contrast in the bilateral pleural spaces."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/8447",
    "time": "30.06.2010"
  },
  "8458": {
    "case_id": 8458,
    "title": "Disseminated cryptococcal infection in immunocompetent patient",
    "section": "Chest imaging",
    "age": "31",
    "gender": "female",
    "diagnosis": "Cryptococcal infection in immunocompetent patient with lung and hepatosplenic involvement",
    "history": "A 31 year old female patient presented to our hospital with low grade fever for one month and pain in the RUQ. The diagnostic workup included chest and abdominal CT along with CT guided biopsy and head MRI.",
    "image_finding": "A 31-year-old woman presented with afternoon low grade fever (up to 38 oC) for the past month and RUQ abdominal pain deteriorating with respiratory movements. The patient reports no other symptoms from her respiratory or gastrointestinal system. Apart from being a smoker, there are no other significant facts from her medical history. She also denies use of illicit intravenous or other drugs. From the laboratory tests there is a normal WBC count and mild elevation of liver enzymes, gGT and ESR. The patient underwent a contrast-enhanced chest and abdominal CT as part of the diagnostic work-up. Multiple nodules with random distribution were revealed in both lungs (Fig 1a,1b,1c), many of which exhibited cavitation (Fig. 1b,1c). No abnormally enlarged mediastinal lymph nodes were found. The abdominal CT showed multiple hypodense lesions in liver and spleen (Fig. 2) with a mild peripheral enhancement also with absence of abnormally enlarged lymph nodes. Some lesions located in close proximity with the fibrous capsule of Glisson were considered responsible for the pain. A CT guided biopsy was performed and the samples obtained from the hepatic lesions revealed Cryptococcus species microabscesses. A head MRI was also performed to rule out CNS infection and was indeed normal. All subsequent tests that were performed to assess the integrity of patient's immune system were proved normal. After the diagnosis of cryptococcosis was established, the patient remembered having cleaned many times pigeon's faeces from her balcony that were assumed to be a source of high cryptococci load.",
    "discussion": "Opportunistic fungal infections - especially in the thorax - are usually caused by the species Aspergillus, Candida, Cryptococcus and Zygomycetes. All the mentioned species are usually the cause of thoracic disease in immunocompromised patients. Fungal infection in immunocompetent patients is uncommon, but when that happens, Aspergillus and Cryptococcus are the more common causes. Dissemination of the infection in other organs outside the thorax (like liver, spleen or the CNS) is rare and happens usually in immunocompromised patients, a progression that is considered serious.Cryptococcus is a yeast that is found worldwide in soil that is contaminated with pigeons excreta or decayed wood. The infection occurs by inhaling cryptococcal particles in the lungs, which explains why thoracic disease is the usual form of the infection [1]. The radiologic findings of cryptococcal infection from the thorax include mycetoma (solitary lung mass that is sometimes mistaken for a primary lung malignancy), multiple nodules or consolidation [3]. Especially in the immunocompromised patients other findings include cavitation, lymph nodes enlargement and pleural effusion [2,3]. Involvement of the liver and spleen is uncommon for cryptococcus. In our case the lesions from the liver and spleen exhibited the radiologic characteristics of pyogenic abscesses: hypodense center with peripheral contrast enhancement. One common place of infection in the disseminated form of cryptococcosis is also the CNS. It is more common in immunocompromised patients [2] and it appears as brain abscesses (enhancing masses throughout the brain parenchyma) or meningitis. In our case the CNS infection was ruled out with an MRI scan.The diagnosis of fungal infection was first implied by the thoracic findings (Fig. 1b,1c). The finding of multiple sharply marginated nodules some of which were cavitated, narrowed the differential diagnosis to: Langerhans cell Histiocytosis, septic emboli, fungal infection and cavitating metastases. Unfortunately the establishment of diagnosis of fungal infection by sputum test or blood samples (e.g. cryptococcal antigen or anticryptococcal titers) is not always possible. Tissue sampling obtained from imaging-guided biopsy -as in our case - is the most accurate way to establish the diagnosis.",
    "differential_diagnosis": "Cryptococcal, infection, in, immunocompetent, patient, with, lung, and, hepatosplenic, involvement",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008458/000001.png?itok=GM48Ea1s",
            "caption": "Contrast enhanced MDCT of the thorax reveals nodules at both apices"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008458/000002.png?itok=7Ofalohr",
            "caption": "Contrast enhanced MDCT of the thorax shows nodules that have been cavitated in the right upper lobe."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008458/000003.png?itok=QJ5Z0Le7",
            "caption": "Contrast enhanced MDCT of the thorax shows cavitated nodule in the right middle lobe."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008458/000004.png?itok=mI00wU05",
            "caption": "Contrast enhanced MDCT of the abdomen reveals multiple hypodense lesions in the liver with mild peripheral contrast enhancement consistent with abscesses"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008458/000005.png?itok=2CMxdTNz",
            "caption": "Contrast enhanced CT of the abdomen reveals multiple hypodense lession in both the liver and spleen."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008458/000006.png?itok=VV-8LhK7",
            "caption": "Contrast enhanced CT of the abdomen reveals multiple hypodense lession in both the liver and spleen."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/8458",
    "time": "02.08.2010"
  },
  "8481": {
    "case_id": 8481,
    "title": "Non-specific interstitial pneumonia associated with Sjogren\u2019s syndrome",
    "section": "Chest imaging",
    "age": "50",
    "gender": "female",
    "diagnosis": "Non-specific interstitial pneumonia associated with Sjogren\u2019s syndrome.",
    "history": "A 50-year-old female patient with Sjogren\u2019s syndrome and long-standing mild shortness of breath.",
    "image_finding": "Multiple selected high-resolution CT images of the chest seen in lung windows show bilateral peripheral ground-glass opacities with superimposed reticulations and very mild traction bronchiectasis. The abnormalities have a bibasilar predominance. Note relative immediate subpleural sparing (arrows in Figs. 6 and 7). In the context of a connective tissue disorder, the constellation of findings is consistent with fibrotic non-specific interstitial pneumonia (NSIP).",
    "discussion": "NSIP is a type of idiopathic interstitial pneumonia (IIP) that is pathologically characterised by chronic interstitial inflammation with variable degrees of fibrosis. NSIP is highly associated with connective tissue disorders including scleroderma, polymyositis and dermatomyositis, mixed connective tissue disease, and Sjogren\u2019s syndrome. It is also commonly idiopathic in nature. Other common causes include drug reaction and hypersensitivity pneumonitis. NSIP can be categorised into two histological types: cellular and fibrotic. On CT, ground-glass opacities are present in both types. Traction bronchiectasis and reticular abnormalities indicate fibrotic changes and are not present in cellular NSIP; however, ground-glass opacity in the absence of these features does not preclude the diagnosis of fibrotic NSIP. The fibrotic pattern is more common in Sjogren\u2019s-associated NSIP.Although only present in a portion of NSIP cases, immediate relative subpleural sparing is a useful sign that helps differentiating fibrotic NSIP from usual interstitial pneumonitis, which is another form of IIP that can be encountered in cases of connective tissue disorders.The value in diagnosing cellular versus fibrotic NSIP lies in the differences in their prognoses. Cellular NSIP holds a more favourable prognosis with a near 100% survival rate, whereas fibrotic NSIP has a 45-90% five-year survival rate and a 35% ten-year survival rate. Other lung findings seen in Sjogren's disease include lymphocytic interstitial pneumonia (LIP), bronchiectasis, usual interstitial pneumonia (UIP) and organizing pneumonia (OP). LIP is characterized by thin-walled cysts, ground-glass opacities in a classic peripheral and bibasal predominance, centrilobular nodules and peribronchovascular consolidation. UIP presents with bibasal peripheral fibrotic features and variable degrees of honeycombing, where ground-glass attenuation is absent or non-predominant. OP can be variable in appearance, but can present with peribronchovascular and subpleural airspace disease, centrilobular nodules, perilobular opacities or reverse halo appearance. In the context of Sjogren's disease, it is important to note that nodules larger than 1 cm, large consolidation or pleural effusions raise the possibility of complicating lymphoma.Patients with Sjogren\u2019s syndrome and NSIP receive long-term clinical follow up, including regular pulmonary function tests and high-resolution CT. If the patient experiences functional decline and symptoms, steroids are started for at least six months with continued pulmonary function tests and high-resolution CT follow up at 2 and 6 months.",
    "differential_diagnosis": "Non-specific, interstitial, pneumonia, associated, with, Sjogren\u2019s, syndrome.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008481/000001.jpg?itok=otqtAPtc",
            "caption": "Bilateral peripheral ground-glass opacities with superimposed reticulations and very mild traction bronchiectasis. The abnormalities have a bibasilar predominance. Note relative immediate subpleural sparing (arrows in Figures 6 and 7)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008481/000002.jpg?itok=PBqJLnYN",
            "caption": "Bilateral peripheral ground-glass opacities with superimposed reticulations and very mild traction bronchiectasis. The abnormalities have a bibasilar predominance. Note relative immediate subpleural sparing (arrows in Figures 6 and 7)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008481/000003.jpg?itok=P7wkw0V8",
            "caption": "Bilateral peripheral ground-glass opacities with superimposed reticulations and very mild traction bronchiectasis. The abnormalities have a bibasilar predominance. Note relative immediate subpleural sparing (arrows in Figures 6 and 7)."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008481/000004.jpg?itok=ObXLk38m",
            "caption": "Bilateral peripheral ground-glass opacities with superimposed reticulations and very mild traction bronchiectasis. The abnormalities have a bibasilar predominance. Note relative immediate subpleural sparing (arrows in Figures 6 and 7)."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008481/000005.jpg?itok=DscBQMHj",
            "caption": "Bilateral peripheral ground-glass opacities with superimposed reticulations and very mild traction bronchiectasis. The abnormalities have a bibasilar predominance. Note relative immediate subpleural sparing (arrows in Figures 6 and 7)."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008481/000006.jpg?itok=R7slGrp7",
            "caption": "Bilateral peripheral ground-glass opacities with superimposed reticulations and very mild traction bronchiectasis. The abnormalities have a bibasilar predominance. Note relative immediate subpleural sparing (arrows in Figures 6 and 7)."
          }
        ]
      },
      {
        "number": "Figure 7",
        "subfigures": [
          {
            "number": "Figure 7",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008481/000007.jpg?itok=OCJ9-ZPY",
            "caption": "Bilateral peripheral ground-glass opacities with superimposed reticulations and very mild traction bronchiectasis. The abnormalities have a bibasilar predominance. Note relative immediate subpleural sparing (arrows in Figures 6 and 7)."
          }
        ]
      },
      {
        "number": "Figure 8",
        "subfigures": [
          {
            "number": "Figure 8",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008481/000008.jpg?itok=HQgPujPZ",
            "caption": "Bilateral peripheral ground-glass opacities with superimposed reticulations and very mild traction bronchiectasis. The abnormalities have a bibasilar predominance. Note relative immediate subpleural sparing (arrows in Figures 6 and 7)."
          }
        ]
      },
      {
        "number": "Figure 9",
        "subfigures": [
          {
            "number": "Figure 9",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008481/000009.jpg?itok=ZQo2NhSe",
            "caption": "Bilateral peripheral ground-glass opacities with superimposed reticulations and very mild traction bronchiectasis. The abnormalities have a bibasilar predominance. Note relative immediate subpleural sparing (arrows in Figures 6 and 7)."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/8481",
    "time": "17.06.2010"
  },
  "8486": {
    "case_id": 8486,
    "title": "Traumatic pneumatocele following a blunt thoracic injury",
    "section": "Chest imaging",
    "age": "24",
    "gender": "male",
    "diagnosis": "Traumatic lung pseudocysts due to blunt thoracic injury.",
    "history": "A 24-year-old motorcyclist presented with dyspnoea and left sided chest pain following a road traffic collision. Computer tomography (CT) scan revealed several traumatic lung cysts, and laceration of the spleen and left kidney, all treated conservatively.",
    "image_finding": "A 24-year-old man was admitted to the hospital following a road traffic accident motorcycle versus van. On admission, he was complaining of left sided chest and abdominal pain, mild dyspnoea and haemoptysis. Clinical examination including primary and secondary trauma surveys was normal and revealed only a graze over the left iliac crest and bruising over the left side of the chest. Patient was haemodynamically stable with no hypoxaemia. Initial blood tests were unremarkable. A plain chest radiograph showed a small left sided pleural effusion and a thin-walled cystic cavity above the left hemidiaphragm, at the level of left heart border. There was no evidence of pneumothorax (Fig. 1). An urgent chest and abdominal CT scan was performed, which demonstrated several cystic cavities in the lower lobe of left lung (one with fluid level within it), surrounded by an area of pulmonary contusion (Fig. 2). No acute bony injury was identified adjacent to the area of pneumatoceles. In addition, a splenic and a small left renal laceration were identified. Patient was admitted for observation and managed conservatively with analgesia and oral antibiotics (Amoxicillin). He made a good recovery and was discharged home five days post injury. A follow up chest radiograph one week after the injury demonstrated a reduction in size (from 4.2cm to 3.2cm) and thickening of the wall of the left basal pulmonary cyst.",
    "discussion": "Traumatic pneumatocele is a rare, but well described presentation of the blunt thoracic injury [1-3]. It is defined as a thin walled, air filed cavity of the lung, which does not have epithelial lining or bronchial wall elements, and is therefore often referred to as a pseudocyst. The lesion is either the direct result of trauma itself (primary pseudocyst), or develops after resolution of pulmonary haematoma (secondary pseudocyst) [1].The majority of traumatic pulmonary pseudocysts occur in children and young adults, mostly due to the flexibility and compliance of their thoracic wall [4-5]. A great external compressing force of trauma is transferred from the chest wall to lung parenchyma, followed by fast decompression and increase in negative intra-thoracic pressure. The rapid compression and decompression lacerates alveoli and interstitium, and subsequent retraction of surrounding lung tissue produces air and /or fluid filled cavities [4, 6]. CT scan is a very sensitive method for early detection of the pseudocysts [1, 7]. Chest X-rays alone demonstrate only about 50% of the lesions, but they are adequate for follow up [3]. On the chest radiograph, lesions may present as air-fluid spaces, with surrounding areas of consolidation due to pulmonary contusion. Computer tomography is more precise in defining the location and size of the cysts, which may appear as spherical, rounded or oval, solitary or multiple lesions. Unlike other cystic or cavitary lesions, the size and shape of the traumatic pseudocysts change relatively quickly, so series of imaging is helpful for monitoring and differentiation from other pathology [2]. Differential diagnoses include bronchogenic cyst, post-infectious pneumatocele, lung abscess, cavitating bronchial carcinoma, and visceral hernia [1-2]. These can be remembered by using a mnemonic 'CAVITY': Carcinoma, Autoimmune, Vascular, Infectious, Trauma, Young (congenital) [8]. Further on, a mnemonic 'I BAN WHIPS' may be helpful in differentiating cyst-like pulmonary lesions, including Infection, Bronchogenic cyst (Bronchiectasis, Bowel), Abscess, Neoplasm, Wegener granulomatosis, Hydatic cyst (Histiocytosis X), Infarction, Pneumatocele, Sequestration [8]. The most common clinical manifestations of the traumatic pneumatocele are cough, haemoptysis, chest pain and dyspnoea, which are not usually associated with significant hypoxaemia [1-5]. The clinical course is mostly benign, with majority of the cases resolving spontaneously within a few weeks. Treatment is typically limited to symptomatic relief, and surgical intervention is rarely required, unless complications such as haemothorax, pneumothorax, and expansion or infection of the cavitary lesion occur [2-3].",
    "differential_diagnosis": "Traumatic, lung, pseudocysts, due, to, blunt, thoracic, injury.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008486/000001.jpg?itok=FyZG3CGj",
            "caption": "An AP supine chest X-ray showing a bulla / cyst at the base of left lung above the left hemi-diaphragm and a small left-sided pleural effusion."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008486/000002.jpg?itok=dmDyylRw",
            "caption": "Axial images of a chest CT scan demonstrating multiple cystic lesions at the base of left lower lung lobe above the left hemi-diaphragm. Lesions are surrounded by areas of pulmonary contusion, and one of them contains an air-fluid level."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008486/000003.jpg?itok=q27Xjs93",
            "caption": ""
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008486/000004.jpg?itok=cr4pnNLe",
            "caption": ""
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008486/000005.jpg?itok=W8m2OmzG",
            "caption": "An PA follow up chest X-ray one week after the injury showing some reduction in size and thickening of the wall of the left basal pulmonary pseudocyst."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/8486",
    "time": "09.08.2010"
  },
  "8546": {
    "case_id": 8546,
    "title": "An aberrant right tracheal bronchus as  incidental finding",
    "section": "Chest imaging",
    "age": "22",
    "gender": "male",
    "diagnosis": "Tracheal bronchus",
    "history": "A 22-year-old man underwent chest CT due to recent trauma.",
    "image_finding": "A 22-year-old man presented at the emergency department after sustaining a motor vehicle accident (MVA). CT examination was deemed necessary due to the high-energy mechanism of the MVA. The standard axial images of 7.5 mm thickness revealed the presence of a right tracheal bronchus (Fig. 1 a-c). The case was subsequently reviewed in detail on a workstation, with thin slices in order to better delineate the relevant anatomy. Coronal reconstruction with the MinIP algorithm better depicted the bifurcation of the tracheal bronchus distally (Fig. 2), as well as the anatomy of the rest of the bronchial tree on the right. The two branches taking-off from the bifurcation of the tracheal bronchus supplied the apical and the anterior segment of the upper lobe. This was consistent with the presence of an aberrant right tracheal bronchus. The anatomical views were finally complemented with the help of virtual bronchoscopy, which confirmed the aforementioned findings (Figure 3 a-c).",
    "discussion": "Tracheal bronchus (TB) is a bronchus usually originating from the lateral wall of the trachea, mostly on the right. The TB usually arises less than 2 cm above the carina, but can be found at any location between the carina and the cricoid cartilage. Bilateral TB are extremely rare.The TB has an incidence of 0.1-3% and was first described by Sandifort in 1785. It is mainly an accidental finding during bronchoscopy or chest CT. TB affects mainly the right upper lobe (RUL). Two types have been described: TB is called displaced (ectopic or aberrant) when it totally supplies one of the segments of the RUL, usually the apical (apical TB) and is called supernumerary when the TB is associated with normal trifurcation of the RUL bronchus. The first variant is not rare in people with azygos lobe and the bronchus for the RUL shows bifurcation for the two other segments.  In the second variant, the supernumerary bronchus may sometimes end in a blind pouch (trachea diverticulum) or may supply a cyst. Among these, the parenchyma supplied from the TB can be extralobar, meaning autonomous blood supply.Rarely, the TB can feed the whole RUL and is called \u201ctrue TB or \u201cbronchus sui\u201d. In that case, the right main bronchus (RMB) is replaced from bronchus intermedius, supplying the rest of the lung, while the blood supply and pleural investment of the affected segment remain normal.The pathogenesis of TB is yet unknown. Two theories seem to be more accurate. According to the first theory dring gestation, the development of the tracheobronchial tree reaches the 17 branches within the 24th week. If some existing bronchial buds fail to regress, TB is a strong possibility. The second theory suggests that parts of mesenchyma are transplanted in the trachea leading to TB. This latter theory could also explain the co-existence of other abnormalities accompanying TB. Most of them are related to the development of the upper thorax such as rib and vertebral anomalies, tracheostenosis, abnormal pulmonary lobulation, cystic lung disease and anomalous blood supply. Patients with Down\u2019s syndrome have increased incidence of TB. Other associated congenital malformations include duodenal, laryngeal webs, oesophageal atresia, pectus excavatum, VACTERL complex (V:vertebral defects, A:anal atresia, C:cardiac abnormalities, TE: tracheoesophageal fistula and/or oesophageal atresia, L:limb defects) and Klippel \u2013 Feil syndrome.The clinical importance of TB is challenging. In children the TB is associated with recurrent infections of the RUL due to retained secretions, respiratory distress, stridor, suspected foreign body aspiration, lobar atelectasis and bronchiectasis. The early discovery of TB due to respiratory manifestations is usually associated with other congenital abnormalities. In adults recurrent upper lobe pneumonia is possible. Some cases of haemoptysis and pulmonary haemorrhage have been described, without direct correlation with the TB. TB does not warrant treatment when asymptomatic. In cases of recurrent pneumonias, excision of the supplied lobe/segment can be therapeutic. Finally it should be stressed that it is very important to be aware of the presence of TB before intubation as it may be inadvertently intubated causing respiratory collapse.",
    "differential_diagnosis": "Tracheal, bronchus",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008546/000003.jpg?itok=_AXNnf_b",
            "caption": "Image at the level of lower trachea: Segmental bronchus (blue arrow) fot the apical segment of the right upper lobe arising from a tracheal bronchus."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008546/000011.jpg?itok=Qa4MZd9B",
            "caption": "Image at the level of lower trachea (lower level than 1a): There is a bronchus taking-off diectly from the trachea on the right (yellow arrow). The segmental bronchus for the anterior segment of the right upper lobe also arises from the tracheal bronchus(red arrow)."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008546/000012.jpg?itok=Ir_NYx-S",
            "caption": "Image at the level of lower trachea (lower level than 1b): The lower part of the tracheal bronchus (yellow arrow) is barely visible (partial volume) at the level just above of the carina."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008546/000006.png?itok=ZH6o4dhM",
            "caption": "Image at the level of the carina (white arrow), depicting the right mainstem bronchus (blue arrow) and the tracheal bronchus (yellow arrow), taking-off adjacent to the right mainstem bronchus."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008546/000008.jpg?itok=Z-KA_NmQ",
            "caption": "A close-up view at the level of the origin of the tracheal bronchus."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008546/000009.jpg?itok=kueQ08ti",
            "caption": "Virtual bronchoscopic view at the level of the distal bifurcation of the tracheal bronchus, giving off the segmental bronchi for the apical and the anterior segments of the right upper lobe."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008546/000013.jpg?itok=FgD-uOli",
            "caption": "On the right from top to bottom there is a tracheal bronchus (yellow arrow), bifurcating distally. Note also the bronchus for the posterior segment of the RUL (black arrow) as well as bronchus intermedius (orange arrow)."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/8546",
    "time": "24.08.2010"
  },
  "8549": {
    "case_id": 8549,
    "title": "xtraskeletal Ewing Sarcom",
    "section": "Chest imaging",
    "age": "22",
    "gender": "female",
    "diagnosis": "Primary  extraskeletal Ewing\u2019s sarcoma - primitive neuroectodermal tumor (PNET) .",
    "history": "A previously healthy  22 year old  woman presented with dry cough, left sided pleuritic chest pain and shortness of breath without any other symptoms.",
    "image_finding": "A 22 year old woman without relevant medical history presented with dry cough, left-sided pleuritic chest pain and shortness of breath for several days. No fever was noted. On physical examination there were diminished breath sounds on the left side. Laboratory analysis on admission did not show any abnormal findings. Chest radiograph showed massive left-sided pleural effusion, atelectasis of LLL and a left parahilar-retrocardiac mass. Contrast enhanced CT demonstrated a left extrapulmonary paravertebral heterogeneously enhancing mass (3,8 x 2,7 x 6,9 cm) at the level of the sixth to eighth thoracic vertebrae. CT did not reveal any extension into the spinal canal or vertebral bone changes. A pleural chest tube was inserted and drained the left pleural effusion, with significant improvement in patient's dyspnoea.  After a few days a CT-guided core biopsy of the mass was performed and histologic examination showed small and round blue cells with round nuclei, small nucleoli, and scanty cytoplasms were observed that appeared to be well organized. Immunohistochemical analysis revealed positive staining for CD99, S-100 and vimentin and negative staining for cytokeratins, neurofilament, synaptophysin, and chromogranins. The CD99 was identified by the 013 antibody, which is a useful immunohistochemical marker for Ewing sarcoma (ES). Based on these findings, the mass lesion was diagnosed as extraskeletal Ewing\u2019s sarcoma- primitive neuroectodermal tumor (PNET).The patient received 4 cycles of neoadjuvant chemotherapy and underwent a new MRI examination, before surgical excision. On restaging MRI examination, the mass showed significant decrease in its size consistent with partial response of the disease to chemotherapy.",
    "discussion": "Extraskeletal  Ewing Sarcoma (EES) belongs to the family of malignant small round cell neoplasms involving soft tissue, including primitive neuroectodermal tumours  PNETs, lymphoma, embryonic rhabdomyosarcoma, and neuroblastoma. Primary extraskeletal ES/pPNET family is uncommon and only rarely affects the vertebral area. Although rare, they need to be considered in the differential diagnosis of primary mediastinal tumours [1]. Classically, the most common neoplasms that arise in the posterior mediastinum include neurogenic tumours like schwannoma, neurofibroma, ganglioneuroma, ganglioneuroblastoma, neuroblastoma and paragangliomas [1]. Definitive diagnosis is reached by biopsy and histological evaluation.  Although its histogenesis remains uncertain, evidence suggests a neuroectodermal origin. Translocation of the long arms of chromosomes 11 and 22 has been found. Characteristic histologic features of ES/pPNET includes  a monomorphic population of small round blue cells with cytoplasmic glycogen confirmed by periodic acid-Schiff and immunohistochemically positive for CD99. Small Cell Lung Cancer (SCLC) is histologically similar to ES and it might be difficult to differentiate these two conditions. SCLC is also strongly related to smoking. In our case the tumor had an extrapulmonary location and the patient was young, with no smoking history. For these reasons SCLC was not included in our differential diagnosis and this was confirmed by the immunohistochemical analysis. EES occurs predominantly in adolescents and young adults between the age 10-30 and there is no significant difference in the prevalence of ESS between the sexes. The most common locations of peripheral PNETs have been the thoracopulmonary region, the retroperitoneal paravertebral soft tissues, the soft tissues of the head and neck, and the intraabdominal and intrapelvic soft tissues and extremities [2]. An aggressive treatment protocol is needed. Combinations of therapy including surgery with chemotherapy plus or minus radiotherapy have been employed [3].",
    "differential_diagnosis": "Primary, extraskeletal, Ewing\u2019s, sarcoma, -, primitive, neuroectodermal, tumor, (PNET), .",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008549/000002.jpg?itok=zpZIv5wr",
            "caption": "a. Non enhanced CT scan showing paravertebral mass and pleural effusion. There is no osseous involvement or spinal extension."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008549/000003.jpg?itok=VPL-Jgww",
            "caption": "b. Contrast enhanced CT scan showing heterogeneous enhancement of the mass."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008549/000004.jpg?itok=BKnOtgFa",
            "caption": "c. Contrast enhanced  CT scan showing pleural effusion and LLL atelectasis."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008549/000005.jpg?itok=tppS34D1",
            "caption": "a. T1WI transverse plane showing the decreased size of the tumor."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008549/000006.jpg?itok=RAn3UsEm",
            "caption": "b. T2WI FS transverse plane  showing the tumor and the decreased pleural effusion."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008549/000010.jpg?itok=4tTHGEBF",
            "caption": "Contrast enhanced T1WI FS coronal plane showing the paravertebral tumor with heterogenous enhancement"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008549/000008.jpg?itok=oNSc2N7V",
            "caption": "PA chest radiograph showing massive left sided pleural effusion and parahilar-retrocardial mass."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/8549",
    "time": "14.07.2010"
  },
  "8555": {
    "case_id": 8555,
    "title": "wing\\&#039;s sarcoma presenting as a posterior mediastinal mass",
    "section": "Chest imaging",
    "age": "10",
    "gender": "female",
    "diagnosis": "Ewing's sarcoma.",
    "history": "A 10-year-old girl with no significant past medical history referred to our institution with a two-month history of posterior thoracic chest pain, which was aggravated by coughing and accompanied by anorexia, weight loss and cachexia.",
    "image_finding": "A 10-year-old girl with no significant past medical history was referred to our institution with a two-month history of posterior thoracic pain, which was aggravated by coughing and accompanied by anorexia, weight loss and cachexia. Physical examination and laboratory tests were unremarkable. Upright posteroanterior and lateral chest radiographs showed a large well-marginated rounded mass in the posterior mediastinum (Fig. 1).Chest CT revealed a midline well-defined soft-tissue mass with a diameter of 12 cm, located in the posterior mediastinum, adjacent to the vertebral bodies from T3 to T8, encasing the descending aorta (Fig. 2). The mass was associated with permeative destruction and osteosclerosis of the 6th thoracic vertebral body (Fig. 2 d-e). There was also extension to the spinal canal through the neural foramina at the 6th to 7th thoracic vertebrae (Fig. 2).Axial T1-weighted, T2-weighted and contrast-enhanced T1-weighted MR images confirmed extension to the spinal canal with involvement of epidural space, displacing the spinal cord posteriorly (Fig. 3 a-c). Coronal and sagital T2-weighted MR images depicted cranial and caudal extent of the tumour (Fig. 3 d-e), as well as the extension to the spinal canal though the neural foramina at the 6th to 7th thoracic vertebrae (Fig. 3 e). Cross-sectional imaging investigation for staging was negative for metastatic involvement. The patient underwent biopsy under thoracoscopy and the tumour was diagnosed as a Ewing's sarcoma. The tumour was considered unresectable at initial presentation and chemotherapy was initiated in order to reduce its size and allow potential future complete tumour resection.",
    "discussion": "In childhood most of posterior mediastinal masses are of neurogenic origin [1]. Ewing\u2019s sarcoma family of tumours, which includes Ewing\u2019s sarcoma, primitive neuroectodermal tumour, neuroepithelioma, and Askin tumour are a rare cause of posterior mediastinal mass and may present with intraspinal extension [2, 3, 4]. These tumours are thought to derive from neural crest cells and genetic analysis revealed that they are associated with a balanced reciprocal translocation between chromosomes 11 and 22, that is t (11; 22) (q24, q12) [5, 6]. Ewing\u2019s sarcoma is composed of small round cells typically with cytoplasmic glycogen, a feature used to differentiate it from primitive neuroectodermal tumours [5, 6]. These tumours are the most common primary spine non-lymphoproliferative tumours in children, which account for 3% to 10% of all primary sites [3]. The tumours are usually centred in the vertebral body, although the extent to posterior elements is not uncommon [3].The clinical presentation of these tumours includes fever, malaise, cough, dyspnoea and painful, palpable mass [1, 6].Ewing\u2019s sarcomas have a male predominance of 1.6:1, and usually occur in patients between 3 and 25 years of age (mean, 13 years) [6]. They typically arise from the bony skeleton with the characteristic radiologic manifestation of a mass associated with bone destruction [6]. Rarely, they can manifest as a large mass with only a small component of bone involvement [6]. Occasionally it may have an extraskeletal origin, usually in the paravertebral region and extend through the neural foramina, and bone involvement is typically absent [5]. These tumours usually tend to displace adjacent structures by mass effect than invade them, although large tumours may directly infiltrate the surrounding structures [5].At CT and MR, small lesions are usually homogeneous, whereas large lesions tend to be more heterogeneous, due to haemorrhage or necrosis [5]. On MRI T1-weighted images, these tumours generally show iso or hyperintensity compared with the muscle, as well as heterogeneous hyperintensity on T2-weighted images [5, 7]. After intravenous administration of contrast media, these lesions usually show marked heterogeneous enhancement [5, 7]. Imaging findings of Ewing\u2019s sarcoma are nonspecific [7]. Nevertheless, the imaging modalities are essential in the assessment of the tumour extension and proper treatment planning [7].Complete tumour resection is the best change of cure and large lesions may require pre-operative chemotherapy and radiation therapy to reduce the tumour and allow curative resection [3, 7]. The prognosis depends essentially on the presence of metastases, which occurs in about 75% of patients, with a 5-year survival rate less than 30% in the presence of metastases versus a 5-year survival near 100% in the absence of metastases [6].",
    "differential_diagnosis": "Ewing's, sarcoma.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008555/000007.jpg?itok=ktHSs3Bl",
            "caption": "(a) Posteroanterior and (b) lateral chest radiograph shows a large well-circumscribed mass in the posterior mediastinum (arrows)."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008555/000008.jpg?itok=5N5SizvD",
            "caption": "(a) Posteroanterior and (b) lateral chest radiograph shows a large well-circumscribed mass in the posterior mediastinum (arrows)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008555/000009.jpg?itok=kBFc4nTA",
            "caption": "(a) Axial nonenhanced, (b) axial contrast-enhanced, (c) axial bone window and (d) sagital reformation bone window CT images shows a large heterogeneously enhancing mass (large arrows) in the posterior mediastinum, adjacent to the thoracic vertebral bodies, that compresses the heart and encases the descending aorta (open arrow). There is extension to the spinal canal (small arrows), as well as permeative destruction and osteoclerosis of the 6th thoracic vertebral body (circle)."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008555/000010.jpg?itok=W_5bJ7uv",
            "caption": "(a) Axial nonenhanced, (b) axial contrast-enhanced, (c) axial bone window and (d) sagital reformation bone window CT images shows a large heterogeneously enhancing mass (large arrows) in the posterior mediastinum, adjacent to the thoracic vertebral bodies, that compresses the heart and encases the descending aorta (open arrow). There is extension to the spinal canal (small arrows), as well as permeative destruction and osteoclerosis of the 6th thoracic vertebral body (circle)."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008555/000011.jpg?itok=cGBtDRyI",
            "caption": "(a) Axial nonenhanced, (b) axial contrast-enhanced, (c) axial bone window and (d) sagital reformation bone window CT images shows a large heterogeneously enhancing mass (large arrows) in the posterior mediastinum, adjacent to the thoracic vertebral bodies, that compresses the heart and encases the descending aorta (open arrow). There is extension to the spinal canal (small arrows), as well as permeative destruction and osteoclerosis of the 6th thoracic vertebral body (circle)."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008555/000012.jpg?itok=6M7c3CcD",
            "caption": "(a) Axial nonenhanced, (b) axial contrast-enhanced, (c) axial bone window and (d) sagital reformation bone window CT images shows a large heterogeneously enhancing mass (large arrows) in the posterior mediastinum, adjacent to the thoracic vertebral bodies, that compresses the heart and encases the descending aorta (open arrow). There is extension to the spinal canal (small arrows), as well as permeative destruction and osteoclerosis of the 6th thoracic vertebral body (circle)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008555/000013.jpg?itok=R9VslIQP",
            "caption": "(a) Axial T1-weighted, (b) axial T2-weighted, (c) contrast-enhanced T1-weighted, (d) coronal T2-weighted and (e) sagital T2-weighted MR images show a large mass (large arrow) in the posterior mediastinum, adjacent to the thoracic vertebral bodies, which is isointense to muscle with T1 weighting and hyperintense to muscle with T2 weighting with focal areas of high signal intensity, consistent with necrosis and fluid and has heterogeneous enhancement. Axial images clearly show the encased descending aorta traversing the mass (open arrow). This mass involves the body of the 6th thoracic vertebra (star) and extends to the epidural space (small arrows in a and b) thought the neural foramina at the 6th to 7th thoracic vertebrae without widening it (small arrow in e)."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008555/000014.jpg?itok=WCi6nmYF",
            "caption": "(a) Axial T1-weighted, (b) axial T2-weighted, (c) contrast-enhanced T1-weighted, (d) coronal T2-weighted and (e) sagital T2-weighted MR images show a large mass (large arrow) in the posterior mediastinum, adjacent to the thoracic vertebral bodies, which is isointense to muscle with T1 weighting and hyperintense to muscle with T2 weighting with focal areas of high signal intensity, consistent with necrosis and fluid and has heterogeneous enhancement. Axial images clearly show the encased descending aorta traversing the mass (open arrow). This mass involves the body of the 6th thoracic vertebra (star) and extends to the epidural space (small arrows in a and b) thought the neural foramina at the 6th to 7th thoracic vertebrae without widening it (small arrow in e)."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008555/000015.jpg?itok=Kdm9Yz3o",
            "caption": "(a) Axial T1-weighted, (b) axial T2-weighted, (c) contrast-enhanced T1-weighted, (d) coronal T2-weighted and (e) sagital T2-weighted MR images show a large mass (large arrow) in the posterior mediastinum, adjacent to the thoracic vertebral bodies, which is isointense to muscle with T1 weighting and hyperintense to muscle with T2 weighting with focal areas of high signal intensity, consistent with necrosis and fluid and has heterogeneous enhancement. Axial images clearly show the encased descending aorta traversing the mass (open arrow). This mass involves the body of the 6th thoracic vertebra (star) and extends to the epidural space (small arrows in a and b) thought the neural foramina at the 6th to 7th thoracic vertebrae without widening it (small arrow in e)."
          },
          {
            "number": "Figure 3d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008555/000016.jpg?itok=0QD8yy3K",
            "caption": "(a) Axial T1-weighted, (b) axial T2-weighted, (c) contrast-enhanced T1-weighted, (d) coronal T2-weighted and (e) sagital T2-weighted MR images show a large mass (large arrow) in the posterior mediastinum, adjacent to the thoracic vertebral bodies, which is isointense to muscle with T1 weighting and hyperintense to muscle with T2 weighting with focal areas of high signal intensity, consistent with necrosis and fluid and has heterogeneous enhancement. Axial images clearly show the encased descending aorta traversing the mass (open arrow). This mass involves the body of the 6th thoracic vertebra (star) and extends to the epidural space (small arrows in a and b) thought the neural foramina at the 6th to 7th thoracic vertebrae without widening it (small arrow in e)."
          },
          {
            "number": "Figure 3e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008555/000017.jpg?itok=-fuxf5G8",
            "caption": "(a) Axial T1-weighted, (b) axial T2-weighted, (c) contrast-enhanced T1-weighted, (d) coronal T2-weighted and (e) sagital T2-weighted MR images show a large mass (large arrow) in the posterior mediastinum, adjacent to the thoracic vertebral bodies, which is isointense to muscle with T1 weighting and hyperintense to muscle with T2 weighting with focal areas of high signal intensity, consistent with necrosis and fluid and has heterogeneous enhancement. Axial images clearly show the encased descending aorta traversing the mass (open arrow). This mass involves the body of the 6th thoracic vertebra (star) and extends to the epidural space (small arrows in a and b) thought the neural foramina at the 6th to 7th thoracic vertebrae without widening it (small arrow in e)."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/8555",
    "time": "01.08.2010"
  },
  "8571": {
    "case_id": 8571,
    "title": "The late sequalae of pulmonary hypertension",
    "section": "Chest imaging",
    "age": "52",
    "gender": "female",
    "diagnosis": "Pulmonary hypertension secondary to a secundum atrial septal defect",
    "history": "A 52-year-old woman was investigated for symptoms suggestive of right-sided heart failure (shortness of breath, lower limb oedema, oligura) shortly after she started taking NSAIDs for ankle pain. Plain radiography, electrocardiography, echocardiography, cardiac catheterisation and cross-sectional imaging revealed a right-to-left shunt secondary to an ostium secundum atrial septal defect.",
    "image_finding": "We present the case of a 52 year old female which was being investigated for shortness of breath, lower limb oedema, oliguria, and tiredness. No chronic medical or surgical history of note was available at the time of assessment. The patient had been complaining of right ankle pain following minor trauma, and has been on Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) for three weeks.The patient was noted to be tachycardic. Auscultation of the chest revealed bi-basal crepitations. Symmetrical pitting lower limb oedema was also evident. Atrial flutter, incomplete right bundle branch block and right axis deviation were seen on electrocardiography. Plain chest radiography (Fig. 1) showed a prominent pulmonary trunk, prominent main pulmonary arteries, a 3 cm peripheral pulmonary nodule in the mid-zone of the right lung, and moderate cardiomegaly. A CT was performed in order to characterise the peripheral pulmonary nodule further, and the findings were very suggestive of a hamartoma (Fig. 2-3).She was therefore examined by a cardiologist. Echocardiogram showed a large atrial septal defect (3.2 cm in diameter) with a left to right shunt, a grossly distended pulmonary artery, a grossly dilated right and hypertrophied right ventricle, a grossly dilated right atrium and very high pulmonary pressures.Formal cardiac catheterisation studies confirmed the echocardiographic findings. Left atrial oxygen saturation was measured at 85.5%, pulmonary artery systolic pressure at 120 mmHg (normally 18-25 mmHg), mean pulmonary pressure at 80 mmHg (normally 12-16 mmHg), and aortic pressure 140/90 mmHg. The coronary arteries were normal.",
    "discussion": "Pulmonary arterial hypertension (PAH) has been defined as a mean pulmonary arterial pressure above 25 mmHg at rest [1]. Our patient had a mean pulmonary pressure of 80 mmHg secondary to pulmonary hypertension as a complication of a large atrial septal defect (ASD).Three types of ASD are recognised - ostium secundum defects (the commonest), ostium primum defects, and sinus venosus defects. ASDs can go undiagnosed for decades, as in this case, due to initial subtle symptoms and signs. Symptoms often develop gradually, and are related to the defect itself (cardiac arrhythmias, valvular disease) or to the resultant pulmonary hypertension. In our case, administration of NSAIDs precipitated the symptoms and signs of right heart failure due to the fluid overload associated with such agents.Pulmonary hypertension can be classified using the WHO classification [2] (Fig. 4). Causes can be divided into precapillary and postcapillary. Precapillary causes include primary PAH, pulmonary thromboembolic disease, pulmonary emphysema, and chronic interstitial lung disease. Postcapillary causes include cardiac septal defects, left atrial myxoma/thrombus, left ventricular failure, constrictive pericarditis, pulmonary veno-occlusive disease, pulmonary vein stenosis, anomalous drainage of the pulmonary veins and fibrosing mediastinitis [3].  The radiological features of PAH are similar, regardless of the cause. Plain radiography may demonstrate enlargement of the central pulmonary arteries with 'pruning' of the peripheral branches. A dilated right ventricle would be reflected by apposition of more than one third of the anterior heart border to the sternum, on the lateral chest radiograph. Another feature suggestive of PAH would be increase in diameter of the right interlobar artery (> 15 mm).  The left interlobar artery is difficult to appreciate on frontal chest radiographs. A normal chest radiograph does not rule out PAH [3].  Contrast enhanced CT is much more useful in depicting the pulmonary vasculature.  PAH can be also defined as the pulmonary trunk exceeding 29 mm in diameter on CT. The widest portion of the main pulmonary artery within 3 cm of the bifurcation was used to determine the value [4,5].  In chronic PAH the enlarged central pulmonary arteries may develop thrombus and peripheral calcification. The right ventricle is often dilated.The role of cardiac MRI in the evaluation of pulmonary hypertension is comparable to that of echocardiography. The cardiac output, pulmonary arterial pressure and right ventricular thickness/mass can be accurately determined on MRI.  These parameters can be used to assess the severity of PAH [6].Formal pulmonary angiography is often reported as being the 'gold standard' in imaging of the pulmonary vasculature. The role of this technique in PAH has been recently questioned, due to the wide availability of modern less invasive cross sectional imaging modalities. Inter-observer variability can reach 10-15%. Complications (2-5%) following pulmonary angiography seem to be related to direct cannulation of the right heart and pulmonary artery, and these vary from cardiac arrhythmias to cardiac perforation leading to tamponade. Patients with high pulmonary pressures are at a higher risk for tamponade [7].",
    "differential_diagnosis": "Pulmonary, hypertension, secondary, to, a, secundum, atrial, septal, defect",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008571/000003.jpg?itok=hyQjP6iv",
            "caption": "Plain frontal chest radiograph demonstrates enlarged central pulmonary arteries, pruning of the peripheral branches, and a well-defined distinct `pulmonary nodule\u00b4 in the midzone of the right lung."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008571/000004.jpg?itok=Qpr1XDtn",
            "caption": "Lateral views confirm the enlarged central pulmonary arteries.  Apposition of more than one third of the anterior heart border to the sternum is evident.  This strongly suggests enlargement of the right ventricle."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008571/000005.jpg?itok=qJfimMQl",
            "caption": "Lateral views confirm the enlarged central pulmonary arteries.  Apposition of more than one third of the anterior heart border to the sternum is evident.  This strongly suggests enlargement of the right ventricle."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_video/2018-08/0000008571/000010F.png?itok=31PdKxIH",
            "caption": "Axial CT shows grossly dilated pulmonary arteries. The pulmonary trunk was dilated with a diameter of up to 6.2cm. Arterialisation of the main pulmonary arteries was also noted, with peripheral mural calcification. Peripheral chronic thrombus can be seen lining the left lower lobe pulmonary artery and its branches. Gross dilatation of the right ventricular and right atrium is also evident, together with prominent trabeculation of the ventricular wall. All these features are consistent with chronic pulmonary arterial hypertension.\n\nA lobulated hypodense lesion was seen within the right lower lobe of lung. This measures 4 cm in cranio-caudal diameter, 2.1 cm in transverse diameter and 2.1 cm in antero-posterior diameter. The lesion has very well delineated margins and appears hypodense, most probably representing an incidental hamartoma."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008571/000011.jpg?itok=OKFVgOeD",
            "caption": "Coronal reconstructions of the axial contrast enhanced CT shown in Figure 2, with proper windowing in order to enhance the appearance of the pulmonary arterial tree."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008571/000012.jpg?itok=4GKhCh6m",
            "caption": "Coronal reconstructions of the axial contrast enhanced CT shown in Figure 2, with proper windowing in order to enhance the appearance of the pulmonary arterial tree."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008571/000013.jpg?itok=2piJfp4I",
            "caption": "Coronal reconstructions of the axial contrast enhanced CT shown in Figure 2, with proper windowing in order to enhance the appearance of the pulmonary arterial tree."
          },
          {
            "number": "Figure 3d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008571/000014.jpg?itok=j_cPjTf7",
            "caption": "Coronal reconstructions of the axial contrast enhanced CT shown in Figure 2, with proper windowing in order to enhance the appearance of the pulmonary arterial tree."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008571/000015.jpg?itok=Yn7ogURT",
            "caption": "The Venice 2003 Revised WHO Classification of Pulmonary Hypertension"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/8571",
    "time": "02.08.2010"
  },
  "8575": {
    "case_id": 8575,
    "title": "Primary Ewing sarcoma of rib",
    "section": "Chest imaging",
    "age": "30",
    "gender": "male",
    "diagnosis": "Primary Ewing sarcoma of rib",
    "history": "A 30-year-old-male presented with pain and swelling on the right side of chest for last 6-months. He also complained of heaviness and noticed a rapidly progressive swelling along the right lower lateral chest wall and upper abdominal wall which progressed to the present size over the last 5-months.",
    "image_finding": "For the above mentioned complaints he was advised to undergo a chest radiograph. The chest radiograph showed osseous destruction of the tenth rib on the right side. This was associated with a subtle thick spiculated perisoteal reaction and a large soft tissue component, which was occupying almost the entire right hemithorax. It was displacing the mediastinum and cardia to the contralateral side. A CT scan of the thorax confirmed the lytic expansion of the right-tenth-rib with associated thick spiculated periosteal reaction. There was a disproportionately large soft tissue component seen on either side of the affected rib. This huge extraparenchymal intra-thoracic mass occupied almost the entire hemithorax and extended into the right recessus costodiaphragmaticus. At the base of the right hemithorax it was seen compressing the liver and displacing it to the left side. Laterally there was a large chest wall component, which extended caudally into the upper abdominal wall. This showed multiple tortuous and serpigeneous feeding vessels representing high vascularity of the lesion. The soft tissue component demonstrated an avid but markedly heterogeneous post contrast enhancement. A chest wall tumor of relatively short duration, demonstrating rib destruction and a disproportionately large soft tissue component raised the suspicion of Ewing's sarcoma and primitive neuroectodermal tumour (PNET). Other differentials, although less common, included chondrosarcoma and osteosarcoma. However there was no chondroid or osseous matrix calcification seen to suggest chondrosarcoma or osteosarcoma. A biopsy was performed and the histolopathology was quite characteristic of Ewing sarcoma.",
    "discussion": "Ewing\u2019s sarcoma (ES) has been named after Sir James Ewing who first described this entity in 1921. ES is a highly malignant small round cell tumour accounting for 5-10% of primary bone tumours. It generally arises from long bones such as tibia, femur and humerus; wherein it involves the meta-or-mid-diaphysis. ES can also arise from flat bones such as ribs, scapula and innominate bone. The majority of ES cases show the cytogenetic translocation t(11;22)-(q24;q12). ES is commonly encountered in children and young adults predominantly during first two decades of life with a slight male preponderance (male-to-female ratio 1.5:1). Although uncommonly, ES has been documented in adult patients demonstrating a similar behavior and prognosis as in children. Approximately 10-15% of ES cases arise from the ribs. It is considered the most common malignant chest wall tumour of childhood. These patients usually present with a painful chest wall mass. Symptoms are usually of a relatively short duration. Characteristic imaging manifestation includes a chest wall tumour with associated osseous destruction. Plain radiograph findings can be highly variable ranging from a subtle rarefaction of the rib to a large soft tissue mass opacifying almost the entire hemithorax with frank rib destruction. When involving the long bones ES may demonstrate a diverse pattern of periosteal reaction ranging from onion-peel/lamellated/laminated/ sunburst/spiculated/hair-on- end/Codman\u2019s triangle. However such an extensive periosteal reaction is not seen in ES of the rib. ES of the rib predominantly shows lytic expansion of the involved rib. Less commonly it may manifest as mixed lytic-sclerotic bone destruction or as purely sclerotic pattern. A disproportionately large soft tissue component has been described as a salient feature of ES of the rib. It has been seen that this soft tissue \u201cengulfs\u201d the affected rib and the intra-thoracic component is usually larger than the extra-thoracic component. The soft tissue component demonstrates smooth or lobulated margins. Cross-sectional imaging such as CT or MRI allows a superior delineation of the tumour characteristics, precise extent, relationship to the adjacent structures, intraspinal extension and metastatic spread if any to the lungs and mediastinal lymph nodes. The large overlying soft tissue can obscure the visualization of affected rib on plain radiograph, which can be better evaluated with a CT-scan. ES show a propensity for systemic spread and hence require an intensive multidrug chemotherapy. Local treatment consists of surgical resection, radiotherapy or a combination of surgery plus radiation therapy. The overall 5-10 year survival rate is approximately 50%. Differentials include chondrosarcoma and osteosarcoma, which are relatively uncommon and demonstrate chondroid and osseous tumour matrix calcification respectively. Closest differential of thoracic ES is the primitive neuroectodermal tumour, also known as Askin tumor. Askin tumor like ES is a small round cell tumours of childhood associated with chromosome 22-translocation which is often indistinguishable from ES on imaging. Cytoplasmic glycogen at periodic-acid\u2013Schiff staining is a feature used to differentiate Ewing sarcoma from primitive neuroectodermal tumors. Other rib lesions such as osteomyelitis, eosinophillic granuloma or leukemia do not demonstrate such an extensive soft tissue component as is seen in ES.",
    "differential_diagnosis": "Primary, Ewing, sarcoma, of, rib",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008575/000002.jpg?itok=ruHJykQC",
            "caption": "Collimated radiograph reveals expansile ill-defined rib destruction with thick spiculated periosteal reaction."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008575/000003.jpg?itok=NpELaM7U",
            "caption": "Expansile destruction of the tenth right rib is better visualised on this abdominal radiograph. It is associated with a large soft tissue component."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008575/000005.jpg?itok=Pr3PNXbZ",
            "caption": "Nonenhanced CT scan shows that the mass is large &amp; heterogeneous. There is osseous destruction and thick spiculated periosteal reaction involving the tenth rib."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008575/000006.jpg?itok=8TJ1ICe7",
            "caption": "The soft tissue component extends medially into right hemithorax and laterally into the subcutaneous soft tissues of the chest wall."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008575/000007.jpg?itok=xpELzE56",
            "caption": "The mass is extending caudally into the right costophrenic sulcus with compression of the adjacent hepatic parenchyma."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008575/000010.jpg?itok=a3CXrgza",
            "caption": "The mass is highly vascular and shows intense heterogeneous post contrast enhancement. It is occupying almost the entire right hemithorax."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008575/000008.jpg?itok=40kpS46z",
            "caption": "Multiple tortuous and serpigeneous vascular channels are seen feeding this intensely vascular mass."
          },
          {
            "number": "Figure 4c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008575/000009.jpg?itok=BWrmHfGO",
            "caption": "There is a massive intra-thoracic component as well as a large extra-thoracic component of the mass."
          },
          {
            "number": "Figure 4d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008575/000011.jpg?itok=9TNJqcNi",
            "caption": "It is displacing and compressing the hepatic parenchyma to the left side."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008575/000012.jpg?itok=w2v2ccdP",
            "caption": "Posteroanterior\nchest radiograph shows a large mass within the right hemithorax that is displacing the cardia to the left. There is associated destruction of the right 10th rib."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008575/000014.jpg?itok=8RzNZ-fs",
            "caption": "There is illdefined expansile destruction of the tenth rib."
          },
          {
            "number": "Figure 6b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008575/000013.jpg?itok=-Tx-SpBt",
            "caption": "There is illdefined expansile destruction of the tenth rib with subtle spiculated periosteal reaction."
          },
          {
            "number": "Figure 6c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008575/000015.jpg?itok=JoLAJq9X",
            "caption": "There is illdefined expansile destruction of the tenth rib with spiculated periosteal reaction."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/8575",
    "time": "30.07.2010"
  },
  "8577": {
    "case_id": 8577,
    "title": "Pancoast tum",
    "section": "Chest imaging",
    "age": "58",
    "gender": "female",
    "diagnosis": "Pancoast tumour - keratinising squamous cell carcinoma.",
    "history": "A 58-year-old woman presented with history of weight loss.",
    "image_finding": "A 58-year-old woman presented with weight loss, upper back and right arm pain. Past medical history was unremarkable. She was an ex-smoker. There was no neurologic deficit and no Horner\u2019s syndrome was present. Chest radiograph showed a subtle opacity in the right apex (Fig. 1). Apical view was requested for further evaluation (Fig. 2). It showed slightly more obvious right apical opacity. Following this, urgent CT staging (Fig. 3) showed a right lung apical mass, pleural thickening and osteolysis of the medial end of 2nd rib and adjacent 2nd thoracic vertebral lamina. There were no other lung lesions, no mediastinal lymphadenopathy and no disease below the diaphragm. Primary diagnosis made on the basis of CT findings was a pancoast tumour. Discussion at the clinicoradiologic meeting recommended biopsy of the lesion and further imaging with MRI and PET. Ultrasound (Fig. 4) guided biopsy was performed. MRI (Fig. 5) of the spine was performed to further assess the spinal involvement. This showed a neoplastic mass arising from the apex of the right lung involving the neural exit foramina of the T1 and T2 nerve roots. PET (Fig. 6) showed FDG avid right apical tumour with right supraclavicular extension and involvement of adjacent ribs and vertebral bodies. No discrete metabolically active nodes in the chest or supraclavicular fossa (separate  from  the  tumour) or distant metastasis.The histology of the biopsy specimen was consistent with keratinising squamous cell carcinoma.",
    "discussion": "Pancoast tumours are neoplasms of pulmonary origin located at the apical pleuropulmonary groove (superior sulcus). Initially, patient may present with arm, shoulder or scapular pain. By direct extension, Pancoast tumours typically involve the lower trunks of the brachial plexus, intercostal nerves, stellate ganglion, adjacent ribs, and vertebrae. If the tumour extends to the sympathetic chain and stellate ganglion, Horner syndrome and anhidrosis develop on the ipsilateral side of the face and upper extremity. More than 95% of Pancoast tumours are non\u2013small cell carcinomas, most commonly squamous cell carcinomas (52%) or adenocarcinomas and large cell carcinomas (approximately 23% for each subtype). Small cell carcinomas are seen in fewer than 5% of cases [1]. Errors in radiological interpretation can significantly delay the treatment of pancoast tumours.  In a study carried out on patients with pancoast tumours at Fukuroi Municipal Hospital, Japan (1999 to 2004), several radiological errors were identified leading to significant delay in treatment [2].Differential diagnoses of masses in the apical chest include primary tumours of the thyroid, larynx and pleura. Other causes may include infectious disorders of the lung, aneurysms of the subclavian vessels, amyloid of pleura and multiple myeloma. The differential diagnoses of arm and shoulder pain are extensive; however, primarily, thoracic outlet syndrome and cervical disc disease must be excluded. Staging is determined by the location of the lesion and its metastases. The true Pancoast tumour is usually T3, which describes the extension of the tumour through the visceral pleura into the parietal pleura and the chest wall. Pancoast tumours are classified as T4 when mediastinal invasion, cervical invasion, or both have occurred. Pancoast tumours were once considered universally fatal. However, improvements in combined modality therapy and the development of new techniques for resection have made curative treatment possible for these tumours. The perfect candidate for resection has a carcinoma restricted to the chest with T3N0M0 staging. Contraindications to surgery include: extensive invasion of the neck, brachial plexus or vertebrae; perinodal mediastinal extension; and peripheral metastases [3]. The bimodality approach of induction radiotherapy followed by surgical resection has been the accepted standard of care for the last 50 years, with reported 5-year survival rates of 30% in selected patients. However, two recent prospective multicentre phase II studies using a trimodality approach of induction concurrent chemoradiotherapy followed by surgical resection (followed by two further cycles of adjuvant chemotherapy in one of the studies), have reported 5-year survival rates of 44-56%. This has led to some authorities advocating the trimodality approach as the new standard of care for the management of Pancoast tumours [4].",
    "differential_diagnosis": "Pancoast, tumour, -, keratinising, squamous, cell, carcinoma.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008577/000001.jpg?itok=uR9OlEgp",
            "caption": "Posteroanterior chest radiograph shows subtle opacity in the right apex. Note the asymmetry of lung apices."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008577/000002.jpg?itok=AAujiXRA",
            "caption": "Apical view of chest radiograph shows slightly more obviously the right apical opacity."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008577/000003.jpg?itok=lWWM31kU",
            "caption": "Sequential images of the lung apices at contrast-enhanced chest CT show a right lung apical mass, pleural thickening and osteolysis of the medial end of 2nd rib and adjacent 2nd thoracic vertebral lamina."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008577/000004.jpg?itok=DXMYWMB5",
            "caption": "Sequential images of the lung apices at contrast-enhanced chest CT show a right lung apical mass, pleural thickening and osteolysis of the medial end of 2nd rib and adjacent 2nd thoracic vertebral lamina."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008577/000005.jpg?itok=z98XcKtF",
            "caption": "Sequential images of the lung apices at contrast-enhanced chest CT show a right lung apical mass, pleural thickening and osteolysis of the medial end of 2nd rib and adjacent 2nd thoracic vertebral lamina."
          },
          {
            "number": "Figure 3d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008577/000006.jpg?itok=6QDaguDd",
            "caption": "Sequential images of the lung apices at contrast-enhanced chest CT show a right lung apical mass, pleural thickening and osteolysis of the medial end of 2nd rib and adjacent 2nd thoracic vertebral lamina."
          },
          {
            "number": "Figure 3e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008577/000007.jpg?itok=Y0FnvPS3",
            "caption": "Sequential images of the lung apices at contrast-enhanced chest CT show a right lung apical mass, pleural thickening and osteolysis of the medial end of 2nd rib and adjacent 2nd thoracic vertebral lamina."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008577/000009.jpg?itok=o7L2D10h",
            "caption": "FDG avid right apical tumour with right supraclavicular extension and involvement of adjacent ribs and vertebral bodies."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008577/000010.jpg?itok=63yl3FRP",
            "caption": "FDG avid right apical tumour with right supraclavicular extension and involvement of adjacent ribs and vertebral bodies."
          },
          {
            "number": "Figure 4c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008577/000011.jpg?itok=9bfWEVTS",
            "caption": "FDG avid right apical tumour with right supraclavicular extension and involvement of adjacent ribs and vertebral bodies."
          },
          {
            "number": "Figure 4d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008577/000012.jpg?itok=DKjtL5ro",
            "caption": "FDG avid right apical tumour with right supraclavicular extension and involvement of adjacent ribs and vertebral bodies."
          },
          {
            "number": "Figure 4e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008577/000013.jpg?itok=l9Up6oL4",
            "caption": "FDG avid right apical tumour with right supraclavicular extension and involvement of adjacent ribs and vertebral bodies."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008577/000014.jpg?itok=KHNcemuJ",
            "caption": "Coronal T1 weighted MRI (a, b) and axial T1 weighted MRI (c, d) show a soft tissue mass arising from the right lung apex."
          },
          {
            "number": "Figure 5b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008577/000015.jpg?itok=5GMyTxRQ",
            "caption": "Coronal T1 weighted MRI (a, b) and axial T1 weighted MRI (c, d) show a soft tissue mass arising from the right lung apex."
          },
          {
            "number": "Figure 5c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008577/000016.jpg?itok=ywnF4f7I",
            "caption": "Coronal T1 weighted MRI (a, b) and axial T1 weighted MRI (c, d) show a soft tissue mass arising from the right lung apex."
          },
          {
            "number": "Figure 5d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008577/000017.jpg?itok=EfcIvLgf",
            "caption": "Coronal T1 weighted MRI (a, b) and axial T1 weighted MRI (c, d) show a soft tissue mass arising from the right lung apex."
          },
          {
            "number": "Figure 5e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008577/000018.jpg?itok=LVdcWXUs",
            "caption": "Coronal T1 weighted MRI (a, b) and axial T1 weighted MRI (c, d) show a soft tissue mass arising from the right lung apex."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008577/000019.jpg?itok=4imn0tTl",
            "caption": "There is a hypoechoic mass in the right lung apex."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/8577",
    "time": "09.09.2010"
  },
  "8584": {
    "case_id": 8584,
    "title": "Broncho-oesophageal fistula due to bronchogenic carcinom",
    "section": "Chest imaging",
    "age": "81",
    "gender": "male",
    "diagnosis": "Broncho-oesophageal fistula due to bronchogenic carcinoma",
    "history": "An 81 year old man presented with dyspnoea, dysphagia and stridor like symptoms. He had a previous history of Non small cell lung carcinoma in the right lower lobe with mediastinal lymphadenopathy and was treated with palliative chemotherapy. His other medical history included sternotomy and coronary artery bypass graft.",
    "image_finding": "Following presentation with above symptoms, the patient underwent chest radiography and CT scan. Chest radiograph revealed a right mid zone consolidation. Subsequent CT demonstrated consolidation  in the right upper lobe. The right lower lobe mass was stable. There was minimal smooth thickening of left parietal pleura which was thought to be related to previous coronary artery bypass surgery and it also remained unchanged. The oesophagus was bulky. Soft tissue windows showed a bulky oesophagus with soft tissue thickening around the carina inseparable from the previously enlarged subcarinal node. There were tiny pockets of gas tracking towards the right main bronchus suggestive of fistulation. To confirm this, the patient underwent a water soluble contrast swallow examination to assess possible fistulation. The contrast study confirmed a fistulous communication between the right main bronchus and oesophagus with the contrast spilling in to the bronchi. An oesophageal stent insertion was planned but unfortunately his condition rapidly deteriorated resulting in death.",
    "discussion": "Broncho-oesophageal fistula in adulthood is rare and usually acquired. The causes are variable including oesophageal malignancy and iatrogenic (radiation). Foreign body ingestion, trauma and infections like tuberculosis and histoplasmosis are some of the benign causes. There is little in the literature on bronchogenic carcinoma as a cause of broncho-oesophageal fistula. We present an unusual case of fistulous communication between bronchus and oesophagus caused by lung cancer and stress the role of radiology in establishing the diagnosis.The fistulous communication in our case was caused by the erosion of the necrotic metastatic malignant subcarinal node into the oesophagus and right main bronchus resulting in bronchoesophageal fistula.",
    "differential_diagnosis": "Broncho-oesophageal, fistula, due, to, bronchogenic, carcinoma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008584/000001.jpg?itok=MscnUN0J",
            "caption": "Chest radiograph shows right mid zone consolidation"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008584/000002.jpg?itok=gIqcoI4I",
            "caption": "Chest CT at mediastinal windowing shows bulky oesophagus with soft tissue thickening around the carina and oesophagus and tiny pockets of gas tracking towards the right main bronchus"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008584/000003.jpg?itok=rgb9b7OH",
            "caption": "Chest CT at lung windowing shows consolidation in the right upper lobe"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008584/000004.jpg?itok=kEHyadGc",
            "caption": "Water soluble contrast swallow demonstrates stricture of the oesophagus with fistulous communication into the right main bronchus."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/8584",
    "time": "09.08.2010"
  },
  "8589": {
    "case_id": 8589,
    "title": "A case report of Legionnaire\\&#039;s disease",
    "section": "Chest imaging",
    "age": "50",
    "gender": "male",
    "diagnosis": "Complicated Legionnaires' disease.",
    "history": "A case of a previously healthy man who presented with non-specific symptoms of shortness of breath, dry cough, anorexia and fever and then progressed to acute respiratory distress syndrome and sepsis is reported. Treatment in the intensive care unit with antibiotics and mechanical ventilation was successful.",
    "image_finding": "A 50-year-old previously healthy man presented complaining of an 11-day history of shortness of breath, dry cough, anorexia and fever. The patient had just returned home from aboard an oil rig off the coast of Congo. On admission he had a CURB-65 score of 3 (C- Confusion of new onset, U- Urea greater than 7 mmol/l, R- Respiratory rate of 30 breaths per minute or greater, B- Blood pressure <90 mmHg systolic or diastolic blood pressure <60 mmHg, 65- age 65 or older). He was tachypnoeic, hypotensive and had bibasilar coarse crackles. Abdominal examination revealed smooth, non-tender hepatomegaly. Arterial blood gases on admission showed type 1 respiratory failure with a pCO2 of 25.6mmHg, a pO2 of 47.7mmHg and arterial oxygen saturation of 87.3% on air. Blood investigations revealed a white cell count of 16.4x 109, activated partial thromboplastin time ratio of 1.46 and deranged liver function tests. His renal function was within normal limits. Urinary legionella antigen test was positive. Chest radiograph showed bilateral pulmonary infiltrates (Fig. 1).He was started on intravenous antibiotics and admitted to the intensive therapy unit for respiratory support. Over the initial 8 days imaging of his lungs continued to deteriorate (Fig. 2). Chest CT revealed bilateral consolidations with diffuse emphysematous changes. Patient\u2019s general condition eventually started to improve, antibiotics were stopped after 21 days of therapy and after 29 days of hospital stay, he was discharged home.A one month follow-up chest x-ray showed residual bilateral fibrotic changes with no focal areas of consolidation (Fig. 3).",
    "discussion": "Legionnaires\u2019 disease refers to the pneumonia caused by the gram-negative bacillus Legionella pneumophila. This bacterium belongs to the Legionellaceae family and is responsible for causing up to 90% of the cases of legionellosis. The natural habitat for L. pneumophila is fresh water or protozoan biofilms, in which the bacteria parasitise and proliferate inside the protozoa. Once the water is transferred into man-made water reservoirs, the Legionella organisms proliferate. Legionella is transmitted to humans via inhalation of colonised aerosols or droplets produced by various sources such as air conditioners, shower heads and water fountains. Advanced age, immunocompromised state, cigarette smoking and chronic lung disease are all risk factors. While most cases are sporadic, 10-20% are linked to outbreaks [1]. Legionnaires\u2019 disease is often initially characterized by the development of anorexia, lethargy and a mild non-productive cough. About half of patients develop pus forming sputum, and about one third develop haemoptysis. Chest pain is prominent in about 30% of patients. Gastrointestinal symptoms are prominent, with up to half of patients having watery diarrhoea, and 10\u201330% suffering nausea, vomiting and abdominal pains. Fever is present in almost all cases. Almost half of the patients suffer from disorders related to the nervous system, such as confusion, delirium and hallucinations. Several laboratory tests can be used to detect the Legionella bacteria within the body.  The most commonly used test is the urinary antigen test, which detects Legionella bacteria from a urine sample.  If the patient has pneumonia and the test is positive, then the patient is considered to have Legionnaires\u2019 disease.  Additionally, if the Legionella bacteria are cultured from a lung biopsy specimen, respiratory secretions, or various other sites, the diagnosis of Legionnaires\u2019 disease is also considered confirmed.  Finally, paired sera that show a specific increase in antibody levels when drawn shortly after illness and several weeks following recovery, can also be used to confirm the diagnosis [2,3].No typical radiographic presentation for Legionnaires' disease exists. Various studies have documented the most common radiological patterns observed. In the majority of cases, the initial presenting chest radiographic finding is of patchy alveolar infiltrates, with unilobar involvement. Lower lobe involvement is a common finding. Other radiological manifestations include a pleural effusion noted in 35 to 63% of patients. This may be found on admission. However, many patients develop an effusion during the first week of hospitalisation.  In most cases, in spite of clinical improvement, chest radiographic findings continue to worsen between days 2 and 6 in the form of increasing consolidation of the same lobe, involvement of a contiguous lobe or ipsilateral non-contiguous lobe, infiltration of the contralateral lung, and development of a pleural effusion. Cavitation is found rarely in immunocompetent hosts, in contrast to immuno-compromised hosts were it tends to be fairly common [4,5]. Imaging features on CT include bilateral and unilateral single and multifocal consolidation and ground glass opacity. Sharply demarcated peribronchovascular foci of consolidation intermingled with ground glass opacity seem to be one of the most frequent CT appearances [6,7].",
    "differential_diagnosis": "Complicated, Legionnaires', disease.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008589/000003.jpg?itok=h1HjhJcO",
            "caption": "Residual fibrotic changes are present bilaterally with no focal area of consolidation."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008589/000004.jpg?itok=pC1ChI5w",
            "caption": "Bilateral lower zone air-space shadowing with relative preservation of the costophrenic recesses and perihilar regions."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008589/000005.jpg?itok=EYcYD5xZ",
            "caption": "Worsening of the radiological findings when compared to the previous chest X-ray showing more pronunced bilateral lower zone air-space shadowing."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/8589",
    "time": "15.09.2010"
  },
  "8617": {
    "case_id": 8617,
    "title": "Intercostal lung herni",
    "section": "Chest imaging",
    "age": "53",
    "gender": "male",
    "diagnosis": "Post-traumatic intercostal lung hernia",
    "history": "We present a case of acute pain on the left hemithorax after weight lifting. Evaluation was performed with radiography and CT.",
    "image_finding": "A 53 year old male presented with acute pain at the mid third of the left hemithorax after some heavy weight lifting. There was subcutaneous swelling of the left hemithorax, which discreetly increased in size on expiration. The patient had a history of previous thoracic trauma 20 years ago after a road traffic accident sustaining injuries on the left hemithorax and limbs. A radiography evaluation of the thorax has been made showing a discrete lucency in the soft tissues of the left hemithorax, witch was better depicted on the negative thoracic radiography. A thoracic CT was suggested for further evaluation. CT evaluation of the lung revealed a left intercostal (between 5-6th ribs) lung hernia to the soft tissues of the left hemithorax, and a few heterogeneous opacities on the posterior regions of both lungs, related to hypo-ventilation. The herniated lung volume was approximately 81cm\u00b3.",
    "discussion": "Lung hernia is a rare abnormal protrusion of the lung to the soft tissues beyond the rib cage. Hernias can be either congenital or acquired. Acquired hernias can be spontaneous, post-traumatic (due to musculoskeletal injury and wall weakness), or pathologic as a result of a neoplastic or inflammatory process. Less then 300 cases were reportred until 1990 [1]. They are sometimes difficult to evaluate or may even be undetected on chest radiographs depending on the lesion severity. CT is usually performed for definite depiction of the lung herniation, associated abnormalities and pre-operative planning [2].",
    "differential_diagnosis": "Post-traumatic, intercostal, lung, hernia",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008617/000009.jpg?itok=a9uZnLPL",
            "caption": "CT scanogram. Clearly depicted intercostal lung hernia of the left hemithorax is seen on the CT scanogram."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008617/000005.png?itok=W793BJb4",
            "caption": "Clearly depicted left intercostal lung hernia on axial images."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008617/000007.png?itok=knOL8iCx",
            "caption": "Intercostal lung hernia of the left lung migrating inferiorly on coronal reformatted image (5-6th ribs). Note the presence of hypo-ventilation related opacities at  the posterolateral region of the left lower lobe."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008617/000008.jpg?itok=HFemIvvi",
            "caption": "CXR showing hypo-expanded lungs and a discrete band-like lucency in the soft tissues of the inferior aspect of the left hemithorax."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/8617",
    "time": "02.08.2010"
  },
  "8653": {
    "case_id": 8653,
    "title": "A case of round pneumonia in an adult",
    "section": "Chest imaging",
    "age": "74",
    "gender": "male",
    "diagnosis": "Round pneumonia",
    "history": "We present the case of a 74 year old man complaining of cough and low grade fever during the last month and a right lung mass on chest X-ray.",
    "image_finding": "A 74 year old man was complaining of cough and low grade fever during the last month. CXR revealed a mass adjacent to the mediastinum on the right mid lung zone (Fig. 1a,b). Chest radiography findings were suspicious for malignancy, as the patient had a smoking history. Further evaluation with CT and probably also CT-guided percutaneous biopsy were deemed necessary, by the referring clinician. Lung CT depicted an oval-shaped 4cm mass in the posterior segment of the RUL. The mass was abutting the major fissure, causing some degree of bulge, but there was no evidence of infiltration towards the lower lobe. On the anterior part its margins were somewhat ill defined with evidence of tiny air-bronchograms. There were no satellite lesions, around the mass. There was also no evidence of enlarged lymph nodes in the mediastinum (Fig. 2a-d, 3a-c). Imaging findings were not typical of malignancy(broad-based configuration with pleura, no associated lymphadenopathy). Laboratory findings included an elevated ESR, white blood cell count within normal range and were otherwise unremarkable. Bronchoscopy was negative. CT-guided biopsy was considered unnecessary. The patient received antibiotic treatment and was advised to have a follow-up CT in a month. The 1-month follow-up CT showed resolution of the mass. There was only some residual scar tissue left in the region previously occupied by the mass, with mild pleural thickening in the major fissure (Fig. 4a-c). The patient was asymptomatic at that time. The mass was attributed to a round pneumonia. No specific causative microorganism was identified.",
    "discussion": "Round pneumonia (RP) is a non-segmental, oval or round-shaped form of acute pneumonia, well recognized in children but uncommonly reported in adults. It is under-reported in adults, as successfully treated pneumonias, are usually never imaged. Its discovery depends on how frequently patients are imaged. During SARS epidemic, with frequent CXR imaging, RP had a high incidence (29%). Adult RP affects patients with a mean age of 40.9 (range 21-68) years. Most RPs are caused by Streptococcus pneumoniae. Other typical and atypical bacterial and viral agents are implicated. Sometimes no organism is isolated. Most RPs are found in the lower lobes, making upper lobe lesions more suspicious for malignancy. RP presents as acute febrile illness, with coughing, dyspnoea and chest pain. Sometimes symptoms may be mild (mimicking a viral syndrome), or absent. A history of cough and fever may be absent, making diagnosis difficult. Leukocytosis may exist, although sometimes is absent. Frequently these patients undergo unnecessary biopsy. The clinical course of RP is usually benign. The outcome depends on pathogen virulence and host immunity. Complicated courses have been described in patients with comorbidities, leading to respiratory failure. Fatalities have also been described. The pathogenesis of RP is unknown. One presumption is that in children <8 years, the collateral pulmonary pathways of circulation (pores of Kohn, canals of Lambert) are underdeveloped. This limits the infection, resulting in a focal, round mass. This may also explain why RP is uncommon in adults with fully developed canals of Lambert. Another assumption is that RP in children is due to the closely apposed connective tissue septa and smaller alveoli, helping form more compact and confluent consolidations. In adults, RP may represent an early manifestation of pneumonia, with the infectious focus spreading centrifugally, either through the collateral pathways, or by destroying the neighbouring acini. This dissemination of exudative fluid through interalveolar communications is responsible for the non-segmental, centrifugal distribution. In SARS patients though, the round opacities did not grow centrifugally suggesting that this growth pattern may simply reflect host immune response. RP mimics lung cancer. On CXRs its margins range from smooth, to irregular and ill-defined. The presence of air-bronchograms, does not differentiate malignancy from RP, as they can appear in both. Recent (within the last 1-2 months) normal radiographs may help the diagnosis. CT may depict RP as a soft tissue-density mass. The lesion margins may be spiculated. Satellite lesions may be more conspicuous at CT. The pleura may be thickened when RP is peripheral. Satellite lesions and broad-based lesion configuration relative to the pleura are distinctive CT features of RP. Even PET/CT cannot differentiate RP from tumours. The differential includes septic emboli, granulomatous infections, vascular malformations, round atelectasis, focal organizing pneumonia, rheumatoid nodules and Wegener\u2019s. RP is an uncommon cause of coin lesions in adults and may be difficult to distinguish from carcinoma, sometimes leading to unnecessary biopsy. Radiologists must be aware of this entity and be prudent to treat with antibiotics first before attempting image-guided biopsy. Follow-up is recommended as only mass resolution can rule out a neoplasm.",
    "differential_diagnosis": "Round, pneumonia",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008653/000001.jpg?itok=ZIMxnccG",
            "caption": "PA CXR: There is a fairly well-defined opacity projecting adjacent the mediastinum on the right mid lung zone, (white arrows)."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008653/000002.jpg?itok=py4CJyOx",
            "caption": "Left lateral CXR: The opacity is located in the posterior segment of the RUL (black arrows)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008653/000003.jpg?itok=9wvplsBU",
            "caption": "There is an oval-shaped,  mass (arrow) in the posterior segment of the right upper lobe.  Its margins bordering the lung are somewhat ill-defined. Some tiny air-bronchograms can be appreciated."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008653/000004.jpg?itok=btH0lpSm",
            "caption": "The oval-shaped mass (arrow) measures 4 cm in its longest diameter. It has a broad-based contact with the right major fissure, causing some degree of bulge. There there is no evidence of infiltration towards the lower lobe, though. Air-bronchograms are also present in this slice."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008653/000005.jpg?itok=5oBVCgf5",
            "caption": "The caudal part of the mass has somewhat irregular margins with the adjacent lung. There is no evidence of satellite lesions."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008653/000009.jpg?itok=FDCkFWAD",
            "caption": "Close-up view of figure 2b, with the black arrowhead pointing to an air-bronchogram."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008653/000006.jpg?itok=bp_DIbMU",
            "caption": "Contrast-enhanced CT at the level of the left main pulmonary artery (same level as 2a), depicting the upper part of the soft tissue density mass (arrow)."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008653/000007.jpg?itok=xgWQvjEO",
            "caption": "Image just below figure 3a showing the oval mass at its greatest dimensions (same level as figure 2b)."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008653/000008.jpg?itok=EQ7r39mo",
            "caption": "Image at the lower part of the mass (same level as figure 2c). There is no evidence of pathologically enlarged lymph nodes."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008653/000010.jpg?itok=_6B4ySXS",
            "caption": "Follow-up CT at the level of the carina, lung windows. There is resolution of the mass. with some residual scar tissue remaining in the right upper lobe, in the region previously occupied by the mass (arrow)."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008653/000011.jpg?itok=UHEyPRFD",
            "caption": "Follow-up CT (non contrast enhanced) at the same level with figure 4a, mediastinal windows. There is definitely no evidence of the mass seen on figures 3a-c."
          },
          {
            "number": "Figure 4c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008653/000012.jpg?itok=mAkYuIvF",
            "caption": "High resolution CT image at same level with 4a. There is some residual pleural thickening at the level of the right major fissure (white arrowheads). Compare with normal major fissure on the left."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/8653",
    "time": "15.09.2010"
  },
  "8670": {
    "case_id": 8670,
    "title": "Azygos Lobe",
    "section": "Chest imaging",
    "age": "60",
    "gender": "female",
    "diagnosis": "Incidental finding of Azygos Lobe in a CT examination.",
    "history": "A 60-year-old female patient underwent a CT examination for pre-surgical staging.",
    "image_finding": "An adult female patient affected by sigmoid colon cancer underwent a CT examination for pre-surgical staging. Incidentally, we noticed the presence of an Azygos Lobe.A preoperative standard chest radiography was performed and we confirmed the presence of an Azygos Lobe.",
    "discussion": "The Azygos Lobe (AL) is a normal variant that is found in 1% of anatomical specimens and on about 0.4% of chest radiographs.AL is symptomless and usually discovered incidentally on chest radiographs.It occurs during fetal development when the right posterior cardinal vein, one of the precursors of the azygos vein, fails to migrate over the apex of the lung and penetrates it instead, carrying along two layers each of the parietal and visceral pleura with it, forming a pleural mesentery. The lung trapped medial to this fissure (azygos fissure) is called the \"Azygos Lobe\" and consists of parts of the apical or posterior segments of the right upper lobe. The AL is supplied by the medial segments of the apical and anterior or posterior branches of the apical segmental bronchial artery and vein.On the chest radiograph, the AL is seen at the right lung apex with the azygos vein lying on its lowermost part forming a \"tear-shaped\" radio-opaque shadow. A fine convex line crosses the apex of the right lung to merge with a triangular-shaped upper part of the AL (trigonum parietale). The triangular-shaped area corresponds to a small amount of extrapleural areolar tissue between the parietal layers of the pleura.According to its size, the AL has been classified in three types: in type A, the trigonum parietale is located in the lateral aspect of the pulmonary apex; in type B, the mesoazygos has a vertical path; and in type C, the trigonum is located medially.Axial CT images give a more accurate representation of the anomalous course of the azygos vein, of the presence of the AL and of their relations with mediastinal organs.CT shows the deep penetration of the lung behind the superior vena cava and the trachea, occasionally contacting the medial wall of the oesophagus and the descending aorta. The azygos vein arch typically is located more cephalad than normal, generally about 2 cm above the carina; it may extend as high as the level of the right brachiocephalic vein. The superior vena cava adopts an ellipitcal shape and its major axis is oriented obliquely towards the left. The superior vena cava is concomitantly displaced anteriorly with respect to the trachea, while the oesophagus is rotated toward the left. This allows lung to intrude deep into the pretracheal and retrotracheal portions of the mediastinum. The fissure is clearly visible and its morphology depends on the size of the lobe. It is C-shaped in large lobes and straight or slightly undulated when the lobe is small. Clinically, the knowledge of Azygos Lobe anatomy is important during thoracic surgical approaches. Partial obstruction of the thoracoscopic view during a bilateral sympathectomy was reported during attempted mobilisation of the Azygos Lobe. Others reported difficulty reflecting the pleura during primary repair of the oesophageal atresia in a pediatric patient. There are also reports of the phrenic nerve coursing within the azygos fissure. Finally, multiple authors have reported spontaneous pneumothorax associated with the Azygos Lobe in both the adult and the pediatric patient.",
    "differential_diagnosis": "Incidental, finding, of, Azygos, Lobe, in, a, CT, examination.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008670/000001.jpg?itok=JkkXFYxp",
            "caption": "Chest radiography in PA: presence of Azygos Lobe."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008670/000003.jpg?itok=GaPurPPN",
            "caption": "Chest radiography in PA: zoom."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008670/000015.jpg?itok=BFNZxVQU",
            "caption": "Standard window: the azygos vein arch is separated from the mediastinum and trachea."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008670/000014.jpg?itok=zR7IiR3b",
            "caption": "Lung window setting at the same level demonstrates the Azygos Lobe medial to the azygos arch."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008670/000009.jpg?itok=-k0QKYsE",
            "caption": "Lung window: azygos fissure. The Azygos Lobe is subtended medially."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008670/000016.jpg?itok=i91F7nuR",
            "caption": "a: normal case;\nb: Azygos Lobe."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/8670",
    "time": "09.09.2010"
  },
  "8683": {
    "case_id": 8683,
    "title": "Chronic thromboembolic pulmonary hypertension: vascular and parenchymal signs.",
    "section": "Chest imaging",
    "age": "73",
    "gender": "male",
    "diagnosis": "chronic pulmonary embolism",
    "history": "We present a case of chronic pulmonary embolism as a cause of pulmonary hypertension. A 73 year old man presented with recurrent and progressive dyspnoea. Radiological evaluation by means of CT-scan and conventional angiography revealed mural adherent filling defects in the pulmonary arteries. The diagnosis of chronic pulmonary embolism was made.",
    "image_finding": "A 73 year old man with recurrent dyspnoea came to our hospital. He had several events of acute chest pain, one followed by a syncope. The diagnosis of pulmonary embolism was made and treatment was started, however the patient relapsed a few times. A chest radiograph, contrast enhanced CT and a conventional angiography were performed. Also a venous duplex examination, a cardiac ultrasound and a combined ventilation perfusion scintigraphy were performed.A chest radiograph showed mild prominent pulmonary arteries (Fig. 1). Contrast enhanced CT-Thorax showed mural-adherent filling defects at the bifurcation of the branches from the right pulmonary artery (Fig. 2). CT-Thorax also showed a mosa\u00efcperfusion pattern (Fig. 3).Conventional angiography showed enlargement of the main pulmonary artery. There was also focal narrowing and irregular margination of the segmental pulmonary arteries in upper, middle and lower lobe. Filling defects presented in subsegmental arteries of the lower lobe (Fig. 4,5).Venous duplex ultrasound of the legs showed no DVT. Cardiac US revealed a right ventricular enlargement and hypertrophy. The diagnosis of mild pulmonary hypertension was made.Combined ventilation perfusion scintigraphy showed a mismatch between normal ventilation and non-perfused areas.Initially, conservative approach was done because of the discrepancy between the severe dyspnoea and the mild degree of pulmonary hypertension. A few months later the patient presented with progressive symptoms: there was progressive dyspnoea, a continuous atypical chest pain and a chronic non-productive cough. Due to those clinical symptoms a bilateral pulmonary artery thromboendarterectomy was performed.",
    "discussion": "Chronic pulmonary embolism is mainly a consequence of incomplete resolution of acute pulmonary embolism. Approximately 0,5 \u2013 4 % of patients with acute pulmonary embolism experience this chronic thrombo-embolic hypertension based on incorporation of thrombotic material in vascular walls [2]. Because clinical signs may be nonspecific, chronic PE requires imaging methods for diagnosis and treatment planning. Identifying those patients with chronic pulmonary embolism is important because they can be cured by a surgical procedure: pulmonary artery thromboendarterectomy [2]. Chest radiographic findings are usually nonspecific. Scintigraphy provides a high sensitivity for PE, but is nonspecific and lacks anatomic resolution. Pulmonary angiography is an invasive procedure, although is accurate [1,3]. MRI offers morphologic and functional information on lung perfusion and right heart failure, however, it cannot replace conventional angiography and right heart catheterization for the preoperative determination of pulmonary vascular resistance and mean pulmonary artery pressure. CT is a useful alternative to conventional angiography for diagnosing chronic PE and for determining which patients are treatable with surgery. CT can also be used to confirm success postoperatively [1]. In general, chronic pulmonary embolism can be diagnosed by vascular and parenchymal signs. The vascular CT-signs include direct pulmonary artery signs, signs related to pulmonary hypertension and signs of systemic collateral supply. The direct visualization of the thrombus is the most important diagnostic criterion on contrast-enhanced CT. Organized embolic material in chronic pulmonary embolism most likely appears as a crescentic, mural-adherent filling defect in the pulmonary arteries. In addition it might be retracted or recanalized, or may contain calcifications. The pulmonary arteries might show abrupt narrowing and mural irregularities.  As result of the pulmonary hypertension the main pulmonary arteries can be enlarged, there might be right ventricular enlargement, hypertrophy and even in severe pulmonary hypertension the bronchial arteries might be enlarged and tortuous [1,2]. The parenchymal signs include scars, a mosaic attenuation pattern and bronchial anomalies. There might be a pleural-based rest of pulmonary infarction. The residual scar is round or wedge shaped, pointing with his tip to the perihilar area [1,2]. The mosaic pattern is the consequence of heterogeneous lung perfusion [4]. Last, pleural effusions, pericardial effusions and ascites may occur with chronic pulmonary embolism and usually indicate right heart failure in pulmonary hypertension [2].  In conclusion, chronic thromboembolic pulmonary hypertension is clearly more common than previously was thought. Knowledge of the radiologic imaging signs is required to detect the condition. Because chronic thromboembolism is potentially curable with pulmonary thromboendarterectomy, early recognition may improve the outcome in cases that are technically operable [2].",
    "differential_diagnosis": "chronic, pulmonary, embolism",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008683/000001.jpg?itok=LBdB5CWr",
            "caption": "Fig. 1-Conventional radiography shows a normal chest radiograph."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008683/000002.jpg?itok=Chmxp4xN",
            "caption": "Fig. 2-Contrast enhanced computed tomography shows residual mural-adherent filling defects in the right pulmonary artery."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008683/000003.jpg?itok=NCHekJk7",
            "caption": "Fig. 3\u2013Computed tomography shows a mosaic perfusion pattern."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008683/000004.jpg?itok=9ppbfqOy",
            "caption": "Fig. 4-The mural-adherent filling defect, visualized on CT, can be visualized on the right pulmonary angiogram as an intimal irregularity."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008683/000005.jpg?itok=0CrNAYiJ",
            "caption": "Fig. 5-Right pulmonary angiogram shows an enlarged right main pulmonary artery."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/8683",
    "time": "02.08.2010"
  },
  "8720": {
    "case_id": 8720,
    "title": "Descending mediastinitis secondary to cervical necrotizing fasciitis due to odontogenic infection",
    "section": "Chest imaging",
    "age": "27",
    "gender": "male",
    "diagnosis": "Descending mediastinitis secondary to cervical necrotising fasciitis due to odontogenic infection",
    "history": "A 27-year-old man was admitted to our institution with fever up to 40\u00b0C, tachycardia and blood pressure 90 / 70. The patient underwent CT examination of neck and chest 3 times during his hospitalisation. The findings are presented.",
    "image_finding": "The patient had a history of dental infection of the third left molar 5 days ago for which he had started treatment with amoxicillin. The neck CT examination performed on the first day, without contrast administration because of renal failure, demonstrated fluid collections with gas bubbles inside them at the left masticator, parapharyngeal, carotid spaces as well as the retropharyngeal space of the neck. There was expansion of the inflammatory process to the left piriformis sinus (Fig. 1 a, b, c, d, e, f). The first chest CT revealed diffuse opacities of the lungs (Fig. 2 a, b).  The patient was intubated, treated with  noradrenaline and intravenous antibiotics, submitted to surgical drainage of the cervical abscesses and extraction of the third left molar. The cultures of the drained fluid revealed Streptococcus Aeroginosus and Prevotella Buccae. The second CT, 4 days later, demonstrated expansion of the infection to the mediastinum with oedema and inflammatory infiltration of its soft tissues (Fig. 3 a, b). Diffuse opacities and regions of atelectasis were present throughout the lung parenchyma (Fig. 4 a, b). The radiographic and clinical signs pointed to ARDS. The third CT examination, 10 days later, was performed with contrast administration and demonstrated  extensive thrombosis of the left jugular vein (Fig. 5 a, b), fluid collections with gas bubbles in the mediastinum and large partially loculated, bilateral pleural effusions (Fig. 6 a, b, c). The patient underwent thoracotomy, mediastinal drainage and debridement of the necrotic tissues.",
    "discussion": "Mediastinitis can be defined as an inflammation of connective tissue that involves mediastinal structures and fills interpleural spaces. When the infection has its origin in the cervical or oral region it is termed as descending necrotising mediastinitis (DNM). It is associated with a high morbidity and mortality rate. Mediastinitis appears to be a disease of young men with a mean age in the mid fourth decade of life and a male-to-female ratio of 6-1. Odontogenic infections is the most common cause of DNM, especially when the second and third lower molars are involved. Other common causes are retropharyngeal and peritonsilar abscesses. Less common causes include cervical lymphadenitis, clavicular osteomyelitis, traumatic endotracheal intubation, external trauma, drug abuse, parotitis and thyreoiditis. The infection uses the fascial planes in the neck to gain access to the mediastinum. The spread downward is facilitated by gravity, breathing and negative intrathoracic pressure. The potential spaces that can allow inflammatory processes from the head and neck to enter the mediastinum are the carotid, the prevertebral and especially the retrovisceral space. The last one is patent from the skull base to the diaphragm. Predisposing factors for DNM are malnutrition, diabetes, drug abuse, alcoholism, chemotherapy for an existing malignancy and other causes of immunosuppression. The microorganisms involved in DNM may be aerobes or anaerobes. The type most commonly isolated is beta- hemolytic oral streptococcus (odontogenic infections are the most common cause).Clinical manifestations range from subacute forms to devastating ones that require immediate intensive care. The most common symptoms and signs are chills, high fever, tachycardia, dyspnoea, productive cough, pleuritic and retrosternal chest pain, odynophagia, oedema and swelling of the neck, crepitus of the chest and neck, stridor, trismus, Hamman sign and cranial nerve deficits. Sepsis, multiorgan system failure, ARDS, pericarditis and pleural effusion - empyema are the most severe complications. The most common vascular complications are jugular vein thrombosis, carotid pseudoaneurysm and aortopulmonary fistula.Soft tissue radiography of the neck may show widening and presence of air in the precervical and retropharyngeal soft tissues. Plain film chest radiographs may show widening of the mediastinal structures. The lateral film may show anterior bulging on the posterior wall of the trachea. Pleural effusions and lung consolidation are also common findings. Swelling and inflammatory infiltration of the soft tissues of the neck and the mediastinum are easily detected on CT. Fluid collections with or without gas bubbles typical of abcesses  in the neck or the mediastinum are also demonstrated. CT examinations can also reveal lung involvement, pleural and pericardial effusions and vascular complications such as jugular vein thrombosis. Preoperative CTs can show the extent of the necrotising process and locate the lesions for surgical drainage. They are also useful for postoperative follow up. MRI is used to confirm the diagnosis of mediastinitis but is usually reserved for children and patients with impaired renal function. Treatment should include drainage of fluids and management of sepsis if it is present, early antibiotic therapy based on the sensitivity results of cervical and mediastinal tissue cultures, and surgical management.",
    "differential_diagnosis": "Descending, mediastinitis, secondary, to, cervical, necrotising, fasciitis, due, to, odontogenic, infection",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008720/000001.jpg?itok=RpdSxsTl",
            "caption": "Presence of fluid collections with gas bubbles inside at the left masticator, parapharyngeal, carotid and retropharyngeal spaces of the neck. There is expansion of the inflammatory process to the left piriformis sinus."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008720/000002.jpg?itok=qvrW8ZSy",
            "caption": "Presence of fluid collections with gas bubbles inside at the left masticator, parapharyngeal, carotid and  retropharyngeal  spaces of the neck. There is expansion of the inflammatory process to the left piriformis sinus."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008720/000003.jpg?itok=nDnAXuKZ",
            "caption": "Presence of fluid collections with gas bubbles inside at the left masticator, parapharyngeal, carotid and  retropharyngeal spaces of the neck. There is expansion of the inflammatory process to the left piriformis sinus."
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008720/000004.jpg?itok=gBSLsMVk",
            "caption": "Presence of fluid collections with gas bubbles inside at the left masticator, parapharyngeal, carotid and retropharyngeal spaces of the neck. There is expansion of the inflammatory process to the left piriformis sinus."
          },
          {
            "number": "Figure 1e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008720/000005.jpg?itok=IACm4Y2C",
            "caption": "Presence of fluid collections with gas bubbles inside at the left masticator, parapharyngeal, carotid and  retropharyngeal spaces of the neck. There is expansion of the inflammatory process to the left piriformis sinus."
          },
          {
            "number": "Figure 1f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008720/000006.jpg?itok=0RLZCK_1",
            "caption": "Presence of fluid collections with gas bubbles inside at the left masticator, parapharyngeal, carotid and  retropharyngeal spaces of the neck. There is expansion of the inflammatory process to the left piriformis sinus."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008720/000007.jpg?itok=MzhIk3Hw",
            "caption": "The first chest CT examination revealing diffuse opacities of the lungs."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008720/000008.jpg?itok=rp46LynO",
            "caption": "The first chest CT examination  revealing diffuse opacities of the lungs."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008720/000009.jpg?itok=fYfu5RU3",
            "caption": "Axial CT images mediastinal windowing showing oedema and inflammatory infiltration of the soft tissues of the mediastinum."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008720/000010.jpg?itok=39xMWokX",
            "caption": "Axial CT images mediastinal windowing showing oedema and inflammatory infiltration of the soft tissues of the mediastinum."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008720/000011.jpg?itok=lie7xaEm",
            "caption": "Axial CT images (lung windowing) demonstrating diffuse opacities and regions of atelectasis throughout the lung parenchyma."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008720/000012.jpg?itok=ZPJuoprA",
            "caption": "Axial CT images (lung windowing) demonstrating diffuse opacities and regions of atelectasis throughout the lung parenchyma."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008720/000013.jpg?itok=uMQ8DIdc",
            "caption": "Regression of the inflammation of the neck and extensive thrombosis of the left jugular vein."
          },
          {
            "number": "Figure 5b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008720/000014.jpg?itok=i27J9HgA",
            "caption": "Regression of the inflammation of the neck and extensive thrombosis of the left jugular vein."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008720/000015.jpg?itok=X9bvuc68",
            "caption": "Presence of fluid collections with gas bubbles in the mediastinum and large partially loculated bilateral pleural effusions."
          },
          {
            "number": "Figure 6b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008720/000016.jpg?itok=9A8tdMvL",
            "caption": "Presence of fluid collections with gas bubbles in the mediastinum and large partially loculated bilateral pleural effusions."
          },
          {
            "number": "Figure 6c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008720/000017.jpg?itok=HCDM77jJ",
            "caption": "Presence of fluid collections with gas bubbles in the mediastinum and large partially loculated bilateral pleural effusions."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/8720",
    "time": "09.09.2010"
  },
  "8804": {
    "case_id": 8804,
    "title": "Bilateral upper lobar neurogenic pulmonary oedem",
    "section": "Chest imaging",
    "age": "68",
    "gender": "male",
    "diagnosis": "Bilateral upper lobar neurogenic pulmonary oedema",
    "history": "68-year-old male patient with decreased level of consciousness.",
    "image_finding": "A 68-year-old male patient presented with decreased level of consciousness. A non-enhanced trans-axial head CT was obtained showing a hypertensive left cerebellar haemorrhage (Fig 1a) and subarachnoid extension (Fig1b). A chest radiograph was obtained at the time of admission showing bilateral upper zonal opacification, with no obvious Kerley B lines or pleural effusions (Fig 2).A follow-up chest radiograph obtained 2 days later showed rapid resolution of the previously seen upper zonal opacities (Fig 3).After stabilization from the neurological point of view, the patient was discharged home. The clinical and radiological findings in this case were consistent with neurogenic pulmonary oedema (NPE).",
    "discussion": "NPE is an interesting and under-recognised condition. It is seen in association with acute brain insults, such as intra-cranial haemorrhage, encephalitis or seizures (1, 2). The patho-physiology is not clearly known, but the process is initiated by increased intra-cranial pressure. This is thought to lead to catecholamine release and a resulting 'sympathetic storm', which leads to pulmonary vasoconstriction (hydrostatic mechanism) and leaky capillaries from stress failure (non-cardiogenic mechanism) (2).The major presentation in cases of NPE is related to the main intra-cranial event, but respiratory symptoms might contribute to the overall picture and necessitate mechanical intubation (1, 2). Given the commonly associated decreased level of consciousness, NPE might be confused for aspiration pneumonitis. In the context of traumatic related head injuries, it can be confused with pulmonary contusions. Since cases of NPE might be associated with a mild degree of leukocytosis, NPE can be also mistaken for pneumonia. The major hint to the diagnosis is that NPE develops shortly after the intra-cranial insult and resolves quickly within 1-2 days (2).Although NPE can present with variable appearances on chest radiographs, unilateral or asymmetric bilateral upper zonal lung involvement is a known classic presentation. In contrast to the garden variety cardiogenic pulmonary oedema, features such as Kerely B lines and pleural effusions are usually absent. Other diagnostic possibilities which might present with bilateral upper zonal pulmonary oedema include: negative pressure pulmonary oedema, high-altitude pulmonary oedema, smoke inhalation and acute mitral regurgitation (2, 3).The respiratory management of NPE is supportive. The main aim of treatment is to control the primary intra-cranial insult (1-3).",
    "differential_diagnosis": "Bilateral, upper, lobar, neurogenic, pulmonary, oedema",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008804/000001.jpg?itok=GsxqALUX",
            "caption": "Non-enhanced trans-axial head CT showing sizable acute hypertensive left cerebellar haemorrhage (1a) with a subarachnoid extension (1b)."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008804/000002.jpg?itok=89aMhC3x",
            "caption": "Non-enhanced trans-axial head CT showing sizable acute hypertensive left cerebellar haemorrhage (1a) with a subarachnoid extension (1b)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008804/000003.jpg?itok=ItZIOWrc",
            "caption": "Supine chest radiograph obtained at the time of admission showing asymmetric bilateral upper zonal opacification, with no obvious Kerley B lines or pleural effusions."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008804/000004.jpg?itok=8yhCLgVm",
            "caption": "Supine chest radiograph obtained 2 days later showing rapid resolution of the previously seen upper zonal opacities."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/8804",
    "time": "12.10.2010"
  },
  "8817": {
    "case_id": 8817,
    "title": "Westermark sign",
    "section": "Chest imaging",
    "age": "62",
    "gender": "female",
    "diagnosis": "Acute pulmonary embolism \u2013 Westermark sign.",
    "history": "A 62-year-old woman was referred to the department of pneumology for further work-up of pulmonary hypertension with dyspnoea. Chest radiograph showed a translucent right lung due to oligaemia.",
    "image_finding": "A 62-year-old woman was referred to the department of pneumology for a further work-up of pulmonary hypertension with dyspnoea NYHA stage III (= marked limitation of physical activity). She had a history of pulmonary embolism with right sided heart failure two years ago. Laboratory findings revealed a decreased protein S, protein C and factor II. A chest radiograph showed an increased translucency and a reduction of vascular markings in the right lung (Fig. 1).Contrast enhanced CT of the chest revealed a clot in the right pulmonary artery with extension into its branches (Fig. 2) and an eccentric mural thrombus in the segmental branch of the left lower lobe (Fig. 3). Mosaic perfusion is seen bilaterally (Fig. 4). The truncus pulmonalis and pulmonary arteries are enlarged.A pulmonary angiography was performed, which showed a complete obstruction of the right pulmonary artery. There is no perfusion in the entire right lung, with sparing of the apicoposterior segmental artery (Fig. 5A). On the left side, the angiogram demonstrates a filling defect in the segmental branch of the left lower lobe and of the lingula with hypo-perfusion of the lower left lobe (Fig. 5B). The angiogram also confirms enlarged pulmonary arteries.",
    "discussion": "Images are compatible with acute pulmonary embolism of the right pulmonary artery and chronic pulmonary embolism in the left lower pulmonary artery. A right sided cardiac catheterisation showed a moderate pulmonary arterial hypertension, which confirmed the diagnosis of chronic pulmonary embolism in the left lower pulmonary artery.The chest radiograph showed an oligaemic right lung, also known as Westermark\u2019s sign. The Westermark sign is an eponym indicating oligemia distal to a large central pulmonary embolus, which causes an obstruction of blood flow more distally. Presumably the lack of flow to these more distal vessels results in the radiographic transparency. The Westermark sign has a low sensitivity (14%) but a high specitivity (92%) [1]. The differential diagnosis of a hyperlucent lung region includes pneumothorax, presence of a huge bulla or hypoperfusion due to small airways disease.Other radiological signs of pulmonary embolism on conventional radiography can be a peripheral, wedge-shaped consolidation with the lung base on the pleural surface (Hampton\u2019s hump), enlarged pulmonary arteries (Fleischner sign), a small pleural effusion or elevation of the ipsilateral diaphragm. The chest radiograph may also be normal. The hypo-perfusion of the left lower lobe is caused by chronic pulmonary embolism. The enlarged pulmonary arteries are due to chronic pulmonary hypertension secondary to chronic thromboembolism.Laboratory findings suggested protein S deficiency. Protein S deficiency is associated with a hypercoagulable state and an increased risk of venous thrombosis and pulmonary embolism. As a treatment, a vena cava filter placement was performed and anti-coagulation was started.DIFFERENTIAL DIAGNOSIS1) Bulla due to emphysema2) Pneumothorax3) Hypoperfusion due to small airway disease",
    "differential_diagnosis": "Acute, pulmonary, embolism, \u2013, Westermark, sign.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008817/000001.jpg?itok=hudgp0Pk",
            "caption": "Chest radiography shows an increased translucency in the right lung and a\nreduction of vascular markings in the right lung."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008817/000003.jpg?itok=iL5ct0Dw",
            "caption": "Contrast enhanced CT of the chest showing an eccentric mural trombus in the segmental branch of the left lower lobe."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008817/000004.jpg?itok=nBd4fXtY",
            "caption": "Contrast enhanced CT of the chest showing bilateral mosaic perfusion."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008817/000007.jpg?itok=acm68e3T",
            "caption": "Contrast enhanced CT of the chest showing a clot in the right pulmonary artery with extension into its branches."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008817/000008.jpg?itok=4JyjUoqw",
            "caption": "Fig. A (left): Complete obstruction of the right pulmonary artery; sparing of the apicoposterior segmental artery.\n\nFig. B (right): Filling defect in the segmental branch of the left lower lobe and of the lingula."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/8817",
    "time": "20.12.2010"
  },
  "8911": {
    "case_id": 8911,
    "title": "A case of Boerhaave\\&#039;s syndrome- spontaneous oesophageal perforation",
    "section": "Chest imaging",
    "age": "69",
    "gender": "female",
    "diagnosis": "Boerhaave's syndrome - spontaneous oesophageal perforation",
    "history": "A 67-year-old woman attended the emergency department following a choking episode with associated chest pain whilst eating. On attendance in the emergency department, surgical emphysema was noted.",
    "image_finding": "Chest radiograph confirmed surgical emphysema, pneumomediastinum and pneumopericardium [Figure 1]. A CT examination of neck, chest and abdomen was then performed. The CT of neck, chest and abdomen was performed following the administration of oral and intravenous contrast medium. Extensive free gas throughout the neck and chest was noted [Figure 2]. Significant pneumomediastinum was seen to extend along the soft tissue planes into the pericardium and superiorly into the soft tissues of the neck and upper chest producing surgical emphysema. It also extended inferiorly to surround the aorta at the aortic hiatus. There was a moderately sized, right-sided pneumothorax and a tiny left-sided pneumothorax. A right-sided pleural effusion was present, which was hyperdense in keeping with leakage of oral contrast medium into the pleural cavity and there was collapse/consolidation of the right lung base. Oral contrast medium was seen within the oesophagus and free contrast medium was seen exiting the distal third of oesophagus and entering the mediastinum and pleural cavity [Figure 2j].  The patient underwent a posterolateral thoracotomy with a primary repair of the oesophagus and drainage of the right hydropneumothorax. Postoperatively the patient made a slow but full clinical recovery.",
    "discussion": "This case demonstrates the classic clinical presentation and imaging findings of Boerhaave's syndrome or spontaneous oesophageal perforation.Boerhaave's syndrome, or postemetic rupture of the oesophagus, first described in 1724, represents a special instance of barogenic trauma to the oesophagus, leading to a challenging clinical syndrome that still bears its describer's name [1, 2].Vomiting is the most frequent cause of Boerhaave's syndrome, but it is certainly not the only cause and it has been reported with straining, weight-lifting, severe coughing, childbirth, blunt trauma, seizures, Cushing's ulcers, seasickness and asthma. In these cases, a rapid rise in intraluminal pressure with sudden distension of the distal oesophagus causes ''barogenic rupture'' [3].The classical presentation of Boerhaave's syndrome is vomiting, chest pain and subcutaneous emphysema, also called Mackler's triad and was present in this case [4]. Regardless of the cause of oesophageal perforation, a fulminant mediastinal inflammatory response may result from extrusion of bacteria and enzyme rich salivary, gastric, and biliary excretions. Circulation of these noxious stimuli throughout the mediastinum and pleural spaces may be exacerbated by the negative intrathoracic pressure that results from the mechanics of ventilation. Fluid transit across excoriated mediastinal and pleural surfaces can lead to systemic hypovolaemia, hypoperfusion, systemic inflammation, sepsis and multisystem organ dysfunction, typically affecting the respiratory apparatus first. Left untreated, this injury has a mortality approaching 100% [2]. It stands to reason that the longer the course of undetected mediastinal soilage, the worse the patient's condition is likely to be at the time of clinical evaluation. Indeed, delayed diagnosis and therapy have been associated with poorer outcomes historically [2]. Although surgical emphysema is pathognomonic, in patients with spontaneous oesophageal rupture it may or may not be evident in patients who present within one hour of perforation and an essential element in diagnosis of these patients is to maintain a high index of suspicion [5].Chest radiograph is the initial imaging procedure and the simple erect film yields the most information [3, 5]. Virtually 80% of cases have a left pneumothorax plus an effusion on chest radiograph [6], however, a negative or normal chest radiograph does not suffice. Contrast oesophagography, using a water soluble agent initially, followed by a barium study if the initial study is negative, represents the most reliable test for demonstrating a perforation and is mandatory for complete evaluation. Contrast enhanced CT may be useful, as in this case, and is particularly useful when contrast studies are negative or impractical when the patient is intubated/sedated [7].The goals of initial therapy are the same: resuscitation and limiting further mediastinal contamination with cessation of oral intake, antibiotic therapy and nasogastric decompression. In the majority of patients, operative intervention is required like in the presented case [2]. The case clearly illustrates the clinical and imaging findings of Boerhaave's syndrome. The CT findings allowed a prompt diagnosis and speedy surgical repair.",
    "differential_diagnosis": "Boerhaave's, syndrome, -, spontaneous, oesophageal, perforation, Airway, trapping, secondary, to, airway, narrowing, or, mucus, plugging, Straining, against, a, closed, glottis, like, in, weight, lifting, Blunt, trauma, with, injury, to, the, trachea, or, bronchus, Sinus, fracture, Iatrogenic, manipulation, following, dental, extraction, Perforation, with, dissection, of, air, into, mediastinum, from, retroperitoneal, space",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008911/000001.jpg?itok=rdRmTpDM",
            "caption": "Axial CT image on soft tissue window showing right dense hydropneumothorax with contrast extravasation into pleural space, pneumopericardium and pneumomediastinum."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008911/000002.jpg?itok=NjKk3znJ",
            "caption": "Axial CT image on lung window showing right dense hydropneumothorax with contrast extravasation into pleural space, pneumopericardium and pneumomediastinum."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008911/000003.jpg?itok=yKkVTLoD",
            "caption": "Axial CT image on soft tissue window showing right dense hydropneumothorax with contrast extravasation into pleural space, pneumopericardium and pneumomediastinum."
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008911/000004.jpg?itok=Bu8_Jmrv",
            "caption": "Extensive surgical emphysema tracking through the soft tissues of the neck."
          },
          {
            "number": "Figure 1e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008911/000005.jpg?itok=VdqTPdnh",
            "caption": "Extensive surgical emphysema tracking through the soft tissues of the neck and thorax."
          },
          {
            "number": "Figure 1f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008911/000006.jpg?itok=0yYYTZIo",
            "caption": "Sagittal CT MPR reconstruction of chest showing hydropneumothorax and extensive surgical emphysema."
          },
          {
            "number": "Figure 1g",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008911/000007.jpg?itok=Xvehe4tS",
            "caption": "Sagittal CT MPR reconstruction of chest showing extensive pneumomediastinum surrounding the oesophagus, pneumopericardium and pneumothorax."
          },
          {
            "number": "Figure 1h",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008911/000009.jpg?itok=e1UQ4ILn",
            "caption": "Coronal CT MPR reconstruction of chest showing hydropneumothorax, extensive surgical emphysema, pneumopericardium and pneumomediastinum."
          },
          {
            "number": "Figure 1i",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008911/000010.jpg?itok=kHoisTEL",
            "caption": "Coronal CT MPR reconstruction of chest showing hydropneumothorax, extensive surgical emphysema, pneumopericardium and pneumomediastinum."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008911/000011.jpg?itok=orclW5Ym",
            "caption": "Chest radiograph showing surgical emphysema, pneumomediastinum and pneumopericardium."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008911/000012.jpg?itok=AeX9yU_h",
            "caption": "Postoperative chest radiograph showing right thoracotomy clips, right internal jugular venous line, nasogastric tube, ET tube and three chest drains in place."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax",
      "Gastrointestinal tract",
      "Head and neck",
      "Lung",
      "Contrast agents",
      "Anatomy"
    ],
    "imaging_technique": [
      "Digital radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/8911",
    "time": "05.12.2011"
  },
  "8921": {
    "case_id": 8921,
    "title": "Chronic loculated thoracic empyema with fade and nonspecific infectious symptoms in an elderly patient with diabetes mellitus",
    "section": "Chest imaging",
    "age": "80",
    "gender": "male",
    "diagnosis": "Chronic loculated thoracic empyema",
    "history": "An 80 year old man, with diabetes mellitus type II and poor glycaemic control, came to our attention for complaints of asthenia and slight rise in body temperature.Physical examination revealed slenderness and overall decrease in muscle mass due to under nutrition. Laboratory tests displayed anaemia and modest increase in white blood cells.",
    "image_finding": "Chest radiography showed an opacity in the lower left lung zone in close proximity to the chest wall, probably due to a loculated pleural effusion, hilar calcified lymph nodes and no signs of pleuroparenchymal lesions in the right lung (Fig. 1).CT examination revealed a loculated and lenticular-shaped pleural effusion, encapsulated by thickened and partly calcified pleural sheaths, adjacent to the left chest wall and extending toward the lateral costophrenic angle, which was suggestive of chronic empyema. CT displayed also an atelectatic area contiguous to the pleural effusion, involving the inferior lingular segment and pulmonary hilum, hilar lymph node calcifications and absence of patency of lingular bronchi (Fig. 2).A follow-up chest radiograph, carried out 6 months later, confirmed the loculated pleural effusion with parietal pleural calcifications, already referred to as chronic empyema. In addition, the radiography showed a collection of free pleural fluid in the basal area of the left lung (Fig.3).",
    "discussion": "Thoracic empyema is an overt pus collection within pleural space [1]. It may result from primary pleural infection or be secondary to: a) infectious spreading from adjacent or distant foci; b) infection by penetrating injuries or surgical procedures; c) other conditions (e.g. diabetes mellitus, drug abuse) [2-3].Symptoms include dyspnoea, productive cough, chest pain, fever and weakness [3-4]. Typical presentation can be suppressed in patients with chronic debilitation or immunodeficiency (\u201csilent\u201d empyema), with difficult diagnosis [3].Chest radiograph represents the best initial screening procedure, in which the exudative pleural effusion appears as an opaque area, frequently with loculation and air-fluid levels. Chronic loculated empyema displays oblong opacity, similar to a mass ascribable to lung cancer or mesothelioma, with possible calcifications of pleural sheaths [2].Chest ultrasound provides information on fluid collection and presence of septations/ loculations, allowing guided-thoracentesis [4-5].CT scan represents the most suitable method for: assessing overall pleural surfaces; determining the extent of pleural involvement and nature of fluid collection; studying underlying lung parenchyma, mediastinum and chest wall; positioning chest drainages; selecting therapeutic approaches. As compared to other methods, CT is more sensitive for detecting small pleural effusions, discriminating them from peripheral parenchymal infiltrates or pleural thickenings, and exploring ultrasound inaccessible areas [4-5].Typical CT appearances of loculated empyema include: elongated shape with thin and smooth walls; compression of adjacent lung parenchyma; fluid separation of pleural sheaths, with occurrence of \u2018\u2018split pleura sign\u2019\u2019. These findings help to differentiate empyema from pulmonary abscess, which appears as a spherical mass with poorly defined walls, surrounded by consolidated lung. Moreover, its interface angle with chest wall is acute, while empyema forms an obtuse angle [3].Early diagnosis of thoracic empyema is essential for a better prognosis, as it avoids chronicity, usually occurring after 4-6 weeks in the absence of adequate treatment, and complications, including broncho-pleural fistula, chest wall erosion, fibrotorax, multi-organ failure [3].In our patient, empyema development and chronicity were likely promoted by aging and immunodeficiency, resulting from under nutrition and diabetes [6]. Indeed, diabetes with poor glycaemic control determines immunologic depression, mostly related to polymorphonuclear dysfunction, with consequent increase in the risk and severity of infections [7]. Moreover, in elderly patients with comorbidities, as in the present case, empyema symptoms can be scant and nonspecific, resulting in delayed diagnosis with prolonged hospitalization, invasive therapeutic procedures, compromised quality of life, and increase in morbidity and mortality  [6-7]. In this respect, the statement of Hippocrates remains still actual: \u201cIf an empyema does not rupture, death will occur\u201d [8].",
    "differential_diagnosis": "Chronic, loculated, thoracic, empyema, Pulmonary, abscess, Mesothelioma, Lung, cancer",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008921/000001.jpg?itok=dNdLJT2y",
            "caption": "A pleurally based opacity is seen in the lower left lung zone with obtuse angles to the chest wall, probably representing a loculated pleural effusion. Hilar calcified lymph nodes are also seen."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008921/000002.jpg?itok=0rWmGTal",
            "caption": "Postero-anterior chest radiograph: loculated pleural effusion with parietal pleural calcifications, already referred to as chronic empyema; collection of free pleural fluid in the basal area of the left lung."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008921/000003.jpg?itok=tUZAujJV",
            "caption": "Lateral chest radiograph: a well- circumscribed opacity is seen in the left lower lobe, which probably represents the left loculated effusion seen on the lateral chest radiograph."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008921/000004.jpg?itok=b9ji--2s",
            "caption": "Lung window. A loculated pleural effusion adjacent to the left chest wall is seen associated with atelectasis of the inferior lingular segment."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008921/000005.jpg?itok=mVSS-O0w",
            "caption": "Lung window. A loculated and lenticular-shaped left pleural effusion is seen, encapsulated by thickened pleural sheaths. Atelectasis of the inferior lingular segment is also seen."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008921/000006.jpg?itok=lkf3G2Nw",
            "caption": "Mediastinal window. A loculated pleural effusion, encapsulated by thickened and partly calcified pleural sheaths, adjacent to the left chest wall is seen."
          },
          {
            "number": "Figure 3d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008921/000007.jpg?itok=iCKB6qWQ",
            "caption": "A loculated and lenticular-shaped pleural effusion, encapsulated by thickened and partly calcified pleural sheaths, adjacent to the left chest wall and extending toward the lateral costophrenic angle is seen."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Respiratory system"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT-High Resolution"
    ],
    "link": "https://www.eurorad.org/case/8921",
    "time": "17.11.2010"
  },
  "8924": {
    "case_id": 8924,
    "title": "Metastatic pulmonary calcification as complication of haemodialysis",
    "section": "Chest imaging",
    "age": "61",
    "gender": "male",
    "diagnosis": "Metastatic pulmonary calcification",
    "history": "A 61 year old man presented with chronic productive cough without haemoptysis or hoarseness. He had a weight loss of 5 kg the  last two months. He had a smoking history of 30 pack/year, but had stopped smoking 14-years ago. He had a history of IgA glomerulonefritis and was treated with haemodialysis.",
    "image_finding": "A 61 year old man presented with a chronic productive cough. A chest radiograph, High-Resolution-Computed-Tomography (HRCT) and bone scan were performed.Chest X-ray was normal. The PA-film demonstrated a moderate decrease of the translucency in the right lower lung, no parenchymal abnormalities on lateral view were visible. Paracardial fat tissue caused the decreased lung-translucency (Fig 1).HRCT showed multiple nodular ground glass opacities, with a centrilobular distribution pattern bilaterally (Fig 2).  Bronchiectasies, consolidations or thickening of the interstitium were not seen. The bone scan showed diffuse increased tracer uptake at the level of both lungs (Fig 3). There was also an increased tracer uptake at the level of the skull and at the right ankle. Bronchoscopy with transbronchial biopsies was done. Histology showed the presence of fibrosis and dystrophic calcifications in the interalveolar septa and focally in the walls of the blood vessels. The diagnosis of pulmonary metastatic calcification was made.",
    "discussion": "Metastatic pulmonary calcification, also named alveolar calcinosis, occurs in diseases with calcium-phosphate metabolism disturbance. It is most commonly seen in chronic renal failure, but has also been described in primary and secondary hyperparathyroidism, vitamin D hypervitaminosis, milk-alkali syndrome, diffuse myelomatosis and extensive bone malignancy [1]. Usually, the process is seen in the cases of failed renal transplantation, and during haemodialysis treatment. Postmortem, metastatic pulmonary calcification can be found in 60-75% of haemodialysed patients at autopsy [2]. In extensive pulmonary calcification, a restrictive lung function, a decreased diffusion capacity and hypoxemia can be detected [1].In chronic renal failure, four conditions predispose to metastatic calcification. First, acidosis leaches calcium and phosphate from the bone. Second, the failing kidneys fail to produce vitamin D, which leads to lesser calcium uptake. There will be increased parathyroid hormone uptake, resulting in an increased calcium and phosphate release from the bone. Third, intermittent alkalosis, which often accompanies haemodialysis, facilitates the precipitation of calcium salts. Finally, the decreased glomerular filtration of phosphate may contribute to an elevated serum calcium-phosphate product. [2, 3]The extent of the physiologic impairment associated with calcium deposition does not necessarily correlate with the degree of macroscopic calcification deposition [2]. Calcium deposition can be found in every all-parenchymal organs, also the lungs.Chest radiograph is not very effective for detecting metastatic pulmonary calcification. HRCT scan and 99mTechnetium-methylene diphosphate (99mTc-MDP) bone scintigraphy are more sensitive and specific for the detection of pulmonary calcification [1,4].Three patterns of pulmonary parenchymal calcification can be seen on HRCT. First, multiple calcified and/or apparently non-calcified nodules distributed diffusely or patchy in the lungs. Second, diffuse or patchy areas of ground glass opacities. Third, relatively dense areas of consolidation [2].Bone scintigraphy with the bone-avid radiotracer 99mTc-MDP can demonstrate calcium deposition, also in lung tissue and can help in the differential diagnosis of pulmonary lesions [2,4].Specific treatment is aimed at correction of isolated hyperphosphatemia or elevated calcium-phosphate product, if present [2].",
    "differential_diagnosis": "Metastatic, pulmonary, calcification, hypersensitivity, pneumonitis, pulmonary, hemmorhage, respiratory, bronchiolitis, interstitial, lung, disease, infectious, disease",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008924/000001.jpg?itok=u0rwXZJn",
            "caption": "The chest X-ray was normal. On the PA-film, a moderate decrease of the translucency in the right lower lung was visible. Paracardial fat tissue was the cause of the decreased lung translucency."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008924/000002.jpg?itok=7KTeBqMQ",
            "caption": "The chest X-ray was normal. No parenchymal abnormalities on lateral view were visible."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008924/000003.jpg?itok=VCsWBSX_",
            "caption": "HRCT of the chest showed multiple nodular ground glass opacities, with a centrilobular distribution pattern in both lungs. Bronchiectasies, consolidations or thickening of the interstitium were not seen."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008924/000004.jpg?itok=l16otc9u",
            "caption": "HRCT of the chest showed multiple nodular ground glass opacities, with a centrilobular distribution pattern in both lungs. Bronchiectasies, consolidations or thickening of the interstitium were not seen."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008924/000005.jpg?itok=giABQYOt",
            "caption": "The bone scan showed a diffuse increased uptake of tracer at the level of both lungs. There was also an increased tracer uptake at the level of the skull."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT-High Resolution",
      "Digital radiography",
      "Nuclear medicine conventional"
    ],
    "link": "https://www.eurorad.org/case/8924",
    "time": "07.11.2010"
  },
  "8926": {
    "case_id": 8926,
    "title": "Solitary Fibrous Tumor of the left fissural pleura (ECR 2010 Case of the day)",
    "section": "Chest imaging",
    "age": "66",
    "gender": "male",
    "diagnosis": "Solitary Fibrous Tumor of the left fissural pleura",
    "history": "Patient referred to our Hospital for staging melanoma in April 2007. He was non-smoker, asymptomatic and in good general condition. Physical examination and laboratory blood tests were within the normal limits. CT examination of the chest, abdomen, pelvis and head was performed.",
    "image_finding": "Chest CT scans (axial images and multiplanar reconstructions) (Figures 1-5) at lung window setting demonstrates in the left hemithorax a well-marginated ovoid mass attached to the fissural pleura with a small pedicle. The mass predominantly forms obtuse angles with the fissure. CT scans at mediastinal window setting, assessed before and after contrast medium injection, show a solid mass with a considerable enhancement (50 HU) (Figures 2 and 3). No hilar and mediastinal lymph nodes are detected. No abnormalities in the brain, abdomen and pelvis were found. The retrospective evaluation of chest radiographs obtained 11 years before (1996) showed a small ovoid well-defined opacity along the course of the left fissure (Figure 6).The mass was surgically resected.",
    "discussion": "Solitary Fibrous Tumors of the pleura (SFTP) are rare primary mesenchymal neoplasms that can arise anywhere along the pleura and can even be seen along the pulmonary fissures (4%). The tumor is often attached by a pedicle to the pleura. SFTP represent about 17% of all benign intrathoracic tumors. It can grow slowly and potentially become big masses with a malignant behaviour and metastases. The ratio between benign and malignant forms is 7:1. Histochemistry is necessary for differentiation between benign or malignant lesions. SFTP is asymptomatic in over 50% of cases and mostly found incidentally. Symptoms (chest pain, dyspnea, cough) tend to be more common in larger lesions. The prognosis is generally favourable and the therapy is surgery, being the complete surgical excision the best prognostic factor. Recurrence has been reported in up to 16% of the non-peduncolated cases. Chest radiography usually shows a well-defined, homogeneous and rounded mass. While small tumors which arise from the parietal pleural classically form obtuse angles with the chest wall, large or peduncolated lesions form acute angles and may be confused with intrapulmonary masses. Computed tomography (CT) usually demonstrates a well-delineated, homogeneous, and occasionally lobulated solid mass in contact with the pleural surface. On contrast-enhanced CT scans the lesion enhances more than the soft tissue does, because of its rich vascularisation. Tumor arising in an interlobar fissure may be more difficult to differentiate from an intraparenchymal mass, because the lesion appears to be surrounded by lung parenchyma. Evaluation of morphology, margins and angles of the mass with respect to the fissure as well as the identification of a pedicle which connects the lesion to the fissural pleura may help in differential diagnosis and in treatment planning. Thin-section CT scans with multiplanar reformations better depict the relationship of the mass to the pleura. MR imaging can better demonstrate the fibrous character of the lesion. Other possible differential diagnoses include intrafissural effusion, that demonstrates fluid attenuation and does not show enhancement after contrast medium injection; malignant pleural mesothelioma that nearly always shows nodular focal or diffuse circumferential thickening of the pleura that encases the hemithorax; pleural metastasis that are more commonly multiple lesions and may show heterogeneous density, calcification and sometimes irregular margins. Pleural effusion is very common in pleural metastases and mesothelioma. In our case the diagnosis was suspected on the basis of the decribed CT appearances which allowed the identification of a pedicle that connected the mass to the left fissure. Moreover, the lesion was present years before on chest X-rays and showed a low growth over the time, indicative of a benign lesion. At surgery the mass was attached to the fissural visceral pleura with a vascular pedicle and the definite diagnosis was confirmed at specimen and immunohistochemical analysis (figures 7 and 8).",
    "differential_diagnosis": "Solitary, Fibrous, Tumor, of, the, left, fissural, pleura, Localized, Malignant, Pleural, Mesothelioma, Fibrous, Tumor, of, the, pleura, Pleural, metastasis, Intrafissural, pleural, effusion, Intraparenchymal, pulmonary, mass",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008926/000001.jpg?itok=sG15-VOv",
            "caption": "Image demonstrates  a well-marginated ovoid mass in the left emithorax, attached to the fissural pleura with a small pedicle (white arrow). The mass predominantly forms obtuse angles with the fissure."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008926/000002.jpg?itok=UTTdAhn7",
            "caption": "Unenhanced axial image shows a soft tissue ovoid mass in the left hemithorax."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008926/000003.jpg?itok=T1Nw7Qzf",
            "caption": "Enhanced axial image confirms the solid nature of the mass, presenting a considerable enhancement (difference in mean density value in the region of interest of 50 HU). No hilar and mediastinal lymph nodes are detected."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008926/000004.jpg?itok=Xcv121Ud",
            "caption": "Sagittal image better shows the elongated mass and its extension into the left fissure."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008926/000005.jpg?itok=yFUgtyx-",
            "caption": "Coronal image better depict a pedicle (white arrow) that connects the lesion to the fissural visceral pleura and the associated thickening of the fissure."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008926/000006.jpg?itok=2mlcIyg6",
            "caption": "Frontal and lateral views (a,b) show a small ovoid opacity within the inferior portion of the left fissure (white arrowhead and arrow)."
          }
        ]
      },
      {
        "number": "Figure 7",
        "subfigures": [
          {
            "number": "Figure 7",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008926/000007.jpg?itok=aMxRwcVN",
            "caption": "Images show proliferation of spindle cell in a richly collagenous matrix with branching capillary channels, large gaping sinusoidal spaces (\u201cstaghorn\u201d configuration). No significant mitotic activity (less than 5 atypical mitoses per 10 high-power fields) was found."
          }
        ]
      },
      {
        "number": "Figure 8",
        "subfigures": [
          {
            "number": "Figure 8",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008926/000008.jpg?itok=I_me3kBl",
            "caption": "Neoplastic cells showed cytoplasmic immunoreactivity to CD34, bcl-2, and CD99 and were consistently negative for CAM 5.2 and S-100 protein"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/8926",
    "time": "20.10.2010"
  },
  "8935": {
    "case_id": 8935,
    "title": "Leiomyosarcoma of the oesophagus",
    "section": "Chest imaging",
    "age": "66",
    "gender": "female",
    "diagnosis": "Leiomyosarcoma of the oesophagus.",
    "history": "A 66-year old female patient presented with progressive dysphagia (mainly for solid food), cachexia and weightloss. Symptoms had evolved over the last six months. No other signs or symptoms were present and no relevant personal medical history was found. Physical examination and blood work were normal.",
    "image_finding": "As a first approach, chest radiograph was performed to exclude any gross change within the mediastinum that could be the cause of the symptoms. Frontal view (Fig. 1) presented a sharply delineated opacity within lower left lung. Due to reported dysphagia, barium study (Fig. 2) of upper gastrointestinal was performed, which demonstrated an ill-defined large filling defect in the lateral contour of the distal of segment of oesophagus, inducing stenosis at that level and dilatation of the remaining upper oesophagus. Along the lateral contour of the mid oesophagus, it was possible to identify the sharp delineation of the remaing upper portion of the mass observed. To further characterize the mass, a CT examination was performed (Fig. 3), that revealed a low density large mass of the posterior mediastinum -13.5 x 12.5 x 9.6 cm-, with peripheral and heterogeneous enhancement after contrast administration. An MRI was performed to further delineate the relations of the mass with the lower oesophagus and oesophagogastric junction (Fig. 4). The MRI confirmed the presence of a mass with extensive areas of necrosis (high signal intensity in T2-weighted sequences), extending from the level of left hilum through the diaphragm to cardia and gastric fundus, invading the mid and lower segments of the oesophagus. There were no distant metastases or mediastinal node enlargement. Left pleural effusion was present.The differential diagnosis included leiomyosarcoma or GIST of oesophagus. Histological analysis of surgical biopsy revealed leiomyosarcoma of the oesophagus.",
    "discussion": "Leiomyosarcoma is a high-graded, smooth muscle tumour of mesenchymal origin that can arise in the gastrointestinal tract or in any tissue containing smooth muscle fibres [1-5]. Gastrointestinal tract accounts for about 40% of all leiomyosarcomas, especially the region of the stomach and the small bowel, with few reported in the colon and oesophagus (about 5% of all gastrointestinal sarcomas) [1-5]. Besides gastrointestinal tract, about 24% of them can occur in genitourinary tract, 19% in retroperitoneum and 14 % in other soft tissues [1-5]. Oesophageal leiomyosarcoma is reported to be responsible for only 0.5% of all malignancy [1, 2], being found more frequently in the middle or distal third of the oesophagus. Its incidence is greater in middle-aged or elderly patients [2, 4]. Usually oesophageal leiomyosarcomas tend to grow submucosally and extraluminally, which can only give symptoms in the late stage of the disease, generally when large masses are present [4].Nevertheless, the most common symptoms can be the presence of dysphagia, usually in a progressive development, due to the slow growth rate of these tumours, as well cachexia and weight loss [1-4].Metastatic disease -especially hepatic and peritoneal - can occur in later stages [4].The radiographic appearance of leiomyosarcoma is rather non-specific. In barium studies it usually presents as a filling defect of submucosal origin, sometimes with ulcerations. In CT [4, 5] usually there is a large mass with low attenuation areas due to the presence of necrosis, showing moderate peripheral rim enhancement. Calcifications are uncommon. MRI [4] can show the presence of an isointense mass in T1 and hypo to isointense in T2-weighted sequences with the same small hyperintense areas of central necrosis.Due to the nonspecific appearance of these tumours, the differential diagnosis should include masses of the posterior mediastinum, such as neurogenic tumours, lymphoma as well as oesophageal neoplasia. Considering oesophageal leiomyosarcoma the diagnosis is based on pathologic and immunohistochemical finding, being distinguished from gastrointestinal stromal tumours, which are more frequent, based on the fact that the last one expresses KIT (CD117), a tyrosine kinase growth factor receptor [3].The treatment is most often surgical and the prognosis is based on the size of the tumour and the histological grade.In conclusion, leiomyosarcoma of the oesophagus is a rare cause of mediastinal mass, having better prognosis than oesophageal carcinoma.",
    "differential_diagnosis": "Leiomyosarcoma, of, the, oesophagus., Gastrointestinal, stromal, tumours, Neurogenic, tumours, Lymphoma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008935/000001.jpg?itok=H5kYyIjQ",
            "caption": "Frontal chest radiograph - Opacity with regular margins within lower left lung."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008935/000002.jpg?itok=IhPnd1vt",
            "caption": "Subtraction image with ill-defined margin at the lateral contour of distal of segment of oesophagus, inducing stenosis at that level and enlargement of remaining upper oesophagus."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008935/000003.jpg?itok=cy89h1OB",
            "caption": "Low-density (a, b) large mass of the posterior mediastinum, with  peripheral and heterogeneous enhancement (c, d) after contrast administration."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008935/000004.jpg?itok=O9lrtY9R",
            "caption": "Low-density (a, b) large mass of the posterior mediastinum, with  peripheral and heterogeneous enhancement (c, d) after contrast administration. Coronal (e) and sagittal (f) planes."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008935/000006.jpg?itok=HhRxPrAc",
            "caption": "Low-density (a, b) large mass of the posterior mediastinum, with  peripheral and heterogeneous enhancement (c, d) after contrast administration. Coronal (e) and sagittal (f) planes."
          },
          {
            "number": "Figure 3d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008935/000007.jpg?itok=gqMWKcW1",
            "caption": "Low-density (a, b) large mass of the posterior mediastinum, with  peripheral and heterogeneous enhancement (c, d) after contrast administration. Coronal (e) and sagittal (f) planes."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008935/000010.jpg?itok=9w-FqE0L",
            "caption": "Mass extending from the level of left hilum through the diaphragm to cardia. Coronal (a, b) and axial (c, d) T2; coronal T2 (e, f) with fat suppression; axial T1 (g, h) after gadolinium."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008935/000011.jpg?itok=0MgrxJeZ",
            "caption": "Mass extending from the level of left hilum through the diaphragm to cardia. Coronal (a, b) and axial (c, d) T2; coronal T2 (e, f) with fat suppression; axial T1 (g, h) after gadolinium."
          },
          {
            "number": "Figure 4c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008935/000012.jpg?itok=bnRKs8Gv",
            "caption": "Mass extending from the level of left hilum through the diaphragm to cardia. Coronal (a, b) and axial (c, d) T2; coronal T2 (e, f) with fat suppression; axial T1 (g, h) after gadolinium."
          },
          {
            "number": "Figure 4d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008935/000013.jpg?itok=R7gY7iRb",
            "caption": "Mass extending from the level of left hilum through the diaphragm to cardia. Coronal (a, b) and axial (c, d) T2; coronal T2 (e, f) with fat suppression; axial T1 (g, h) after gadolinium."
          },
          {
            "number": "Figure 4e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008935/000014.jpg?itok=0Dyoc_Fq",
            "caption": "Mass extending from the level of left hilum through the diaphragm to cardia. Coronal (a, b) and axial (c, d) T2; coronal T2 (e, f) with fat suppression; axial T1 (g, h) after gadolinium."
          },
          {
            "number": "Figure 4f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008935/000015.jpg?itok=6X9E9iSW",
            "caption": "Mass extending from the level of left hilum through the diaphragm to cardia. Coronal (a, b) and axial (c, d) T2; coronal T2 (e, f) with fat suppression; axial T1 (g, h) after gadolinium."
          },
          {
            "number": "Figure 4g",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008935/000019.jpg?itok=Az_hNfXB",
            "caption": "Mass extending from the level of left hilum through the diaphragm to cardia. Coronal (a, b) and axial (c, d) T2; coronal T2 (e, f) with fat suppression; axial T1 (g, h) after gadolinium."
          },
          {
            "number": "Figure 4h",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008935/000018.jpg?itok=JHkHGZvV",
            "caption": "Mass extending from the level of left hilum through the diaphragm to cardia. Coronal (a, b) and axial (c, d) T2; coronal T2 (e, f) with fat suppression; axial T1 (g, h) after gadolinium."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Mediastinum",
      "Gastrointestinal tract"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "MR",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/8935",
    "time": "21.12.2011"
  },
  "8953": {
    "case_id": 8953,
    "title": "Achalasia of the oesophagus",
    "section": "Chest imaging",
    "age": "87",
    "gender": "male",
    "diagnosis": "Achalasia",
    "history": "An 87 year old man was scheduled for a pacemaker implantation. A routine chest radiograph revealed widening of the upper mediastinum. A chest radiograph obtained two years before also showed a discrete widening of the mediastinum with an air-fluid level in the mediastinum.",
    "image_finding": "A chest radiograph in an 87 year old man revealed widening of the upper mediastinum. A chest radiograph obtained two years before also revealed a discrete widening of the mediastinum with an air-fluid level. A barium-swallow test (Fig 2-4) showed: 1) narrowing of the cardia with dilatation of the oesophagus, 2) severe motility disorder of the oesophagus with absent peristaltic waves of the body of the oesophagus and intermittent appearance of tertiary contractions and 3) delayed and incomplete emptying of the oesophagus with important stasis of the contrast fluid. The diagnosis of achalasia was established.The present chest radiograph however showed marked widening of the upper mediastinum, with a right convex border (Fig 5). To exclude underlying pathology, a CT scan was made (Fig 6, 7). This excluded the presence of haemomediastinum, but revealed a pronounced dilatation of the oesophagus with food stasis as cause of the mediastinal widening.",
    "discussion": "Achalasia of oesophagus is an uncommon neuromuscular disorder in which oesophageal dilatation and hypertrophy of the circular muscle layer occur without organic stenosis. There is loss of peristalsis and the lower oesophageal sphincter fails to relax in response to swallowing. This impairs oesophageal emptying and causes functional obstruction of the oesophagus that persists until hydrostatic pressure of retained material exceeds the pressure generated by the sphincter muscle [1,2,3].Chest radiograph is initially normal. According to disease progression, diagnosis of achalasia can be suggested on radiographic findings if there is one of the following features [2,3]: 1) an additional soft tissue density line parallel to the mediastinal contour with widening of the mediastinum representing the dilated oesophagus (Fig 1, 5). In figure 5, there is more food impaction compared to figure 1 causing more pronounced oesophageal dilatation. This additional density is mostly a right convex opacity projected behind the right heart border or in the upper part of the thorax. Occasionally dilatation of the oesophagus can also cause a left convex opacity (Fig 5); 2) the normal gastric air bubble is usually present in early stages, but is mostly absent in the later stages of the disease; 3) on a lateral chest radiograph, an air-fluid level within the oesophagus may be present (Fig 1), usually in a retrosternal location, but it can also occur in the neck.The classic CT  features of achalasia are (Fig 6,7): 1) narrowing at the cardia; 2) oesophageal enlargement with air-fluid level or mottled food residue.The most important role of CT is to exclude other causes of oesophageal dilatation. A barium swallow test (barium oesophagram with fluoroscopy) is the best initial diagnostic test. Even in early achalasia, as in our patient (Fig 2-4), this examination can demonstrate the classic features of achalasia [2, 4]: 1)the narrowing at the cardia has a characteristic contour and the dilated body of oesophagus blends into a smooth cone-shaped area of narrowing (Fig 2,3); 2) on fluoroscopy the peristaltic waves are weak, simultaneous, irregular, uncoordinated, or absent (Fig 4). 3) as the disease progresses, the oesophagus dilates further and becomes tortuous and, in far-advanced cases, sigmoid in shape (Fig 3,5). This is called the \"bird's beak\"-sign. The lowermost segment retains the classic long, linear narrowing even in late stages of the disease. The column of barium is held up at the narrowed area because the sphincteric mechanism fails to relax normally.",
    "differential_diagnosis": "Achalasia, haemomediastinum, goiter",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008953/000001.jpg?itok=09Ee7Bpk",
            "caption": "Posteroanterior conventional chest radiograph shows an air-fluid level in the upper mediastinum. There is a discrete widening of the mediastinum."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008953/000008.jpg?itok=cTxNUPdi",
            "caption": "Lateral chest radiograph shows an air-fluid level in the upper mediastinum. The oesophagus is dilated."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008953/000002.jpg?itok=y3eRX_vR",
            "caption": "A barium swallow test shows narrowing of the cardia accompanied by a significantly dilated body of the esophagus."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008953/000003.jpg?itok=IYnsjwL6",
            "caption": "A barium swallow test shows progression of achalasia, the esophagus dilates further and becomes tortuous and sigmoid in shape. This is called the bird\\\\\\'s beak-sign."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008953/000004.jpg?itok=ynhqInLh",
            "caption": "A barium swallow test shows the mucosal folds at the narrowing of the cardia."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008953/000005.jpg?itok=7RSltclr",
            "caption": "Conventional chest radiograph shows widening of the mediastinum with a right convex opacity in the upper mediastinum.  There is also an additional soft tissue density line projected behind the left heart border."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008953/000006.jpg?itok=L3JouhUw",
            "caption": "A CT scan of the chest shows pronounced enlargement of the esophagus with stasis of food residue suggestive of marked progression of the achalasia."
          }
        ]
      },
      {
        "number": "Figure 7",
        "subfigures": [
          {
            "number": "Figure 7",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008953/000007.jpg?itok=cpdnNa7R",
            "caption": "The CT scan of the chest shows the dilated esophagus causing the additional soft tissue density line behind the left heart border on chest radiograph."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Mediastinum",
      "Oesophagus"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/8953",
    "time": "12.12.2010"
  },
  "8955": {
    "case_id": 8955,
    "title": "Pulmonary metastatic calcification in chronic renal failure",
    "section": "Chest imaging",
    "age": "71",
    "gender": "female",
    "diagnosis": "metastatic pulmonary calcifications",
    "history": "A 71-year-old woman presented with a non-healing wound at the hospital. She had a history of chronic pyelonephritis and chronic renal failure. She was treated with chronic haemodialysis-haemofiltration.",
    "image_finding": "Chest radiograph, HRCT of the chest and a whole-body 99mTc-MDP-scan were performed. Chest radiograph showed diffuse cloudy opacifications in the right upper lobe. On the left side, there was an elevation of the diaphragm, and some pleural effusion (Fig 1). A HRCT of the chest showed multiple nodular, centrilobular and calcified opacities in the right upper lobe, but also, in lesser degree in the left upper lobe, right lower lobe and lingula (Fig 2). Some of the nodular opacities seen in the right upper lobe demonstrated also punctate calcifications. A whole-body 99mTc-MDP-scan showed a diffusely increased tracer-uptake at the level of the right upper lobe (Fig 3).",
    "discussion": "Pulmonary parenchymal calcifications can be divided into dystrophic and metastatic calcifications. Dystrophic lung calcifications are calcifications seen in inflammatory processes, hemorrhage or infarction. Metastatic calcifications occur in diseases with calcium-phosphate disturbance. The common causes are primary or secondary hyperparathyroidism, chronic renal failure and neoplastic destructive bone lesions as multiple myeloma [1]. In 60 to 75% of patients treated with haemodialysis, metastatic calcifications can be found at autopsy [2]. In extensive pulmonary calcification, a restrictive lung function, a decreased diffusion capacity and hypoxemia can be detected [3]. In chronic renal failure, four conditions predispose to metastatic calcification: 1) Acidosis leaches calcium and phosphate from the bone. 2) Kidneys fail to produce vitamin D, which leads to a decrease of calcium uptake. Parathyroid hormone uptake will increase, resulting in an increased calcium and phosphate release from the bone. 3) Intermittent alkalosis, which often accompanies haemodialysis, facilitates the precipitation of calcium salts. 4) A decreased glomerular filtration of phosphate may contribute to an elevated serum calcium-phosphate product [2, 4].Calcium deposition can be found in all parenchymal organs including the lungs. The extent of the physiologic impact associated with calcium deposition does not necessarily correlate with the degree of macroscopic calcification: massive calcifications can be completely asymptomatic [1].To detect metastatic pulmonary calcification, chest radiograph is not very effective. HRCT of the chest and 99mTechnetium-methylene diphosphate (99mTc-MDP) bone scintigraphy are more sensitive and specific for the detection of pulmonary calcification [3,5].On HRCT of the chest three patterns of pulmonary parenchymal calcification can be seen: 1) multiple, diffusely or patchy distributed, macroscopically or microscopically calcified nodules, 2) diffusely or patchy distributed areas of ground-glass attenuation and, 3) dense area(s) of consolidation [2]. The relative stability of these pulmonary infiltrates - in contrast to infectious processes - is of diagnostic value [1].99mTc-MDP bone scintigraphy demonstrates calcium deposition, also in lung tissue, and can help in the differential diagnosis of pulmonary lesions [2,5]. In patients undergoing haemodialysis or patients with an elevated calcium-phosphate product, metastatic pulmonary calcifications must be taken up in the differential diagnosis of persistent pulmonary parenchymal opacifications [3]. Specific treatment is directed to a correction of isolated hyperphosphatemia or elevated calcium-phosphate product, if present [2].",
    "differential_diagnosis": "metastatic, pulmonary, calcifications, pulmonary, amyloidosis, pulmonary, alveolar, microlithiasis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008955/000001.jpg?itok=C4HzAkqK",
            "caption": "Chest X-ray shows diffuse cloudy opacifications in the right upper lobe."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008955/000002.jpg?itok=OojzPeBC",
            "caption": "Chest X-ray shows diffuse cloudy opacifications in the right upper lobe."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008955/000003.jpg?itok=w2jzu-KG",
            "caption": "Chest CT shows multiple nodular, centrilobular and calcified lesions in the right and left upper lobe."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008955/000004.jpg?itok=bICwSKUE",
            "caption": "Chest CT shows multiple nodular, centrilobular and calcified lesions in the right upper lobe."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008955/000005.jpg?itok=7IiLOUTu",
            "caption": "Chest CT shows multiple nodular, centrilobular and calcified lesions in the right lower lobe, and in the lingula."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008955/000006.jpg?itok=F4Sq9gpO",
            "caption": "Chest CT shows multiple nodular, centrilobular and calcified lesions in the right lower lobe."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008955/000007.jpg?itok=ITamY_Pn",
            "caption": "99mTc-MDP bone scintigraphy shows a diffusely increased tracer-uptake in the right upper lobe."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT-High Resolution",
      "Nuclear medicine conventional"
    ],
    "link": "https://www.eurorad.org/case/8955",
    "time": "11.11.2010"
  },
  "8961": {
    "case_id": 8961,
    "title": "Late onset left diaphragmatic herni",
    "section": "Chest imaging",
    "age": "32",
    "gender": "female",
    "diagnosis": "Late onset left diaphragmatic hernia.",
    "history": "A young female patient with no trauma history came to the radiology department with the suspicion of pleural effusion. Thoracic ultrasound was performed and no pleural fluid was detected. She denied further examinations. Twenty months later she came back with dyspepsia, abdominal distention and flatulence.",
    "image_finding": "Chest radiograph (Fig. 1) detected an extensive area of high density in the region of left lower lobe with round bowel-shaped hypodensities inside. These findings raised the suspicion of left diaphragmatic hernia.A contrast-enhanced thoracoabdominal CT was performed (Fig. 2). It demonstrated a left diaphragmatic defect with intrathoracic herniation of small bowel, distal ileum, cecum, right and transverse colon. Left colon, stomach, spleen and left kidney were located inside abdominal cavity and retroperitoneum. Thoracic apex was occupied by a segment of colon. Volume rendering images demonstrate relationship between colon and left atelectatic lobe (Fig. 3).",
    "discussion": "A diaphragmatic hernia is an abnormal opening in the diaphragm, allowing parts of the abdominal organs to herniate into the thoracic cavity. Congenital diaphragmatic hernia is caused by the improper fusion of the diaphragmatic structures during fetal development. It is seen in 1/2200 to 1/5000 live births, 80 to 90% of cases occurring on the left side.Abdominal viscerae inside the pleural cavity causes pulmonary hypoplasia and affects bronchial and pulmonary vasculature development that leads to pulmonary hypertension.These patients may present with cleft palate, neural tube defects, oesophageal atresia and cardiac defects. Furthermore, some genetic anomalies are associated with congenital diaphragmatic hernias, like trisomies 13, 18 and 21 and tetrasomy 12p (Pallister-Killian syndrome).Traumatic rupture of the diaphragm indicates a high energy impact and is associated with other severe injuries like head injury, pelvic fractures and splenic and renal injuries.In the present case, no traumatic history was reported. Moreover, no anatomical defects were detected, except for left pulmonary loss of volume. It could be hypothesised that a small diaphragmatic defect, with no or minimal repercussion on pulmonary haemodynamics, may have be present at birth. This defect may have grown during the following years with subsequent intrathoracic herniation of small bowel and colon that caused the digestive symptoms.Teaching points:a) Diagnosis of congenital diaphragmatic hernia may be missed at birth.b) Some genetic diseases are associated with congenital diaphragmatic hernias.c) Traumatic diaphragmatic defects indicate a high energy impact, so other associated injuries should be suspected.",
    "differential_diagnosis": "Late, onset, left, diaphragmatic, hernia., Pleural, effusion, Diaphragmatic, eventration",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008961/000001.jpg?itok=QcrDAgg0",
            "caption": "Chest radiograph. Left lower lobe is occupied by a heterogeneous density. Note mediastinum is slightly displaced towards the right side."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008961/000002.jpg?itok=yzKJCfRB",
            "caption": "In lateral projection normal right diaphragm is seen. In chest anterior region air inside some bowel loops (colon) is seen. This finding raised the suspicion of diaphragmatic hernia."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008961/000003.jpg?itok=LXgXT_9M",
            "caption": "Coronal reconstruction. Left pleural cavity is occupied by abdominal viscera. Note colon in apical pleural position. Left lower lobe atelectasis is also seen."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008961/000004.jpg?itok=TZ5iPLz0",
            "caption": "Sagittal rexonstruction. Left hemithorax is occupied by abdominal viscera. Note colon in apical pleural position. Diaphragmatic defect is also seen. Spleen and left kidney are infradiaphragmatic."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008961/000005.jpg?itok=wA26eSny",
            "caption": "Volume rendering reformation from CT images. Relationship between colon and left atelectatic lobe is best depicted."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax",
      "Colon",
      "Gastrointestinal tract",
      "Lung"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/8961",
    "time": "29.12.2010"
  },
  "8994": {
    "case_id": 8994,
    "title": "Atypical bronchial carcinoi",
    "section": "Chest imaging",
    "age": "37",
    "gender": "female",
    "diagnosis": "Atypical bronchial carcinoid with hepatic metastases.",
    "history": "A 37-year-old woman with diarrhoea and abdominal cramps lasting for 15 days.",
    "image_finding": "A 37-year-old female patient was admitted to our department for diarrhoea and abdominal cramps lasting for 15 days. Ultrasonography was performed showing multiple hepatic hypoechoic lesions (Fig. 1). Total body CT scan confirmed hepatic lesions that appeared hypodense in precontrast phase, hyperdense in arterial phase and hypodense in portal phase and also detected obstruction of the right main bronchus and right upper lobe atelectasis (Fig. 2). OctreoScan examination demonstrated abnormal tracer accumulation in the anatomic region of the liver and in the right lung (Fig. 3). The hepatic lesions, on biopsy, were consistent with atypical carcinoid tumour. The patient immediately underwent a lobectomy of the right upper lobe (Fig.4). Biopsy specimen confirmed the diagnosis of atypical carcinoid (well differentiated), on the basis of number of mitosis and proliferation index, instead morphology was suggestive for the typical form.Post-surgical total body CT scan showed no regional relapse (Fig. 5). The liver metastases were treated with somatostatin analogs.",
    "discussion": "Bronchial carcinoid tumours are rare neuroendocrine tumours, accounting for up to 2.5% of all pulmonary neoplasms. They originate from the neurosecretory cells of bronchial mucosa. Two different types have been identified. The first and most common is referred to as typical carcinoid. It is a low-grade tumour, with 10-year survival rate approaching 90%. It is capable of local invasion, including invasion of local lymph-nodes, but rarely metastasizes. The second type, atypical carcinoid, is much more aggressive and carries a 5-year survival rate of 25% to 69% [1].It metastatizes in 70% of the cases to regional lymph-nodes, liver, bone or brain. Both subtypes tend to arise from the bronchial tree and spread by local invasion. Typical carcinoid tumour is more commonly found centrally within the major bronchi, whereas the atypical carcinoid tends to arise from the peripheral and central bronchi with equal frequency. The typical carcinoid tumour shows insular and trabecular foci of uniform cells with regular central nuclei and a faintly eosinophilic cytoplasm. There is no significant cytological atypia or nuclear pleomorphism and mitoses are few. On the other hand, the atypical variant of bronchial carcinoid tumour is characterised by disorganised histological structure with increased cellularity, cellular and nuclear pleomorphism, increased mitoses and focal necrosis [2, 3]. The most frequently (58%) presenting symptoms of carcinoid are lobar obstruction, haemoptysis, dyspnoea, cough, and lobar pneumonia secondary to obstruction. Some are found on chest radiographs in asymptomatic patients. Rarely (1-3%) patients may present symptoms related to serotonin secretion (diarrhea, flushing, wheezing, and carcinoid heart disease) or other hormonally active tumor products such as Cushing's syndrome, hypercalcaemia, hypoglycemia and acromegaly and this reflects liver metastases. Typically, the carcinoid syndrome occurs when hepatic spread results in hormonally active tumor products exceeding the hepatic capacity for degradation [4]. Both types of carcinoid tumours of the lung can occur in patients of any age, without gender preference. The role that smoking plays in the development of carcinoids is still under debate. Chest radiography is the first-line imaging investigation in most patients, is abnormal in 90% of patients with bronchial carcinoids. Computed tomography (CT) is useful for detecting lesions not visible on CXR, for assessing endobronchial lesions, and for characterising and staging tumours. These findings include dense ossification, scattered calcifications, and intraluminal location [5]. Nuclear medicine studies (octreoscan) hold great promise not only for diagnosing and staging of tumours but also for predicting the potential response to somatostatin analogues and other therapeutic radioligands. Definitive diagnosis and classification is made by biopsy and pathologic examination of the tissue. Due to its predilection for arising from the luminal surface of the major bronchi, adequate tissue samples can often be obtained through endobronchial biopsy. Alternatively, tissue may be obtained through CT-guided fine-needle biopsy or thoracotomy. Carcinoid is treated surgically, with the approach dependent on the size, location, and tissue type. Chemotherapy has not been demonstrated to be successful as a treatment option but, rather, is limited to a palliative role in the management of diffuse metastatic carcinoid.",
    "differential_diagnosis": "Atypical, bronchial, carcinoid, with, hepatic, metastases., SCLC, Non, small, cell, lung, carcinoma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008994/000001.jpg?itok=DqlYmsDA",
            "caption": "Precontrast phase: multiple hypodense hepatic lesions.\n(\u00a9 Department of Radiology, Medical University of Pisa, Italy, 2010)"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008994/000004.jpg?itok=3SSt5Jo4",
            "caption": "Arterial phase: peripherally hyperdense hepatic lesions.\n(\u00a9 Department of Radiology, Medical University of Pisa, Italy, 2010)"
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008994/000005.jpg?itok=p80t2MHn",
            "caption": "Portal phase: the lesions get again hypodense.\n(\u00a9 Department of Radiology, Medical University of Pisa, Italy, 2010)"
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008994/000026.jpg?itok=qYzclfAi",
            "caption": "Right bronchus obstruction...\n(\u00a9 Department of Radiology, Medical University of Pisa, Italy, 2010)"
          },
          {
            "number": "Figure 1e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008994/000011.jpg?itok=oFUUCjs2",
            "caption": "...with right upper lobe atelectasis.\n(\u00a9 Department of Radiology, Medical University of Pisa, Italy, 2010)"
          },
          {
            "number": "Figure 1f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008994/000024.jpg?itok=uXOTzJmz",
            "caption": "Lung windowing.\n(\u00a9 Department of Radiology, Medical University of Pisa, Italy, 2010)"
          },
          {
            "number": "Figure 1g",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008994/000010.jpg?itok=KWVLjvXL",
            "caption": "This image shows a calcification inside the lesion.\n(\u00a9 Department of Radiology, Medical University of Pisa, Italy, 2010)"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008994/000012.jpg?itok=YEOtJWGW",
            "caption": "Histological image shows uniform cells arranged\nin sheets and trabeculae...\n(\u00a9 Department of Anotomopathology, Medical University of Pisa, Italy, 2010)"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008994/000013.jpg?itok=SrLe7cMM",
            "caption": "...the cells are polygonal with abundant eosinophilic\ngranular cytoplasm. The nuclei are regular and\nrounded and contain a fine, stippled chromatin\nand small nucleoli.\n(\u00a9 Department of Anotomopathology, Medical University of Pisa, Italy, 2010)"
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008994/000015.jpg?itok=ijRN5_1G",
            "caption": "Rich, fibrovascular stroma separates the cellular sheets or trabeculae.\n(\u00a9 Department of Anotomopathology, Medical University of Pisa, Italy, 2010)"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008994/000016.jpg?itok=5WPL49tD",
            "caption": "A 6 hours delayed  OctreoScan image demonstrates abnormal hepatic and pulmunary tracer accumulation.\n(\u00a9 Department of Nuclear Medicine, Medical University of Pisa, Italy, 2010)"
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008994/000018.jpg?itok=JWzaWJpr",
            "caption": "A 24 hours delayed  OctreoScan image.\n(\u00a9 Department of Nuclear Medicine, Medical University of Pisa, Italy, 2010)"
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008994/000019.jpg?itok=lCPHZV5i",
            "caption": "A 6 hours delayed whole body OctreoScan image demonstrates abnormal hepatic and pulmonary tracer accumulation and the urinary excretion.\n(\u00a9 Department of Nuclear Medicine, Medical University of Pisa, Italy, 2010)"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008994/000020.jpg?itok=te9SyPwG",
            "caption": "Hepatic hypoechoic lesions.\n(\u00a9 Department of Radiology, Medical University of Pisa, Italy, 2010)"
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008994/000021.jpg?itok=R0vQmfPe",
            "caption": "Hepatic hypoechoic lesions.\n(\u00a9 Department of Radiology, Medical University of Pisa, Italy, 2010)"
          },
          {
            "number": "Figure 4c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008994/000022.jpg?itok=0ER_sSv3",
            "caption": "Hepatic hypoechoic lesions.\n(\u00a9 Department of Radiology, Medical University of Pisa, Italy, 2010)"
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000008994/000023.jpg?itok=EGhSIzxw",
            "caption": "Post-surgical total body CT scan shows no loco-regional relapse.\n(\u00a9 Department of Radiology, Medical University of Pisa, Italy, 2010)"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Abdomen",
      "Thorax",
      "Lung"
    ],
    "imaging_technique": [
      "Ultrasound",
      "CT",
      "Nuclear medicine conventional"
    ],
    "link": "https://www.eurorad.org/case/8994",
    "time": "25.02.2011"
  },
  "9009": {
    "case_id": 9009,
    "title": "Kartagener syndrome",
    "section": "Chest imaging",
    "age": "18",
    "gender": "male",
    "diagnosis": "Kartagener syndrome",
    "history": "An 18-year-old male patient presented to ENT department with a chronic history of sinusitis.On further questioning the patient also revealed a history of multiple lower respiratory tract infections.On physical examination heart sounds were heard best on the right side of the chest.",
    "image_finding": "The heart apex points towards the right (dextrocardia). The horizontal fissure is seen in the left hemithorax. Cystic changes and 'tram tracking' are noted in both lower lobes, in keeping with bronchiectasis.Aortic arch is right-sided.The stomach gas bubble is seen beneath the right hemidiaphragm in keeping with situs inversus.",
    "discussion": "Kartagener syndrome is a rare (incidence of 1:32, 000) autosomal recessive disorder which affects the dynein arms in cilia lining the respiratory epithelium and fallopian tubes, and within the flagella of sperm [1]. The abnormal microstucture of the cilia results in their abnormal motility and defective function [2].Kartagener syndrome is one of a group of disorders classified as primary ciliary dyskinesias. The syndrome also involves situs inversus, chronic sinusitis and bronchiectasis (with lower lobe predominance.)The abnormal ciliary function results in reduced mucus clearance and this in turn acts as a substrate for the growth of bacteria. Patients present with chronic lower respiratory tract infections, but also sinusitis and otitis media. The chronicity of the infections invariably leads to bronchiectasis due to chronic damage of the bronchial tree. Similarly, chronic otitis media may lead to hearing loss. The syndrome is associated with infertility due to defective sperm motility.Though clinical signs and symptoms may be typical for the syndrome, the diagnosis is often only made when irreversible damage has been caused.Bronchiectasis is a common finding both on plain radiography and Computed Tomography (especially high resolution CT).Though the underlying aetiology for bronchiectasis is varied, the radiologist should identify any secondary aids to narrow the differential diagnosis.In Kartagener syndrome, such additional findings include those pointing to situs inversus. Such findings can be identified on both plain films and CT, and include dextrocardia, a left-sided liver, a displaced gastric bubble, and the left lung having 3 lobes as identified by a left-sided horizontal fissure [3].Additional views or sequences showing paranasal sinusitis and the clinical history of chronic recurrent respiratory tract infections also point towards Kartagener syndrome as a unifying diagnosis.Thus the radiologist should be familiar with the clinical and radiological manifestation of the disease, and should raise the possibility of the diagnosis.The diagnosis is usually made by a combination of imaging studies, audiological testing, pulmonary function tests and semen analysis. The diagnosis is confirmed by mucosal biopsy which is examined for ciliary movement. Electron microscopy analysis for abnormal ciliary microstructure is also possible though not commonly used in clinical practice.Screening tests include the saccharin test and the measurement of nasal and exhaled nitric oxide.Early diagnosis is the key to reduce the incidence of infections and slow the progression of the disease. Chest physiotherapy is used as a first line treatment to clear inspissated mucus. Aggressive measures to prevent respiratory infections and treatment of superinfection are thought to slow disease progression.Even with aggressive measures, structural destruction often progresses relentlessly, and patients may require lung or lung/heart transplantation [4]. Kartagener syndrome can be suggested initially by a radiologist reading a plain X-ray or CT. Therefore sound knowledge of the radiological signs and clinical symptoms is essential. The findings of bronchiectasis and situs inversus should lead to a full clinical work-up of the syndrome. Early diagnosis may slow disease progression, thus prompt identification is crucial.",
    "differential_diagnosis": "Kartagener, syndrome, Primary, ciliary, dyskinesia, Dextrocardia, Bronchiectasis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009009/000001.jpg?itok=OlDweZyW",
            "caption": "Chest radiograph reveals dextrocardia as part of a situs inversus complex. Cystic changes and \\'tram tracking\\' in the lower lobes suggest bronchiectatic changes. Radiological findings are pathognomonic of Kartagener syndrome."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/9009",
    "time": "09.05.2012"
  },
  "9049": {
    "case_id": 9049,
    "title": "A case report of congenital cystic adenomatoid malformation (CCAM)",
    "section": "Chest imaging",
    "age": "21",
    "gender": "male",
    "diagnosis": "Congenital cystic adenomatoid malformation, type I.",
    "history": "A 21-year-old man with right subscapular pain and tachycardia.",
    "image_finding": "A 21-year-old male patient was admitted to the Emergency Department for right subscapular pain and tachycardia suspicious for pneumothorax. Chest radiograph was performed showing multiple right lung cysts associated with an increase in volume and the subsequent mediastinal shift to the left, but no pneumothorax (Fig. 1). Thoracic CT scan confirmed that the whole of the right lung was replaced with cysts (Fig. 2). Therefore,  a presumptive diagnosis of congenital cystic adenomatoid malformation (CCAM) was made, which was then confirmed by histologic examination.",
    "discussion": "CCAM is a rare developmental,  non-hereditary anomaly of the lung characterised by proliferation of terminal bronchiole-like interconnecting structures with formation of cysts of varying sizes. It constitutes up to 25% of congenital cystic lung lesions. It is classified into three subtypes based on the clinical, gross and histological features. Type I (50\u201370% of cases) is characterised by multiple large cysts,  (up to 10 cm) or a single dominant often multiloculated cyst surrounded by multiple smaller cysts. It has a good prognosis. Type II (20-40% of cases) shows multiple small cysts (< 2 cm). Type III is rare (10% of cases) and consists of a solid mass with cysts less than 0.5 cm mimicking the terminal bronchioles and the alveolar ducts; it is now considered a form of pulmonary hyperplasia.  Types II and III have usually a poor prognosis because they are often associated with other congenital anomalies [1, 2]. The pathogenesis of CCAM is uncertain. The primary defect during development that leads to CCAM has been described as either bronchial atresia or maturation arrest in bronchopulmonary segments before the 17th week of gestation. The morphology of the lesion is then determined by the dysplastic lung growth beyond the atretic segment. In general, lungs with CCAM have a normal arterial supply and venous drainage. The malformation is usually unilateral and sublobar or lobar in size, but occasionally it can be multilobar or bilateral with no special predilection for any lobe. Up to 70% of such cases are asymptomatic at birth, 80\u201385% of cases are diagnosed in the first 2 years of life with signs of respiratoy distresjavascript:view_section(9049,9)s; rarely the presentation is delayed until adulthood. Up to 25% of cases can be associated with other congenital anomalies,  including extralobular sequestration,  diaphragmatic hernia,   pulmonary hypoplasia and cardiovascular malformations. Clinically, adults most frequently show recurrent or persistent pulmonary infections. Other ways of presentation include haemoptysis,  hemothorax, pneumothorax,   pyopneumothorax,   shortness of breath or as an incidental finding on a chest radiograph.The prenatal diagnosis can usually be established by ultrasonography. Chest X-ray and CT represent the postnatal diagnostic method of choice. Radiological abnormalities range from a soft-tissue mass containing single or multiple air-filled cysts of varying sizes to a solid homogeneous mass. CT imaging has a good accuracy in characterising the various types and is indispensable in identifying the true extent of the lesion [3].The differentiation of CCAM from the diaphragmatic hernia can be done noting the presence of abdominal contents in the chest cavity.Pulmonary sequestration appears as a well-circumscribed,   solid mass that receives its blood from the aorta whereas CCAM is usually supplied by the pulmonary artery. Bronchogenic cysts are found predominantly near the carina,  are small and appear as smooth round masses. Congenital lobar emphysema can be distinguished by the presence of bronchovascular markings extending to the periphery of the involved lobe and by atelectasis of adjacent tissues.CCAM has been associated with the development of neoplasms (bronchioloalveolar carcinoma, blastomas and rhabdomyosarcoma). Treatment of CCAM is usually surgical,   involving complete resection of the affected lung lobe [4].",
    "differential_diagnosis": "Congenital, cystic, adenomatoid, malformation,, type, I., Diaphragmal, herniation, Pulmonary, sequestration, Congenital, lobar, emphysema, Bronchogenic, cyst",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009049/000001.jpg?itok=4kf__qbz",
            "caption": "Chest radiograph shows increase of lung volume on the right sight due to the presence of multiple lung cysts...\n\u00a9 \\\"Department of Radiology, Medical University of Pisa, Italy 2011\\\""
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009049/000002.jpg?itok=-vj0njXI",
            "caption": "... more evident at the middle and lower part of the lung, with a significant mediastinal shift to the left. \n\u00a9 \\\"Department of Radiology, Medical University of Pisa, Italy 2011\\\""
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009049/000003.jpg?itok=o_rqdTVp",
            "caption": "Chest CT scans confirm an abnormal right lung with\nextensive and well-defined cystic lesions. There is a mediastinal shift to the left.\n\u00a9\\\\\\\"Department of Radiology, Medical University of Pisa, Italy 2011\\\\\\\""
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009049/000004.jpg?itok=fClXSGlq",
            "caption": "Chest CT scans confirm an abnormal right lung with\nextensive and well-defined cystic lesions. There is a mediastinal shift to the left.\n\u00a9\\\\\\\"Department of Radiology, Medical University of Pisa, Italy 2011\\\\\\\""
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009049/000005.jpg?itok=d47-dqfP",
            "caption": "Chest CT scans confirm an abnormal right lung with\nextensive and well-defined cystic lesions. There is a mediastinal shift to the left.\n\u00a9\\\\\\\"Department of Radiology, Medical University of Pisa, Italy 2011\\\\\\\""
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009049/000006.jpg?itok=xE1mc_i4",
            "caption": "Coronal Reconstruction.\n\u00a9\\\\\\\"Department of Radiology, Medical University of Pisa, Italy 2011\\\\\\\""
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "CT",
      "Conventional radiography"
    ],
    "link": "https://www.eurorad.org/case/9049",
    "time": "04.04.2011"
  },
  "9057": {
    "case_id": 9057,
    "title": "Hodgkin\\&#039;s lymphom",
    "section": "Chest imaging",
    "age": "11",
    "gender": "male",
    "diagnosis": "Hodgkin lymphoma",
    "history": "A previously healthy 11 year old boy presented for the second time to the emergency department in a three week period complaining of sharp retrosternal chest pain.",
    "image_finding": "An 11 year old previously healthy boy presented to the emergency department complaining of a three week history of intermittent sharp retrosternal chest pain.  He did not report any other features on further questioning.His initial observations were within normal limits; however, he had a low-grade pyrexia of 37.6. Cardiovascular examination was unremarkable and his electrocardiogram showed no acute changes. Abdominal examination revealed non-tender hepatosplenomegaly.  Respiratory examination revealed no abnormality.Chest radiograph revealed a large retrosternal mass in the mediastinum with some displacement of the trachea (Fig. 1).   CT imaging of the chest, abdomen and pelvis revealed enlarged lymph nodes in the neck and supraclavicular fossa bilaterally.  There were multiple nodes in the mediastinum with the largest measuring 5.7 x 5.2 x 9.8 cm (Fig. 2).  It also demonstrated enlargement of the liver and spleen (Fig. 3).He was subsequently diagnosed with Hodgkin Lymphoma (HL) following a surgical biopsy of a superficial cervical lymph node.",
    "discussion": "Hodgkin Lymphoma (HL) is a B-cell malignant disorder predominately affecting lymphatic tissue. It is a rare disease with a slight male predominance (1.3:1) and a peak incidence in the third decade. The presence of the Reed-Sternberg cell is pathognomonic, and is derived from germinal centre B cells. The aetiology of Hodgkin Lymphoma is thought to be multifactorial, but there is a well documented link between Hodgkin lymphoma and Epstein-Barr virus (EBV), accounting for approximately 50% of cases worldwide [1,2,3,4].Hodgkin Lymphoma normally presents with lymphadenopathy, typically cervical nodes, which are usually painless and resistant to antibiotic therapy.  There may be accompanying hepatosplenomegaly. Patients with mediastinal adenopathy may present with respiratory symptoms such as shortness of breath, chest pain or cough [3,5].Imaging studies that should be undertaken when Hodgkin Lymphoma is suspected include chest radiography with AP and lateral views to assess the bulk of the mediastinum. CT/MRI of the neck, chest, abdomen and pelvis are also useful to assess the extent of the disease and look for extranodal involvement. Ultrasound scanning has a small role to play in the initial diagnosis but can be used for follow up and monitoring particularly of cervical nodes, as it is relatively simple and non-invasive. Fluorodeoxyglucose (FDG) positron emission tomography (PET) has a proved role for HD in adults but the role of this imaging technique is as yet uncertain in children. However, it may play a role in distinguishing between benign masses and active disease post treatment [5]. No single imaging technique can provide a definitive diagnosis and lymph node biopsy remains the gold standard for diagnosis as fine-needle aspiration is not recommended because of lack of stromal tissue obtained which leads to difficulty classifying the Hodgkin lymphoma [5]. Today, the majority of children and adolescents diagnosed with Hodgkin's lymphoma will be cured following treatment with chemotherapy alone or in combination with low-dose, involved-field radiation, with a recurrence rate of less than 10% [6]. This has lead to concerns that repeated doses of radiation delivered in the course of \"routine\" post therapy surveillance would be detrimental. Clinicians managing these cases should carefully consider the long term implications of serial scans and question the use of imaging studies in these patients beyond those performed for initial assessment and response to treatment, with good clinical follow up and examination yielding a 98% pick up rate for recurrence without the need for imaging [7].",
    "differential_diagnosis": "Hodgkin, lymphoma, Non-Hodgkin, lymphoma, Lymphadenopathy, Acute, lymphoblastic, leukaemia, Tuberculosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009057/000003.jpg?itok=M5gJG4jZ",
            "caption": "Posteroanterior Chest radiograph taken at the time of presentation showing bilateral paratracheal and hilar lymphadenopathy, worse on the right side.  It also demonstrates some displacement of the trachea to the left."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009057/000004.jpg?itok=sslGYS6W",
            "caption": "This scan demonstrates the largest paratracheal node (5,7x5,2x9.8) causing minimal tracheal compression & extending into right lung, along with nodes encircling the arotic arch &amp; SVC causing no large vessel compression/occlusion."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009057/000006.jpg?itok=k1d96mjM",
            "caption": "Scan at the level of T4 demonstrating the nodes encircling the arotic arch &amp; SVC causing no large vessel compression/occlusion. It also highlights the minimal tracheal compression with slight wall collapse on the right side."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009057/000007.jpg?itok=4Xbb2OYQ",
            "caption": "CT Reconstruction in the sagittal plane demonstrating the largest node extending into the right lung field. It also demonstrates the extent of hepatomegaly."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009057/000008.jpg?itok=LoGNgTkS",
            "caption": "CT Reconstruction in the coronal plane demonstrating the largest node extending into the right lung field. It also demonstrates the extent of hepatosplenomegaly."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009057/000005.jpg?itok=JYLW8i62",
            "caption": "Contrast-enhanced CT at portal venous phase demonstrates the abnormal texture of the spleen showing heterogeneous enhancement.\nIt also demonstrates hepatosplenomegaly."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/9057",
    "time": "17.02.2011"
  },
  "9074": {
    "case_id": 9074,
    "title": "Scleroderma:  A focus on pulmonary findings",
    "section": "Chest imaging",
    "age": "58",
    "gender": "female",
    "diagnosis": "Scleroderma, Systemic sclerosis",
    "history": "A 58-year-old woman with chronic dyspnoea and reflux undergoes evaluation for worsening shortness of breath. The patient has a chronic medical condition and is on immunosuppressive medication. Chest radiograph,  CT,  and high-resolution CT (HRCT) are performed.",
    "image_finding": "The chest radiograph shows increased interstitial markings and decreased lung volumes. Associated esophageal dilation with an air-fluid level,  as seen in this case (Fig. 1),  suggests the diagnosis of scleroderma. Colonic dilation,  an additional manifestation of the disease's smooth muscle involvement,  is also seen (Fig 1). Although not appreciated on the chest radiograph,  pulmonary arterial dilation from pulmonary hypertension is seen on CT (Fig. 2b). HRCT shows the classic pulmonary findings in scleroderma,  which cosist of a non-specific interstitial pneumonia (NSIP) pattern. These findings are most apparent in the lower lobes and include reticulonodular interlobular septal thickening,  subpleural ground-glass opacities,  and traction bronchiectasis (Fig. 3a-c). There is notable absence of pleural-based honeycombing,  which is seen in usual interstitial pneumonia (UIP) / idiopathic pulmonary fibrosis (IPF),  and not NSIP. Predominant involvement of the lower lobes,  with extensive volume loss,  can be appreciated on the coronal reformat (Fig. 4). Esophageal dilation is also noted (Fig. 2a, b and Fig 3c).",
    "discussion": "Scleroderma is a collagen vascular disease of unknown etiology that leads to inflammation and fibrosis in multiple organ systems including the skin,  GI tract,  heart,  and lungs. Pathogenesis involves inflammatory mediators from alveolar macrophages causing fibrotic changes in the lung. Similar to other immune-mediated diseases,  it presents most commonly in middle-aged women. Two main variants are the limited and systemic forms,  with the limited form obsoletely described as CREST syndrome (Calcinosis,  Raynaud phenomenon,  esophageal dysmotility,  sclerodactyly,  and telangiectasia) [1]. Clinical pulmonary findings include dyspnea on exertion and dry cough.     The most common radiographic findings in scleroderma are those of the respiratory tract. Interstitial lung disease occurs in approximately 80% of patients and pulmonary hypertension occurs in up to 50% of patients [2]. Pulmonary radiographic findings include a basilar irregular reticular or reticulonodular pattern with interlobular septal thickening,  ground-glass opacities,  traction bronchiectasis,  and pleural thickening. High resolution CT (HRCT) in scleroderma more closely resembles non-specific interstitial pneumonia (NSIP) with pulmonary fibrosis that is less coarse with more ground glass opacification compared to usual interstitial pneumonia (UIP) / idiopathic pulmonary fibrosis (IPF). Scleroderma rarely has multiple subpleural cysts termed \u201choneycombing\u201d or findings of upper lobe fibrosis characteristic of UIP. Histopathologic and survival data in scleroderma patients with pulmonary findings also more closely resemble those seen in patients with idiopathic NSIP rather than UIP/ IPF. [3]     HRCT is superior to chest radiograph in detecting pulmonary findings; however,  the degree of fibrosis does not correlate to clinical presentation [4]. There is asymptomatic esophageal dilatation in 80% of cases and mediastinal adenopathy in 60% [5]. Subpleural cysts,  seen in the lower lobes,  can cause spontaneous pneumothorax. Alveolar infiltrates are occasionally seen and can be secondary to aspiration from esophageal dysmotility.      Differential diagnosis includes other collagen vascular diseases,  such as systemic lupus erythematosus (SLE),  rheumatoid arthritis,  Sjogren's syndrome,  dermatomyositis-polymyositis,  and mixed connective tissue disease. Lung disease secondary to rheumatoid arthritis is associated with air trapping,  mosaic perfusion,  and cavitating subpleural rounded opacities. Lung disease associated with SLE is more frequently seen with pleural and pericardial effusions. Less likely differentials include asbestosis which would have calcific pleural plaques with less ground-glass opacities and bronchiectases; or drug-toxicity which would have more ground-glass opacities [6].      Clinical diagnosis is supported with serologic markers of specific autoantibodies,  bronchoalveolar lavage,  and rarely,  lung biopsy. Patients with scleroderma have increased risk of lung cancer [7]. The disease progresses towards fibrosis and respiratory failure. Steroids and other immunosupressants are used to manage disease progression which may lead to further pulmonary complications of drug-toxicity and opportunistic infections. Pulmonary disease has become the leading cause of death in scleroderma patients with the advent of improvements in the treatment of renal complications [8].     Teaching Point:Radiographic findings of a dilated esophagus and HRCT findings consistent with an NSIP pattern are suggestive of scleroderma.",
    "differential_diagnosis": "Scleroderma,, Systemic, sclerosis, Systemic, lupus, erythematosus, (SLE), Rheumatoid, arthritis, Sjogren`s, syndrome, Dermatomyositis-Polymyositis, Mixed, connective, tissue, disease, Nonspecific, interstitial, pneumonitis, (NSIP), Usual, interstitial, pneumonia, (UIP), Asbestosis, Drug-toxicity",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009074/000001.png?itok=Pax4GTHs",
            "caption": "Posteroanterior chest radiograph shows a large, dilated, air-filled esophagus, reticular interstitial lung markings, bilateral lower lobe volume loss, and dilated loops of bowel. No enlargement of the pulmonary arteries can be appreciated."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009074/000002.png?itok=RXQuFtnG",
            "caption": "The 5 mm thick coronal reformat shows peripheral, subpleural groundglass opacity, prominent reticular markings, and traction bronchiectasis with lower lobe predominance consistent with nonspecific interstitial pneumonia (NSIP) and scleroderma."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009074/000003.png?itok=Oer4VKh-",
            "caption": "Sequential 1.25mm axial HRCT images. Peripheral, subpleural groundglass opacity, prominent reticular markings, and traction bronchiectases are seen with lower lobe predominance consistent with nonspecific interstitial pneumonia (NSIP) and patient\u2019s history of scleroderma."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009074/000004.png?itok=9NkRGGr3",
            "caption": "Sequential 1.25mm axial HRCT images. Peripheral, subpleural groundglass opacity, prominent reticular markings, and traction bronchiectases are seen with lower lobe predominance consistent with nonspecific interstitial pneumonia (NSIP) and patient\u2019s history of scleroderma."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009074/000005.png?itok=bGYMHYb1",
            "caption": "Sequential 1.25mm axial HRCT images. Peripheral, subpleural groundglass opacity, prominent reticular markings, and traction bronchiectases are seen with lower lobe predominance consistent with nonspecific interstitial pneumonia (NSIP) and patient\u2019s history of scleroderma."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009074/000006.jpg?itok=RiSDNZhq",
            "caption": "Initial CT on lung windows, at the level of the aortic arch demonstrates a dilated oesophagus with an air-fluid level and normal appearing lung parenchyma."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009074/000007.jpg?itok=PbKceLhz",
            "caption": "Soft tissue windows demonstrate mild dilation of the pulmonary arteries. This is evidenced by the diameter of the main pulmonary artery equaling the adjacent aortic root. Air-fluid level in the oesophagus is seen."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Oesophagus",
      "Lung"
    ],
    "imaging_technique": [
      "Digital radiography",
      "CT",
      "CT-High Resolution"
    ],
    "link": "https://www.eurorad.org/case/9074",
    "time": "17.03.2011"
  },
  "9103": {
    "case_id": 9103,
    "title": "Bilateral aspergillomas",
    "section": "Chest imaging",
    "age": "48",
    "gender": "male",
    "diagnosis": "Bilateral aspergillomas",
    "history": "A 48-year-old male patient with history of long exposure to dusts (especially plaster) and previous pulmonary tuberculosis (TB) presented with dyspnea on exertion, cough and hemorrhagic sputum. Smoking habit was not reported.Physical examination revealed decreased intensity of vesicular breathing in right side and diffuse crackles at pulmonary auscultation.",
    "image_finding": "Chest radiograph demonstrated two cavitary lesions presenting with the \"air-crescent sign\" in medial and upper zones of the lungs, bilaterally (Fig. 1).In high resolution CT (HRCT) of the chest, diffuse fibrotic changes with areas of disruption of normal lung anatomy were present,  associated with cavitations,   most likely secondary to the previous TB infection. More specifically there were two thick-walled lung cavities containing radiodense \"material\". One of them presented with the  classic \"sponge like\" appearance (Fig. 2),   which changed position in prone HRCT (Fig. 3). The findings were consistent with the presence of fungus balls within the preexisted cavities.The imaging findings are typical of multiple aspergillomas and the patient presented Aspergillus spp. in the sputum samples.",
    "discussion": "Aspergillus infection is caused by fungi of the genus Aspergillus,  abundant in soil and water. Several species exist,  however,  the most common are Aspergillus fumigatus and Aspergillus flavus [1,  2].The spectrum of diseases in lungs range from aspergilloma to angio-invasive or airway-invasive aspergillosis,  depending on immune system or concomitant diseases of the host [1,  2].Aspergilloma (also known as mycetoma or fungus ball) is a collection of hyphae of fungus,  almost with the morphology of a ball,  also accumulating cellular debris [2],  which usually colonizes already existing cavities,  generally as a result of previous pulmonary diseases,  such as sarcoidosis or pulmonary tuberculosis [1,  2]. This colonization usually begins as a nodular thickening of the cavity,  formed by the conglomeration of hyphae. When not supportable within the inner wall,  the fungus ball falls in the cavity,  mixing with cellular debris and having a \u201csponge like\u201d appearance due to presence of air pockets within the lesion. As there is no attachment to the wall of the cavity,  the aspergilloma changes its position with the mobility of the patient.Aspergillomas are more common in middle-aged patients,  being asymptomatic and discovered accidentally. However,  sometimes aspergillomas can be found following an episode of haemoptysis [1-3],  which is a relatively frequent presentation. The cause of hemoptysis is not completely understood [1]. Our patient had a follow-up examination because of the history of tuberculosis, but nevertheless he presented hemorrhagic  sputum as well.The other types of Aspergillus infection allergic bronchopulmonary aspergillosis,  semi-invasive aspergillosis,  airway-invasive aspergillosis and angioinvasive aspergillosis [2].Radiologic appearance of aspergilloma is very characteristic,  especially on CT examination,  which is virtually pathognomonic. Sputum cultures or the presence of precipitating antibodies can also be found,  but neither is specific [1].On chest radiograph there is a rounded opacity within a preexisting cavity,  most commonly located in the upper lung lobes. As the opacity does not fill the cavity completely, the \u201cair crescent\u201d sign is seen [1-3]. On CT this sign can be well seen,  with the presence of the fungus ball inside of a thickened wall cavity,  usually with a \u201csponge like\u201d appearance,  and its mobility can be confirmed by changing the patient into prone position [1-3].Differential diagnosis includeS necrotising pneumonia (invasive aspergillosis),  echinococcal cyst or bronchogenic carcinoma. A minority of aspergillomas can resolve spontaneously [2]. In cases of severe haemoptysis surgical resection is indicated [2].",
    "differential_diagnosis": "Bilateral, aspergillomas, Necrotising, pneumonia, (invasive, aspergillosis), Echinococcal, cyst, Bronchogenic, carcinoma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009103/000001.png?itok=MdIVbtJl",
            "caption": "Frontal chest radiograph shows at least two thick-walled cavities bilaterally (arrows) presenting air-crescent sign."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009103/000002.png?itok=k08k9wUa",
            "caption": "HRCT of the chest, in supine position presenting \\\"material\\\" within the two lung cavities (arrows)."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009103/000003.png?itok=jyiyqLXl",
            "caption": "HRCT of the chest, in supine position presenting \\\"material\\\" within the two lung cavities (arrows)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009103/000004.png?itok=pJDVQ1Tm",
            "caption": "Prone HRCT of the chest, showing mobility of the \\\"material\\\" within the cavities (arrows)."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax",
      "Lung"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT-High Resolution"
    ],
    "link": "https://www.eurorad.org/case/9103",
    "time": "28.03.2011"
  },
  "9125": {
    "case_id": 9125,
    "title": "Primary leiomyosarcoma of the mediastinum",
    "section": "Chest imaging",
    "age": "58",
    "gender": "female",
    "diagnosis": "Primary leiomyosarcoma of the mediastinum",
    "history": "A  58 year-old woman was admitted to our hospital for dyspnoea and chest tightness.",
    "image_finding": "Chest radiograph showed a large homogenous opacity,  with well-defined contours,  in the right superior mediastinum (Fig 1).To further investigate the mass chest CT was performed. CT showed a large soft tissue mass,  14x11x14 cm,  with multilobulated edges located at the right superior mediastinum. The mass displaced the mediastinal structures without evidence of cleavage plane with the mediastinal structures. Contrast-enhanced CT showed heterogeneous enhancement of the lesion due to areas of necrosis; the mass appeared to be highly vascularised with evidence of neoangiogenesis (Fig. 2). It infiltrated the superior vena cava and the pleural wall,  and many collateral vessels were observed (Fig. 3). The patient underwent mediastinoscopy to perform biopsy. The histological examination classified the lesion as a richly cellular leiomyosarcoma with areas of necrosis and high grade of mitosis (50 mitosis/10HPF).Due to the local spreading of the disease the patient underwent radiotherapy and chemotherapy with doxorubicin.",
    "discussion": "The primary tumours of the mediastinum include: thymomas,   lymphomas,   sarcomas,  germ cell tumours and vascular tumours.Primary sarcomas of the thorax are rare; they are classified according to their histological features and constitute a large group of tumours that occur in the lung,   mediastinum,   pleura  and chest wall. Angiosarcoma,   leiomyosarcoma,   rhabdomyosarcoma,   and mesothelioma (sarcomatoid variant) are the most commonly encountered histopathological types. Leiomyosarcomas are extremely rare tumours, which develop from smooth muscle, usually in the esophagus and large vessels. In very rare cases,  leiomyosarcomas develop from small vessels in the soft tissue of the mediastinum. Approximately 5-10 % of all tissue sarcomas are leiomyosarcomas and they affect predominantly women during the 5th and 6th decade of life. Clinical symptoms of mediastinal leiomyosarcoma such as dysphagia and dyspnoea are related to its large size and the subsequent compression of mediastinal structures. CT is the study of choice in the evaluation of a mediastinal mass because it can show characteristic features of malignancy, it can evaluate the local extension, the spreading of the disease and the relationship between the mass and the surrounding structures. Although primary thoracic sarcomas commonly manifest as large, heterogeneous masses, they have a wide spectrum of radiological manifestations, including solitary pulmonary nodules, central endobronchial tumours and intraluminal masses within the pulmonary arteries. Leiomyosarcoma of the mediastinum may manifest at CT as a large necrotic multilobular mass which dislocates and invades the surroundings organs as in the case reported [3].Treatment of localised leiomyosarcoma is based on surgical excision, either alone or in combination with radiotherapy of the mediastinum. In the case of locally advanced disease or metastatic disease surgery is not recommend and chemotherap - generally doxorubicin - is the treatment of choice with or without radiotherapy [4].In conclusion, mediastinal leiomyosarcoma is a rare tumor, which can be suspected when the CT excludes the presence of a primary tumour of the lung or metastatic disease. It appears as a wide necrotic mass with high tendency to invade the surrounding organs, is highly aggressive,   and histological examination is required to reach a reliable diagnosis.",
    "differential_diagnosis": "Primary, leiomyosarcoma, of, the, mediastinum, Other, mediastinal, tumours, Metastatic, disease, Primary, tumours, of, the, lung",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009125/000001.jpg?itok=puHcu-bw",
            "caption": "Contrast enhanced CT scans at two levels (a,b)  detect a mediastinal mass  at the right superior mediastinum. The mass shows heterogeneous enhancement with  necrotic areas. There is contralateral shift of mediastinum to the left."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009125/000003.jpg?itok=efzaoeRI",
            "caption": "Contrast enhanced CT scans at two levels (a,b)  detect a mediastinal mass  at the right superior mediastinum. The mass shows heterogeneous enhancement with  necrotic areas. There is contralateral shift of mediastinum to the left."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009125/000002.jpg?itok=5y8a2ony",
            "caption": "Multiplanar reconstruction  in coronal (a) and sagittal (b) planes confirms \ninvasion of the superior vena cava and  shows the local spreading of the disease ."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009125/000004.jpg?itok=KpWbv4g-",
            "caption": "Multiplanar reconstruction  in coronal (a) and sagittal (b) planes confirms \ninvasion of the superior vena cava and  shows the local spreading of the disease ."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009125/000005.jpg?itok=Nl_NIU-z",
            "caption": "Chest radiograph in two projections (a,b) shows a wide mass in the right superior mediastinum."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009125/000006.jpg?itok=OXwDq_NQ",
            "caption": "Chest radiograph in two projections (a,b) shows a wide mass in the right superior mediastinum."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax",
      "Mediastinum"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/9125",
    "time": "05.04.2011"
  },
  "9148": {
    "case_id": 9148,
    "title": "An anterior mediastinal mass",
    "section": "Chest imaging",
    "age": "64",
    "gender": "female",
    "diagnosis": "Benign mature teratoma",
    "history": "A 64-year-old woman was sent to the hospital for evaluation of a suspected mass in her left breast. A preoperative chest radiograph showed en enlarged mediastinum. On chest CT, an anterior mediastinal mass was found. To further characterise and stage this mass, a PET-CT was performed.",
    "image_finding": "A preoperative chest radiograph showed an enlarged mediastinum, suggestive of a mediastinal mass (Fig. 1). A PET-CT was performed to characterize and stage this mediastinal mass.\nContrast-enhanced CT scan showed an encapsulated mass in the anterior/middle mediastinum. It contained soft tissue and fat densities (Fig. 2), but also multifocal and irregular calcifications in the mass were seen (Fig. 3). The presence of fat and calcifications made the diagnosis of teratoma highly suggestive. A compression of the pulmonary trunk and the left hilum was present (Fig. 4). No lymphadenopathy or metastases were detected.\nFDG-PET (Fig. 5) and PET-CT (Fig. 6) showed a voluminous mass with a hypermetabolic rim but no central FDG uptake. There were no FDG-avid distant lesions.\nThis mediastinal mass was surgically removed. The mass showed a mixture of hair, sebum, bone, synovium and cartilage (Fig. 7). The diagnosis of a mediastinal teratoma was made.",
    "discussion": "Benign mature teratomas are tumours that belong to the group of germ cell tumours, typically occur in young patients and have an approximately equal sex ratio. They are derived from primitive cells that fail to migrate completely during early embryonic development. They predominantly consist of ectodermal elements including skin, sebaceous gland, hair and calcification.\nMediastinal teratomas account for 10-20% of all mediastinal tumours and are usually found in the anterior mediastinum [1]. Most patients are completely asymptomatic as the tumour grows slowly. As they enlarge they may cause symptoms by compressing surrounding structures. Extrinsic compression of the heart and great vessels appears to be very rare [2, 3]. Benign teratomas do have the potential to undergo malignant transformation into a variety of malignancies as rhabdomyosarcoma, adenocarcinoma, leukaemia and anaplastic small cell tumours [4].\nDiagnostic assessment of mediastinal tumours is performed with plain chest radiographs and chest CT. Although the presence of fat and calcification within an anterior mediastinal mass suggests a teratoma, the preoperative diagnosis is often difficult on plain films because of the inability to detect the fat or calcification. CT accurately estimates the density of all included tissues, such as soft tissue (in virtually all cases), fluid (88%), fat (76%), calcification (53%) and teeth, which are considered specific imaging findings [5, 2]. MRI is a very valuable tool in detecting the anatomical relations to the mediastinal and the hilar structures, like vessels and airways. A large anterior mediastinal mass with a well-defined wall and predominantly cystic component is highly suggestive of a benign cystic teratoma. With calcifications in the wall of the mass or small spherical or irregular calcifications within the mass, mature cystic teratoma is even more likely. Unequivocal fat within the mass, particularly a fat-fluid level, makes this diagnosis certain.\nComplete surgical resection is the treatment of choice, but also subtotal resection can relieve symptoms.",
    "differential_diagnosis": "Benign, mature, teratoma, Mediastinal, lipomatosis, Thymolipoma, Liposarcoma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009148/000002.jpg?itok=A0zndck5",
            "caption": "A 64-year-old woman with a mediastinal mass. Axial chest CT images on mediastinal window showed  a mass in the anterior mediastinum with soft tissue and fat densities."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009148/000003.jpg?itok=GvljUX9S",
            "caption": "A 64-year-old woman with a mediastinal mass. Axial chest CT images on mediastinal window showed  a mass in the anterior mediastinum with soft tissue and fat densities."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009148/000004.jpg?itok=o7RRROLd",
            "caption": "A 64-year-old woman with a mediastinal mass. Axial contrast-enhanced chest CT image on mediastinal window showes a mass in the anterior mediastinum with compression of the pulmonary trunk and the left hilum."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009148/000005.jpg?itok=NkBtyb23",
            "caption": "FDG-PET, coronal view (Fig 5a) and axial view (Fig 5b) showed a large mass in the anterior mediastinum with a hypermetabolic rim, but without central FDG uptake."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009148/000006.jpg?itok=YUkb0a62",
            "caption": "FDG-PET, coronal view (Fig 5a) and axial view (Fig 5b) showed a voluminous mass in the anterior mediastinum with a hypermetabolic rim, but without central FDG uptake."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009148/000007.jpg?itok=r1rxmujp",
            "caption": "FDG-PET-CT, axial view showed a large mass in the anterior mediastinum with a hypermetabolic rim in the wall of the lesion, but without central FDG uptake."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009148/000008.jpg?itok=5oLSKcDH",
            "caption": "PA view of the chest showed an enlarged left anterior mediastinum. Within this suspected mediastinal mass, irregular calcifications are visible."
          },
          {
            "number": "Figure 6b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009148/000009.jpg?itok=gocgmm27",
            "caption": "Lateral view of the chest showed an anterior mediastinal mass. Within this suspected mediastinal mass, irregular calcifications are visible."
          }
        ]
      },
      {
        "number": "Figure 7",
        "subfigures": [
          {
            "number": "Figure 7",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009148/000011.jpg?itok=H6_AetEw",
            "caption": "Surgical specimen of 500 grams showed a mixture of tissue: hair, sebum, bone, synovium and cartilage."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Mediastinum"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT",
      "PET",
      "PET-CT"
    ],
    "link": "https://www.eurorad.org/case/9148",
    "time": "17.03.2011"
  },
  "9152": {
    "case_id": 9152,
    "title": "Subglottic stenosis in Wegener\u2019s disease",
    "section": "Chest imaging",
    "age": "70",
    "gender": "female",
    "diagnosis": "Subglottic stenosis of the trachea in Wegener granulomatosis",
    "history": "A 70-year-old female patient with known Wegener\u2019s granulomatosis presented with worsening stridor and exertional dyspnoea of 3 months duration; high-dose corticosteroid therapy did not relieve her symptoms.",
    "image_finding": "A Computed Tomography (CT) of the neck with IV-contrast medium was performed to evaluate the subglottis region and trachea. The patient\u2019s history mentioned a polypectomia 2 centimetres below the true vocal cords, which was highly suspicious of Wegener\u2019s disease on pathological examination. A previous plain chest radiography showed a tracheal stenosis (Fig. 1). CT examination revealed a circumferential, symmetrical soft tissue swelling in the trachea, from the most proximal subglottis area extending into the proximal trachea (Fig. 2). The lumen of the trachea measured 6.7 millimetres on the most narrowed part. The lumen-total tracheal diameter ratio at this point was 0.50. The subsequent bronchoscopy showed a critical stenosis with a diameter between 5 and 6 millimetres. This finding was also visible on virtual bronchoscopy (Fig. 3). A lasering of the inflammatory tissue was performed.",
    "discussion": "Wegener's granulomatosis (WG) is a multisystem necrotising granulomatous vasculitis affecting arteries, capillaries and veins (small to medium-sized), with a clinical predilection for involvement of the upper airways, lungs, and kidneys. Wegener's granulomatosis is part of a larger category of vascular syndromes, including microscopic polyangiitis and Churg-Strauss syndrome. This categorisation is based on a mutual feature: autoimmune attack by an abnormal type of circulating antibodies, ANCAs, against small and medium-size blood vessels. A broad range of aetiological agents and pathogenic processes has been considered. Prevalence of Wegener\u2019s granulomatosis per 1,000,000 adults (in France) is estimated at 24; the overall prevalence was 2.0 times higher for subjects of European ancestry than for non-Europeans [1]. The mean age at onset is 40. WG is more common in men, with a male-to-female ratio of 1.5:1. Subglottic stenosis (SGS) occurs in 8-23% of Wegener patients. The subglottic region of the trachea is susceptible to stenosing forces. Several contributing factors have been identified: exposure of the epithelium through laryngopharyngeal reflux, a weak blood supply, strong subglottic airflow and the complete ring that comprises the cricoids cartilage are frequently cited causes [2].SGS can be the presenting feature of Wegener; it is found to occur more frequently in patients with an early onset (below the age of 20). Whenever SGS is not the presenting feature, it is diagnosed at a median time of 12 months after the diagnosis of Wegener is made. The majority of patients had organ involvement outside of the sinuses and subglottis at some point in their disease course. The overall pattern of organ involvement reveals that in patients with SGS, sinus involvement and saddlenose deformity are more common than lung and renal involvement.Dyspnoea is the most common presenting symptom is SGS (80% of the patients). Voice changes and hoarseness are also noted to herald the onset of disease [3].CT shows nodular or smooth (mucosal or submucosal granulomatous) thickening of the tracheal wall. This thickening may narrow the lumen and calcifications can occur [4].A combination of cyclophosphamide (intravenous or oral) and glucocorticoids is recommended for induction of remission in generalised WG. Regarding active subglottic-involved disease, tracheostomy for airway protection (required in up to half of the patients) constitutes the first-line surgical treatment of respiratory obstruction, complementend by medical therapy. More aggressive or specific surgical options (laser treatment, balloon dilatation, resection of the stenotic area with reanastomosis) should be kept for non-active cases [5].",
    "differential_diagnosis": "Subglottic, stenosis, of, the, trachea, in, Wegener, granulomatosis, Tumour, Sarcoidosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009152/000001.jpg?itok=othqe0EC",
            "caption": "Chest radiograph shows a mild narrowing of the proximal trachea in the subglottic region."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009152/000002.jpg?itok=Jv6F6YZM",
            "caption": "Axial CT image of the trachea demonstrates  thickening of the wall of the proximal, subglottic trachea with small calcifications."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009152/000003.jpg?itok=XKAoVF0w",
            "caption": "Coronal reconstruction of the trachea depicts narrowing of the lumen of the proximal, subglottic trachea."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009152/000004.jpg?itok=xNlHtAKy",
            "caption": "Retrograde virtual bronchoscopic view from distal trachea to the vocal cord. The vocal cords are visualised through a narrowing of the subglottic trachea."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009152/000005.jpg?itok=N9c3Wvmd",
            "caption": "Retrograde virtual bronchoscopic view at the level of the tracheal stenosis with a view on the vocal cords. The retrograde view is one of the advantages of virtual bronchoscopy over fiberoptic bronchoscopy."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009152/000006.jpg?itok=siUuZaxk",
            "caption": "Antegrade virtual bronchoscopic view from the mouth through the open vocal cords demonstrating a stenosis of the proximal subglottic trachea."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Respiratory system"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/9152",
    "time": "11.03.2011"
  },
  "9189": {
    "case_id": 9189,
    "title": "Malignant thymoma (thymic carcinoma)",
    "section": "Chest imaging",
    "age": "76",
    "gender": "female",
    "diagnosis": "Thymic carcinoma (malignant thymoma)",
    "history": "The patient presented with cough,  chest pain and dyspnoea. She had lost 10 kg of weight in the past 3 months.",
    "image_finding": "Biplane chest radiograph showed a dense mass in the anterior middle mediastinum without displacement of the tracheal band. There was left pleural effusion and high-riding diaphragm suggesting phrenic nerve palsy (Fig. 1). On MSCT, there was a bulky mass with heterogeneous enhancement in the left anterior mediastinum, which invaded the pericardium and bulged out against the S3 segment of the left lung (Fig. 2). At bronchoscopy, tumour invasion of the left S3 bronchus was found and biopsy was performed. The specimens were classified as thymic carcinoma (WHO type C). The extent of the disease was attributed stage IV according to the Masaoka system [1]. Given the advanced stage of the disease and the age and general state of the patient, primary radiotherapy was chosen as the most appropriate treatment option. Follow-up imaging of the thorax one year after the first diagnosis showed partial remission of the tumour (Figs. 3, 4).",
    "discussion": "The normal thymus is composed of epithelial and stromal cells deriving from the 3rd and 4th pharyngeal pouches, and lymphocytes, deriving from the mesoderm. It is the organ, where lymphoid precursors from the bone marrow migrate to complete their differentiation into T-cells. After puberty, it gradually involutes and gets replaced with fatty tissue. Neoplasms arising from the epithelial cells of the thymus are termed thymomas. They are more common than neoplasms from the lymphoid constituents. In fact, thymomas are the most common space-occupying lesions of the anterior mediastinum in adults (about 40%). The disease affects men and women alike, mostly in the 5th to 6th decade of life. In up to 40%, it is associated with various autoimmune diseases, myasthenia gravis being the most common. However, up to one half of patients are asymptomatic, and myasthenia is rather a favourable prognostic indicator, for it is found more frequently in less advanced stages. Other symptoms are unspecific, and the tumour is usually detected on routine radiographs of the chest [2]. Overall incidence of thymic neoplasms in the US is about 0.15 per 100, 000 [3], carcinoma accounting for probably less than 1%.The aetiology of thymic neoplasms is unknown. The WHO has devised a classification system based on histologic features [4] that requires sufficient amounts of tissue to be collected. Fine-needle aspiration can often not even differentiate thymoma from lymphoma [2]. The extent of the disease is traditionally determined at surgery, using the Masaoka staging system [1], modified by the French Study Group on Thymic Tumors (GETT) [5]. CT has the ability to differentiate between invasive and non-invasive thymomas [6, 7]. Hence, it can be used as a pretherapeutic staging modality and may predict local unresectability. Histologic type and Masaoka stage are probably independent predictors of survival [8].Treatment of thymomas should be operative, whenever feasible. In advanced stages like the present case, a multimodality approach is preferred in eligible patients [9]. Radiotherapy alone or in combination with chemotherapy is also an acceptable option, if the patient is unable or unwilling to undergo a surgical procedure [10].",
    "differential_diagnosis": "Thymic, carcinoma, (malignant, thymoma), Thymoma, Lymphoma, Lung, carcinoma, Germ, cell, tumours, Substernal, goitre",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009189/000001.jpg?itok=7DlHu0nE",
            "caption": "Posteroanterior radiograph of the chest. Left high-riding diaphragm, pleural effusion and mediastinal mass."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009189/000002.jpg?itok=2gVfbEeO",
            "caption": "Lateral radiograph of the chest. The mass is located in the anterior mediastinum."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009189/000003.jpg?itok=TiRrDbGU",
            "caption": "A bulky, heterogeneously enhancing mass in the thymic region with pericardial invasion (including retro-aortic recess) is seen. Left pleural effusion is also noted."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009189/000004.jpg?itok=vWxKaz9Y",
            "caption": "CT section at the level of the pulmonary trunk."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009189/000005.jpg?itok=1dUKlIZa",
            "caption": "Posteroanterior radiograph of the chest. The left mediastinal mass has become smaller, the effusion has gone, but the left phrenic palsy has remained."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009189/000006.jpg?itok=9GMtSd1A",
            "caption": "Lateral radiograph. The retrosternal opacity has resolved."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009189/000007.jpg?itok=5PN7bFJz",
            "caption": "CT shows a left paramediastinal residual band of tumour tissue."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009189/000008.jpg?itok=tmR48jpS",
            "caption": "Residual tumour extends down to the level of the left main bronchus."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/9189",
    "time": "13.08.2011"
  },
  "9245": {
    "case_id": 9245,
    "title": "Late distant metastasis of adenoid cystic carcinoma to lung",
    "section": "Chest imaging",
    "age": "61",
    "gender": "male",
    "diagnosis": "Late distant metastasis of adenoid cystic carcinoma to the lungs",
    "history": "History significant for mild dyspnoea and non-productive cough over the past several months. Distant history of adenoid cystic carcinoma (ACC) of the right lacrimal gland treated with orbital exenteration nearly two decades ago and chronic lymphocytic leukaemia. On physical examination, decreased breathing sounds and rales noted at right lung base.",
    "image_finding": "Chest radiograph revealed a 2 cm solitary pulmonary nodule in the left mid-lung zone (Fig. 1). Further evaluation with CT demonstrated an irregularly shaped soft tissue mass in the superior segment of the left lower lobe without evidence of lymphadenopathy (Fig. 2).  Biopsy of the lesion was performed and pathologic findings were suggestive of ACC but nondiagnostic. Wedge resection of left lower lobe was performed and showed vascular invasion from basaloid cells with a cribiform growth pattern arranged concentrically around glandlike \u201cpseudocysts\u201d (Fig. 3). Findings were consistent with ACC. Tumour margins were negative. He was followed with imaging until four years later when a repeat CT demonstrated a nodule suspicious for recurrent metastasis as well as pleural-based carcinomatosis (Fig. 4).  Due to his history of CLL, he was precluded from experimental chemotherapy trials. Follow-up CT two years later revealed multiple bilateral lesions with worsening of pleural carcinomatosis (Fig. 5).",
    "discussion": "Adenoid cystic carcinoma (ACC),  first characterised by Billroth in 1856 and called \u201ccylindroma\u201d [1],  is a rare neoplasm that typically arises from the salivary or lacrimal glands and compromises less than 2% of all malignant tumours of the oral and maxillofacial region [2]. Other primary sites of occurrence include the parotid, mucous glands of the nasal cavity, tracheobronchial tree, uterine cervix, Bartholin glands, and breast [2]. ACC is an invasive, slow-growing tumour composed of basaloid cells with a tendency towards perineural rather than lymphatic spread [3]. ACC demonstrates a female predominance, occurring at various ages but most commonly between the fifth and sixth decades of life [4]. Pulmonary metastases result from haematogenous spread. Direct extension into the airways may also occur along submucosal planes, and results in an intraluminal mass, similar to primary pulmonary ACC. On imaging, primary ACC in the lung is seen intraluminally in the major airways, whereas metastatic ACC to lung is seen as solitary or multiple parenchymal nodules. Late distant metastases (most commonly to the lung) occur up to several decades after initial presentation and even after adequate locoregional control; consequently, long-term follow up imaging and clinical evaluation is recommended [5]. Distant metastases are more commonly seen in patients with a predominantly solid histologic pattern of growth as well as patients with locoregional treatment failure [6]. Bone involvement with or without lung metastases carries a worse prognosis than those with lung metastases alone [6]. Median survival ranges between 15 and 70 months after initial diagnosis of distant metastasis [6]. Many patients remain asymptomatic and functional late into the course of the disease. Prognosis is guarded for these patients given the lack of an established role for chemo or radiotherapy, although they are sometimes utilised for palliative purposes [7].",
    "differential_diagnosis": "Late, distant, metastasis, of, adenoid, cystic, carcinoma, to, the, lungs, Adenoid, cystic, carcinoma, metastasis, to, lung, Other, lung, metastasis, Primary, lung, cancer, Benign, lesions, (e.g., hamartoma, or, granuloma, if, solitary, pulmonary, nodule;, e.g., granulomata, or, abscesses, if, multiple, nodules)",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009245/000013.jpg?itok=9Vv4zLIZ",
            "caption": "Ill-defined 2 cm pulmonary nodule seen in the left mid lung zone. There is prominence of the left hilum consistent with pulmonary vasculature."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009245/000014.png?itok=VjZMD_yP",
            "caption": "Solitary 2.5 cm subpleural soft tissue multilobulated mass in the left lower lobe. No adenopathy or additional nodules / lesions were seen."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009245/000016.jpg?itok=re_ntyJd",
            "caption": "Tumour composed of basaloid cells with a cribiform growth pattern. Cells arranged concentrically around glandlike \u201cpseudocysts\u201d typically filled with mucin produced by tumour cells."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009245/000015.jpg?itok=yALaYHbq",
            "caption": "Non-infiltrative pattern of growth with preservation of normal lung parenchyma is seen in 3(b), which is less characteristic of adenoid cystic carcinoma, typically an early microinvasive neoplasm."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009245/000022.jpg?itok=Zq2Xqciy",
            "caption": "Corresponding slices on a study performed two years later show interval progression of disease with multiple masses and nodules now present in the right lung and worsening pleural carcinomatosis."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009245/000023.jpg?itok=vIk0Vwb1",
            "caption": "Corresponding slices on a study performed two years later show interval progression of disease with multiple masses and nodules now present in the right lung and worsening pleural carcinomatosis."
          },
          {
            "number": "Figure 4c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009245/000024.jpg?itok=j7K4El11",
            "caption": "Corresponding slices on a study performed two years later show interval progression of disease with multiple masses and nodules now present in the right lung and worsening pleural carcinomatosis."
          },
          {
            "number": "Figure 4d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009245/000025.jpg?itok=nvXiQ07X",
            "caption": "Corresponding slices on a study performed two years later show interval progression of disease with multiple masses and nodules now present in the right lung and worsening pleural carcinomatosis."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009245/000029.jpg?itok=0aONCdj4",
            "caption": "Pleural carcinomatosis in the left hemithorax with solitary pulmonary nodule seen in Fig 4b concerning metastatic disease. Coronal images (Fig 4c-d) better show extent of pleural carcinomatosis. Central airways do not demonstrate intraluminal lesions."
          },
          {
            "number": "Figure 5b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009245/000026.jpg?itok=Z7pd9ktr",
            "caption": "Pleural carcinomatosis in the left hemithorax with solitary pulmonary nodule seen in Fig 4b concerning metastatic disease. Coronal images (Fig 4c-d) better show extent of pleural carcinomatosis. Central airways do not demonstrate intraluminal lesions."
          },
          {
            "number": "Figure 5c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009245/000027.jpg?itok=jh6anhcg",
            "caption": "Pleural carcinomatosis in the left hemithorax with solitary pulmonary nodule seen in Fig 4b concerning metastatic disease. Coronal images (Fig 4c-d) better show extent of pleural carcinomatosis. Central airways do not demonstrate intraluminal lesions."
          },
          {
            "number": "Figure 5d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009245/000028.jpg?itok=e8LXMLz6",
            "caption": "Pleural carcinomatosis in the left hemithorax with solitary pulmonary nodule seen in Fig 4b concerning metastatic disease. Coronal images (Fig 4c-d) better show extent of pleural carcinomatosis. Central airways do not demonstrate intraluminal lesions."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Respiratory system",
      "Oncology"
    ],
    "imaging_technique": [
      "CT",
      "Conventional radiography"
    ],
    "link": "https://www.eurorad.org/case/9245",
    "time": "05.05.2011"
  },
  "9269": {
    "case_id": 9269,
    "title": "Pulmonary alveolar microlithiasis",
    "section": "Chest imaging",
    "age": "92",
    "gender": "female",
    "diagnosis": "Pulmonary alveolar microlithiasis",
    "history": "A 92-year-old ex-peasant female patient presented at our institute with a fracture of the femoral neck; a preoperative chest radiograph was made. She reported to have been always in good health during her long life but in the last months she had noticed a mild dyspnoea.",
    "image_finding": "The preoperative chest radiograph (obtained in supine position as the patient was on a stretcher) (Fig.1) demonstrated diffuse multiple,  bilateral,  ill-defined calcifications,  relatively less extended in the upper left lobe. Linear calcification of the pleural surfaces was also seen. Due to the discrepancy between these marked radiographic findings and the mild symptoms reporteded by the patient (she did not report respiratory disease) a CT evaluation was requested with a 16-detector row equipment. The axial scans with coronal MPR and MinIP reconstructions (Fig. 2,  3,  4) clearly showed the almost ubiquitous distribution of the calcifications with overlapped interstitial fibrosis,  intraparenchymal cyst and paraseptal emphysema (more evident at the upper left lobe explIning the relative sparing of lung parenchyma at that level).",
    "discussion": "Pulmonary alveolar microlithiasis (PAM) is a rare disease characterised by the presence of myriad of tiny calculi (calcospherites) within the alveoli of the lungs. The classic radiographic findings consist of multiple small \u201csand-like\u201d opacities diffusely involving both lung parenchyma, especially the lower lobes, with a subpleural and peribronchovascular predominance. These findings may change as the disease progresses [1].The natural evolution of PAM in years brings some anatomo-radiographic changes, so that a classification in four stages can be made,  starting from a preclinic phase in which the chest radiograph is normal,  to a progressive stage characterised by growth in number and volume of the calculi with overlapped interstitial fibrosis, intraparenchymal cyst and paraseptal emphysema.High resolution CT can define the extension and the gravity of the disease but, depending on the stage of disease,  a differential diagnosis with diffuse alveolar septal amyloidosis,  tuberculosis,  pneumoconiosis and some types of sarcoidosis has to be made. So the final diagnosis is made when multiple tiny calculi called \"microliths\" are found in the BAL or during transbronchial biopsy [2].Patients generally present between the ages of 30 to 50 years, although a few paediatric cases have also been reported. There is a strong familiar history (recently the responsible gene of the disease SLC34A2 has been discovered) [3, 4]. Most patients are asymptomatic at the time of diagnosis, with the disease incidentally being detected on chest radiographs obtained for other reasons. However, the disease is slowly progressive and there is a tendency for development of pulmonary fibrosis and cor pulmonale in progressive stages.Our case demonstrates that the evolution of the disease can be very slow in years and even with such a severe involvement of the lung parenchyma, symptoms may be very blurred and misinterpreted as mild respiratory failure and chronic pulmonary heart.",
    "differential_diagnosis": "Pulmonary, alveolar, microlithiasis, Diffuse, alveolar, septal, amyloidosis, Tuberculosis, Coal, workers\\', pneumoconiosis, Sarcoidosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009269/000001.png?itok=Hv2qn5pi",
            "caption": "Axial scans at different levels: distribution of the calcifications with overlapped interstitial fibrosis, intraparenchymal cyst and paraseptal emphysema (more evident at the upper left lobe)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009269/000002.png?itok=7Ro6AOdP",
            "caption": "Coronal MPR reconstructions."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009269/000003.jpg?itok=ZCoZYbdY",
            "caption": "MinIP reconstruction."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009269/000004.jpg?itok=YcbIMXek",
            "caption": "Supine chest radiography (patient on a stretcher). Multiple, bilateral, ill-defined calcifications, relatively less extended in the upper left lobe. Linear calcification of the pleural surfaces is also seen."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/9269",
    "time": "17.07.2011"
  },
  "9274": {
    "case_id": 9274,
    "title": "Penetrating injury to the lung from wooden foreign object",
    "section": "Chest imaging",
    "age": "31",
    "gender": "male",
    "diagnosis": "Penetrating lung injury from a wooden foreign object",
    "history": "A 31-year-old man was brought to the emergency department of our hospital after being found lying unconscious in a crop field. It was reported that he had been thrown into it out after falling out from a car accident. He was in a grave condition.",
    "image_finding": "Chest radiograph showed a large focal density at the left upper lung zone,  and atelectasis of the left lower lobe with significant blunting of the left costophrenic angle consistent with pleural effusion (Fig. 1). Computed tomography (CT) images disclosed a large loculated effusion at the anterior segment of left upper lobe with a small air-fluid-level at the non-dependant part of it raising concern for empyema or abscess formation (Fig. 2-4). None of these images revealed the presence of a foreign body within the loculated effusion. Ultrasonography (US) performed at the lesion site showed an echogenic focus within the effusion, demonstrating acoustic shadowing posteriorly (Fig. 5). The patient underwent an operation, which revealed the presence of a wooden foreign object within the lesion (Fig. 6). The object was extracted successfully (Fig. 7), and the patient did well afterwards, being discharged from the hospital in a rather short period of time.",
    "discussion": "Thoracic trauma is a common cause of significant disability and mortality, being the leading cause of death from physical trauma after head and spinal cord injury (1, 2). Blunt thoracic injuries are the primary cause of about a quarter of all trauma-related deaths with a mortality rate of about 10% (2). Chest trauma is classified as blunt or penetrating. On the other hand, most penetrating injuries are chest wounds and have a mortality rate around 10%. Penetrating chest trauma can injure vital organs such as the lung and heart. Impalement injuries are relatively uncommon during vehicular trauma (3). Penetration of the chest with a wooden object, particularly during a traffic accident, is a rarer event. But there are case reports in the literature, concerning wooden object impalement in the chest (3, 4, 5, 6). Because wood, as a substance, is not easily visualised by means of X-ray examination, the diagnosis of a foreign wooden object in the chest may sometimes be difficult, as was in our case.When the presented patient was brought to the emergency department, he was in a grave clinical condition. His posteroanterior chest radiograph and CT revealed a mass-like opacity and a loculated pleural effusion accordingly in the left upper lung region containing an air-fluid level, indicative of an empyema or abscess-like inflammatory process. In none of these examinations could a proper diagnosis of a foreign object embedment be made. It was only when an US examination was performed, that a foreign object with an acoustic shadow could be demonstrated. US played a major role in the diagnosis process. The patient underwent an operation which verified the presence of a wooden foreign object within the lesion. We conclude that a multimodality radiological approach is fundamental in the evaluation of a trauma patient, especially in the presence of clues pointing to the possibility of a traumatic foreign object implantation.",
    "differential_diagnosis": "Penetrating, lung, injury, from, a, wooden, foreign, object, Haematoma, due, to, chest, trauma, Coincidental, pleural, mass",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009274/000001.jpg?itok=_TUudOaa",
            "caption": "This initial PA-chest radiograph shows a large focal density at the lateral aspect of the left upper lung zone, together with blunting of the left costophrenic angle, consistent with left pleural effusion and/or thickening."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009274/000003.jpg?itok=3gM7TMbk",
            "caption": "Axial CT scan obtained in lung window settings reveals a well-defined extrapulmonary mass at the level of the LUL."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009274/000004.jpg?itok=Bdy4ayiW",
            "caption": "Axial CT scan at lung window settings. There is an air-fluid level in the non-dependant part of the lesion consistent with an abscess formation."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009274/000005.jpg?itok=toLHPMLO",
            "caption": "The air-fluid level within the lesion and the thickened pleura posteriorly, are better visualised at mediastinal window settings."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009274/000006.jpg?itok=SFqeYj0A",
            "caption": "A fluid collection with an echogenic focus and an acoustic shadow behind it are clearly depicted on ultrasound examination."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009274/000007.jpg?itok=YRqeAWrP",
            "caption": "This intraoperative picture demonstrates the wooden object embedded in the tissues, and the reactive tissue changes surrounding it."
          }
        ]
      },
      {
        "number": "Figure 7",
        "subfigures": [
          {
            "number": "Figure 7",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009274/000008.jpg?itok=2Wk1ZHH4",
            "caption": "The wooden foreign object is seen as an extracted material in this picture, after being removed from the patient."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Thorax",
      "Trauma"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT",
      "Ultrasound"
    ],
    "link": "https://www.eurorad.org/case/9274",
    "time": "02.09.2011"
  },
  "9307": {
    "case_id": 9307,
    "title": "Thymic hyperplasia secondary to thyrotoxicosis",
    "section": "Chest imaging",
    "age": "56",
    "gender": "female",
    "diagnosis": "Lymphoid thymic hyperplasia secondary to thyrotoxicosis",
    "history": "We present a case of a 56-year-old female patient with a history of thyrotoxicosis a month before, who underwent a CT examination because of constitutional symptoms.",
    "image_finding": "CT showed an incidental finding of a diffuse symmetric enlargement of the thymus, with preservation of normal shape (figures 1, 2 and 3). These findings were suggestive of thymic hyperplasia. There were no other abnormal findings. One month before, the patient had presented a hypermetabolic clinical syndrome resulting from serum elevations in thyroid hormone levels,   and she was diagnosed with thyrotoxicosis.",
    "discussion": "There are two distinct histologic types of thymic hyperplasia: true thymic hyperplasia and follicular hyperplasia. Both types manifest as diffuse symmetric enlargement of the thymus [1].The true thymic hyperplasia is defined as an increase of both size and weight of the gland while it maintains normal microscopic architecture. Enlargement of the thymus gland is reported as a form of rebound phenomenon in a number of conditions like recovery from severe stress situations,  after administration of steroids,  and after treatment of malignant tumours [2]. Follicular or lymphoid hyperplasia of the thymus refers to the presence of an increased number of lymphoid follicles. This condition is frequently found in association with autoimmune disorders,  especially in patients with myasthenia gravis,  being seen in up to 65% of cases [1]. Lymphoid hyperplasia of the thymus is observed in a number of immunologically mediated disorders,  including SLE,  rheumatoid arthritis,  scleroderma,  vasculitis,  thyrotoxicosis and Graves disease.Although benign thymic hyperplasia is a known feature of hyperthyroidism,  this is infrequently appreciated by clinicians. Approximately one third of patients with thyrotoxicosis will have microscopic abnormalities of the thymus gland with the presence of medullary lymphoid follicles upon biopsy. However,  massive enlargement of the thymus detectable radiologically is uncommon and has been infrequently reported [3]. Thymic hyperplasia appears to be induced as a consequence of immunological and hormonal reactions in hyperthyroidism. Treatment with appropriate antithyroid therapy results in regression of the thymus.",
    "differential_diagnosis": "Lymphoid, thymic, hyperplasia, secondary, to, thyrotoxicosis, True, thymic, hyperplasia, Thymoma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009307/000002.jpg?itok=5VBzrefC",
            "caption": "Axial enhanced-CT image shows a homogeneous soft-tissue lesion in the anterior mediastinum."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009307/000003.jpg?itok=RDe-Ojzp",
            "caption": "Coronal enhanced-CT image shows the anterior mediastinal mass."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009307/000004.jpg?itok=YeFCQ1E4",
            "caption": "Sagittal enhanced-CT image shows the thymic mass in the anterior mediastinum retrosternally."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Mediastinum"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/9307",
    "time": "26.05.2011"
  },
  "9308": {
    "case_id": 9308,
    "title": "Packets filled with heroin in the oesophagus and colon",
    "section": "Chest imaging",
    "age": "23",
    "gender": "male",
    "diagnosis": "Packets filled with heroin in the oesophagus and colon.",
    "history": "A 23-year-old man,  with no medical or surgical history,  presented to the emergency room with dyspnoea and agitated.",
    "image_finding": "Radiographic imaging reveals an ovoid opaque area,   at the C6-C7 level,  with the longest diameter of approximately 3.5cm. These radiographs show the air column of airway displaced by an ovoid well described radiodense lesion (Fig.1; Fig.2). There are also numerous radiodense lesions mainly oval-shaped in the intestine (Fig.6; Fig.7).CT confirms the presence of an ovoid foreign body (vertical diameter of 30 mm,  transverse diameter of 28 mm and anterior-posterior diameter of 20 mm) within the proximal third of the oesophagus (Fig.3,  Fig.4,  Fig.5).",
    "discussion": "\u201cBody-packing\u201dis a means of international drug-smuggling. It involves packets containing drugs by either swallowing or inserting the packets rectally or vaginally[3]. Various materials -latex-condoms, cellophane, pig intestines- can be used for wrapping.Abdominal-radiograph is the initial imaging method of choice. It may reveal the \"tic-tac-sign\" (multiple oblong-shaped-opacities); the \"rosette-like\" sign at one end of the packet (the air trapped in the knot where a condom is tied) and the \"double-condom-sign\" (a rim of air between layers of latex,   when a double-wrapped condoms is used)[2;3]. Ultrasonography leads to a high rate of false positive and false negative scans[3]. CT is more sensitive than radiography and may demonstrate packages within the bowel not identified with radiography[2;3]. The appearance of each drug depends on its density: hashish appears denser than stool,   cocaine similar to faeces and heroin demonstrates a gaseous transparence[2;3]. The radiological density of a drug depends also strongly on its grade of purity. Heroin, hashish and cocaine may appear very similar to each other. Hashish has a density like bone, cocaine is less dense than fat and the Hounsfield-units of heroin lie between fat and air[4].Constipating agents (diphenoxylate, loperamide)  are frequently used by smugglers, after haning swallowed the packets,  in order to mask them[2].The person who ingests or inserts drug-filled-packets into his or her rectum or vagina,  in order to get across borders without being detected is called \u201cmule\u201d or \u201cbody-packer\u201d[1]. On the other hand,  the person who ingests drugs urgently, is a \u201cbody-stuffer\u201d.  He is a drug dealer or a drug abuser, who swallows illegal drugs fast because of no time to pack the drugs carefully, in an effort to avoid being arrest[5].Early surgery intervention was formerly recommended for asymptomatic body-packers,   because of the high rate of rupture of packets with primitive wrapping. The current approach is conservative therapy with bowel irrigation,   close observation,   and careful monitoring in the hospital[2]. Our patient presented dyspnoea and he was agitated,   because of his difficulty in breathing,   until the spontaneous passage of the foreign-body in the stomach. The main medical complications are bowel obstruction and acute drug toxicity caused by rupture of condoms. There have been reports of sudden deaths[1]. In such an emergency the priority is to maintain airway patency and administer naloxone.",
    "differential_diagnosis": "Packets, filled, with, heroin, in, the, oesophagus, and, colon., Other, foreign, bodies, Packet, filled, with, cocaine, or, other, drugs",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009308/000003.png?itok=5ApjpFha",
            "caption": "An ovoid foreign body is seen within the lumen of the proximal third of the oesophagus."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009308/000004.png?itok=4CdVZcIk",
            "caption": "An ovoid foreign body is seen within the lumen of the proximal third of the oesophagus."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009308/000005.png?itok=UnYhghLk",
            "caption": "A rounded foreign body is seen within the lumen of the oesophagus."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009308/000007.png?itok=nIw4gT4b",
            "caption": "Numerous well-defined oval-shaped dense lesions are seen in the intestine."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009308/000008.png?itok=KOD-dnoe",
            "caption": "Numerous well-defined oval-shaped dense lesions are seen in the intestine."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009308/000009.jpg?itok=lF-BaZ7d",
            "caption": "Chest radiograph reveals an ovoid opaque area, at the C6-C7 level. The air column of airway is displaced by the ovoid dense lesion."
          }
        ]
      },
      {
        "number": "Figure 7",
        "subfigures": [
          {
            "number": "Figure 7",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009308/000010.jpg?itok=uGbnrZiq",
            "caption": "Lateral radiograph of the neck reveals an ovoid dense lesion, at the C6-C7 level."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax",
      "Oesophagus",
      "Abdomen"
    ],
    "imaging_technique": [
      "Digital radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/9308",
    "time": "04.06.2011"
  },
  "9374": {
    "case_id": 9374,
    "title": "Follicular Bronchiolitis",
    "section": "Chest imaging",
    "age": "40",
    "gender": "male",
    "diagnosis": "Follicular bronchiolitis",
    "history": "A 40 year old male patient presented at the pulmonary medicine department with worsening dyspnoea. Until admission the diagnosis of recurrent atypical pneumonia was made and he had received treatment with various antibiotics. On admission he showed a partial ventilatory insuffiency and there were marked restrictive changes at lung function.",
    "image_finding": "The initial radiograph showed marked interstitial changes associated with low lung volumes (Fig. 1).  A chest high resolution computed tomography (HRCT) examination with a slice thickness of 1 mm was further indicated. The most characteristic HRCT finding were disseminated centrilobular micronodules of ground-glass opacity. There were also well defined areas of air-trapping and geographic areas of ground-glass opacity. There were no findings consistent with fibrosis and there were no consolidations (Fig. 2,  3). For further diagnosis a video assisted thoracoscopic biopsy (VATS) was performed and histologic specimens were obtained. On pathology the most prominent finding was follicular bronchiolitis. There were also slight changes consistent with fibrosing alveolitis. Consequently the diagnosis of follicular bronchiolitis,  presumably caused by a hypersensitivity reaction,  was established. Postoperatively the patient recovered well and symptoms improved with cortisone medication.",
    "discussion": "Follicular bronchiolitis is characterised by a reactive hyperplasia of the pulmonary lymphoid system. Histologically a typical polyclonal hyperplasia of lymphoid tissue around bronchioles is found [1].  Follicular bronchiolitis is most often associated with connective tissue diseases,  immunodeficiency,  pulmonary infections or hypersensitivity reactions. It can also be idiopathic [1,  2]. Most patients present with progressive dyspnoea, like in our case [2]. HRCT is the imaging evaluation of choice. In their study of CT findings of 12 patients with histologically proven follicular bronchiolitis Howling et al. found that disseminated centrilobular nodules were the prominent finding and were present in all patients,  while further peribronchial nodules and ground glass opacities could not be found in every case [1]. The typical centrilobular nodules of ground-glass opacity were also be found in our case. Coexistent slight fibrotic changes may point to an underlying disease like lung involvement in autoimmune diseases or an exogenous allergic alveolitis. In these cases,  treatment should be directed to the underlying disease. In idiopathic cases however,  treatment consists mainly of bronchodilatators and cortisone [2].",
    "differential_diagnosis": "Follicular, bronchiolitis, Hypersensitivity, pneumonitis, Langerhans, histiocytosis, Organizing, pneumonia",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009374/000001.jpg?itok=h0gidSYo",
            "caption": "Chest radiograph of a 40-year-old patient with worsening dyspnoea. There is a marked reticular pattern with low lung volumes."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009374/000002.jpg?itok=joaG1gBf",
            "caption": "The HRCT image of the chest shows disseminated hazy centrilobular nodules  throughout both lungs. There are some geographic areas of air trapping and ground-glass opacity. There were no findings consistent with fibrosis or consolidations."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009374/000003.jpg?itok=tT125gIA",
            "caption": "Detail of a the chest HRCT at the level of the right upper lobe showing the hazy centrilobular nodules and a small well-defined area of air-trapping."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "CT",
      "Conventional radiography"
    ],
    "link": "https://www.eurorad.org/case/9374",
    "time": "17.07.2011"
  },
  "9394": {
    "case_id": 9394,
    "title": "A case of thyroid angiosarcom",
    "section": "Chest imaging",
    "age": "74",
    "gender": "male",
    "diagnosis": "Thyroid angiosarcoma with pulmonary and bone marrow metastasis.",
    "history": "A 74-year-old man, living in Modena in a non-Alpine area, with a history of goitre for 20 years reported increasing dyspnoea, initially only under stress and later even at rest.",
    "image_finding": "The general practicioner prescribed a chest radiograph (Fig. 1), which showed a right mediastinal mass dislocating and compressing the trachea to the opposite side. The CT of the thorax demonstrated an enlarged right thyroid lobe with inhomogeneous enhancement, low density nodules and calcifications (Fig. 2).After one month the right lobe of the thyroid was completely surgically extirpated. Histological specimen revealed a thyroid angiosarcoma reaching the stripe of resection, CD31+/CD34+.After two weeks from surgery the patient reported thoracic pain. Chest radiograph showed again a right mediastinal mass dislocating the trachea  (Fig. 3). CT showed a big hematoma (Fig. 4), with quite similar characteristics to the removed lesion. CT also revealed multiple suspicious pulmonary nodules (Fig. 5) and bone marrow lesions (Fig. 6). These findings were confirmed as hypermetabolic at PET-CT (Fig. 7).A month later the patient presented with a pathological fracture of the right shoulder blade (Fig. 8, 9).",
    "discussion": "Thyroid sarcomas are malignant tumours of mesenchymal derivation. Angiosarcoma of the thyroid is a very rare entity almost unknown in most parts of the world except in European Alpine regions [1, 2, 3], where it represents about 16% of thyroid malignancies in association with iodine-deficient goitre [4]. Few cases without previous goitre have been reported [5].Usually the lesion begins as a painless enlarging mass, poorly encapsulated and with infiltrative growth [1, 6]. The tumour is typically large with extensive areas of necrosis and hemorrhage, mimicking a hematoma. This type of tumour typically metastasizes to bone marrow and lungs [7].Because of the nonspecific aspects at imaging studies (inhomogeneous mass with calcifications, areas of necrosis and hemorrhage) the differential diagnosis with goitre and other thyroid tumours is difficult. Moreover also after extensive surgery the occurrence of hemorrhage can resemble a very early recurrence. Either biopsy or complete resection of the tumour with a detailed histological investigation is usually the only way to make a diagnosis [8]. Histological specimen reveals freely joined channels lined by typical endothelial cells associated with a papillary configuration, that is due to a predominantly intraluminal growth pattern. The nuclei of the epithelioid endothelial cells are often large, vesicular and endowed with a large basophilic or amphophylic nucleolus connected by chromatin strands to the nuclear membrane. Mitoses, typical and atypical, are found in large numbers. The pattern of growth is nearly always highly invasive and tumour necrosis is prominent. The tumour cells express vascular markers such as Factor VIII, CD 31 and CD 34 [2, 9, 10, 11].The tumour is locally aggressive and has a destructive behaviour with high recurrence rate. The treatment of choice is radical surgery but if the tumour cannot be treated by surgery, then radiotherapy and eventually chemotherapy is indicated [5]. The prognosis is not favourable. Data on survival are dispersed but Goh et al. reported average 5-years survival of 33.3% [4].",
    "differential_diagnosis": "Thyroid, angiosarcoma, with, pulmonary, and, bone, marrow, metastasis., Goitre, Thyroid, adenoma, Thyroid, cyst, Thyroiditis, Thyroid, papillary, carcinoma, Thyroid, follicular, carcinoma, Thyroid, anaplastic, carcinoma, Thyroid, medullar, carcinoma, Thyroid, lymphoma, Thyroid, sarcoma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009394/000001.jpg?itok=WhKcvZC5",
            "caption": "The chest radiograph shows right mediastinal mass with maximum diameter of 8 cm, dislocating and compressing the trachea to the opposite side."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009394/000002.jpg?itok=qKe1oMPR",
            "caption": "The chest radiograph shows right mediastinal mass with maximum diameter of 8 cm."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009394/000003.jpg?itok=uEbcfTQU",
            "caption": "The arterial phase of dynamic CT of the torax demonstrated an enlarged right thyroid lobe with inhomogeneous enhancement, low density nodules and calcifications, dislocating and compressing the trachea to the opposite side."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009394/000014.jpg?itok=ZtnoC87A",
            "caption": "The venous phase demonstrated the poor  enhancement of the lesion."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009394/000015.jpg?itok=1pn1YDX_",
            "caption": "CT multiplanar coronal reformat of the thorax showing craniocaudal extension of the mass and its relationships to the main mediastinal structures."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009394/000004.jpg?itok=BOx4D18V",
            "caption": "The chest radiograph 2 weeks after surgery showed a right mediastinal mass dislocating the trachea to the opposite side."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009394/000005.jpg?itok=Efr-jN2Z",
            "caption": "The chest radiograph 2 weeks after surgery showed a right mediastinal mass."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009394/000006.jpg?itok=IzMRcsFp",
            "caption": "The CT 2 weeks after surgery showed a large hematoma in right thyroid lodge that has similar characteristics to the removed lesion."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009394/000016.jpg?itok=dMGK2zpe",
            "caption": "CT multiplanar coronal reformat showing a big hematoma following surgery with almost similar characteristics to the previous removed lesion."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009394/000017.jpg?itok=BZ5rCqAV",
            "caption": "Lung windowing of the pre-surgery CT shows no pulmonary nodules - especially in the lower right lobe. Micronodular thickening of the interstitium in left lower lobe is appreciable."
          },
          {
            "number": "Figure 5b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009394/000007.jpg?itok=Cy1H7N04",
            "caption": "Lung windowing of post surgery  CT (2 weeks interval) revealed multiple pulmonary nodules."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009394/000020.jpg?itok=nXZDrx5h",
            "caption": "The pre-surgery CT showed no bone marrow lesion at the level of the left shoulder"
          },
          {
            "number": "Figure 6b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009394/000008.jpg?itok=DWPZBqs3",
            "caption": "The CT performed 2 weeks after surgery revealed an osteolytic bone marrow lesion at the left scapula."
          }
        ]
      },
      {
        "number": "Figure 7",
        "subfigures": [
          {
            "number": "Figure 7a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009394/000018.jpg?itok=9MorQVoX",
            "caption": "The PET-CT examination showing hyper metabolic  pulmonary lesions."
          },
          {
            "number": "Figure 7b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009394/000009.jpg?itok=OyhNiMN5",
            "caption": "The PET-CT examination confirmed bone marrow lesions.\nIn the image a right iliac bone lesion."
          },
          {
            "number": "Figure 7c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009394/000010.jpg?itok=fpeeyrBB",
            "caption": "The PET-CT examination confirmed bone marrow (shoulder) and pulmonary lesions."
          },
          {
            "number": "Figure 7d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009394/000019.jpg?itok=bp5e8ca3",
            "caption": "The PET-CT examination confirmed bone marrow lesions.\nIn the image a right anterior iliac bone lesion."
          }
        ]
      },
      {
        "number": "Figure 8",
        "subfigures": [
          {
            "number": "Figure 8",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009394/000011.jpg?itok=90spoZBG",
            "caption": "The radiograph showed a pathological fracture of the left shoulder-blade."
          }
        ]
      },
      {
        "number": "Figure 9",
        "subfigures": [
          {
            "number": "Figure 9a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009394/000013.jpg?itok=MwMrA39l",
            "caption": "CT confirmed the fracture of the left shoulder-blade."
          },
          {
            "number": "Figure 9b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009394/000012.jpg?itok=6VnUYWhF",
            "caption": "Multiplanar reconstruction confirms the pathological fracture of the left shoulder-blade."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax",
      "Bones",
      "Mediastinum",
      "Thoracic wall"
    ],
    "imaging_technique": [
      "PET-CT",
      "Digital radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/9394",
    "time": "13.08.2011"
  },
  "9433": {
    "case_id": 9433,
    "title": "Accessory cardiac bronchus",
    "section": "Chest imaging",
    "age": "62",
    "gender": "male",
    "diagnosis": "Accessory cardiac bronchus",
    "history": "A 62-year-old man was admitted in our hospital with a parahilar mass in the anterior segment of the right upper lobe, proven to be lung adenocarcinoma after transthoracic biopsy. Staging CT demonstrated mediastinal invasion and contralateral metastatic nodules (stage T4N0M1a). The patient underwent radiotherapy and chemotherapy with partial response.",
    "image_finding": "During follow-up, the patient complained of recurrent haemoptysis and bronchoscopy revealed an accessory bronchial orifice containing blood residues that arose from the medial wall of the bronchus intermedius.CT demonstrated post-therapeutic findings, as well as an accessory cardiac bronchus (ACB) arising from the medial wall of the bronchus intermedius, progressing towards the mediastinum and ending as a blind diverticulum (Figs. 1-2). There was no lung tissue surrounding the bronchus. Virtual endobronchial view (Fig. 3) and 3D-volume rendering techniques (Fig. 4) assist in clearly depicting the anatomy of the bronchial tree.ACB was considered to be the strongest contributor to the recurrent haemoptysis, mainly based on the optical bronchoscopy findings, but a concurrent role for the radiotherapy-induced inflammatory changes cannot be neglected, although its exact importance is difficult to ascertain.Due to the frail condition of the patient, only conservative measures were undertaken, and the episodes of haemoptysis ceased spontaneously after several weeks.",
    "discussion": "Anomalies of bronchial anatomy are diagnosed with increasing frequency as a result of improvements in modern imaging techniques and include abnormal origin, absent branches and supernumerary branches [1].ACB is a rare congenital bronchial anomaly first described by Brock in 1946, with the frequency ranging from 0.09% to 0.5% in the general population [2, 3].The ACB is a developmental aberration of bronchial branching, likely occurring between the 4th and 6th weeks of embryonic life. It is lined by endobronchial mucosa and, in distinction to acquired fistulas or diverticula, there are cartilaginous rings within its walls [4].In most cases, an ACB is incidentally detected and characteristically arises from the medial wall of the proximal third of the bronchus intermedius, almost directly opposite to the origin of the right upper lobe bronchus and before the origin of the superior segmental bronchus to the right lower lobe and of the middle lobe bronchus [1]. It may also arise directly from the right main bronchus in a small number of cases [2]. The bronchus then progresses caudally for 1-5 cm towards the pericardium, paralleling the bronchus intermedius.The length of the ACB is variable, ranging from a short, blind-ending bronchial stump to a longer branching structure in those cases in which a cuff of lung tissue is present [4]. An enhancing soft tissue mass around the tip of the bronchus corresponds to collapsed vestigial parenchyma [2].The ACB is not recognised in plain chest radiographs, but may be demonstrated by bronchoscopy or CT. Although the CT imaging features of ACB have been reported infrequently, its characteristic location arising from the medial wall of the bronchus intermedius allows it to be recognised; multiplanar reformations, three-dimensional reconstructions or virtual endobronchial viewing may be of value in establishing the diagnosis [2, 5].Rarely, an ACB can become symptomatic through recurrent infections and haemoptysis (occasionally massive). These symptoms arise from the accumulation of secretions in the ACB, leading to inflammation, hypermicrovascularisation, and haemoptysis. This is especially the case when the ACB is long or has an accessory lobe. However, due to the low incidence of this anomaly, and the even lower incidence of associated clinical manifestations, recognition is a challenge [3, 5].Failure to recognise the characteristic imaging features of ACB may result in delayed diagnosis and postponement of adequate treatment, including surgical resection when symptomatic [6].",
    "differential_diagnosis": "Accessory, cardiac, bronchus, Acquired, bronchial, fistula, Traction, diverticulum, Mucus, strands, in, the, bronchus, intermedius, (2D, cross-sectional, imaging)",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009433/000001.jpg?itok=V_v9RD9h",
            "caption": "Image at the level of the proximal third of the bronchus intermedius shows an anomalous bronchus (arrow) arising from the medial wall."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009433/000002.jpg?itok=pTel5b1D",
            "caption": "Slightly below 1a.\nSequential CT images show the accessory bronchus progressing caudally towards the mediastinum."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009433/000006.jpg?itok=S1PX_j70",
            "caption": "Slightly below 1b. \nPost-therapeutic findings are also seen in the RUL and superior segment of the RLL, with multiple subsegmental atelectases, traction bronchiectases and pleural thickening."
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009433/000004.jpg?itok=rbiMDQYv",
            "caption": "Slightly below 1c."
          },
          {
            "number": "Figure 1e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009433/000007.jpg?itok=U9jxqu52",
            "caption": "Slightly below 1d."
          },
          {
            "number": "Figure 1f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009433/000008.jpg?itok=xTR6bHju",
            "caption": "Slightly below 1e.\nThe accessory bronchus ends as a blind diverticulum (arrow) and is no longer seen."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009433/000009.jpg?itok=OmjRH4sI",
            "caption": "Coronal CT image shows to better advantage the position of the accessory cardiac bronchus (arrow) in the bronchial tree and its relation with the medial wall of the proximal third of the bronchus intermedius."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009433/000010.jpg?itok=URwekmNe",
            "caption": "Virtual endobronchial view shows the accessory cardiac bronchus (left) separated by a spur (arrow) from the middle part of the bronchus intermedius; the origin of the RUL bronchus (right) is also seen."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009433/000011.jpg?itok=33xVafKt",
            "caption": "Three-dimensional volume rendering image in the coronal plane clearly depicts the origin of the accessory cardiac bronchus from the medial wall of the bronchus intermedius, almost directly opposite to the origin of the RUL bronchus."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/9433",
    "time": "02.09.2011"
  },
  "9444": {
    "case_id": 9444,
    "title": "Bronchiolitis obliterans as manifestation of pulmonary graft-versus-host-disease",
    "section": "Chest imaging",
    "age": "40",
    "gender": "male",
    "diagnosis": "Bronchiolitis obliterans from pulmonary graft-versus-host-disease",
    "history": "40-year-old male patient presented with mild shortness of breath. He had a history of multiple myeloma and had received autologous stem cell transplant eight years before, and a second,  allogeneic stem cell transplant from matched sibling donor ten months before.",
    "image_finding": "Chest radiograph demonstrated mild hyperinflation with central bronchial wall thickening. Conventional non-contrast CT obtained at end expiration with 5 mm slices demonstrated mild mosaic attenuation, which was better demonstrated on the high-resolution end-expiration images with a 1.25 mm slice thickness. Mild bilateral bronchial wall thickening consistent with bronchiectasis can be appreciated on both studies. On end expiratory images, there was evidence of air trapping seen as geographic areas of decreased attenuation. There were no increased reticular markings or honeycombing to suggest underlying fibrosis. There were no focal consolidations or evidence of pulmonary oedema. Central airways were patent.",
    "discussion": "Bronchiolitis obliterans (BO) is a late-phase pulmonary finding seen in up to 10% of bone marrow transplant patients, occurring as sequela of graft-versus-host disease (GHVD). Other less common pulmonary manifestations of GHVD include diffuse alveolar damage, organizing pneumonia, or lymphocytic interstitial pneumonitis. GHVD occurs more commonly in the setting of allogenic rather than autologous grafts. Pathologically, BO is characterised by obstructive granulation tissue in the lumen of bronchioles. Histologic features include bronchiolitis with a peribronchiolar neutrophilic and lymphocytic infiltrate [1]. In bone marrow transplant recipients, BO can arise from chronic rejection related to GVHD or drug toxicity. Other causes of bronchiolitis include previous viral or bacterial infection, medication treatment, collagen vascular disease, toxic inhalation exposure,  and small vessel vasculitis [2]. Symptoms of BO are of variable severity and can include dyspnoea upon exertion, breathlessness, dry cough, or severe airflow obstruction [3]. BO is a diagnosis of exclusion. Other causes for obstructive lung disease including emphysema, chronic bronchitis, and asthma must be excluded first. Diagnosis is clinical as determined by FEV1 testing and can be confirmed with transbronchial biopsy. Supportive plain radiographic findings include hyperinflation, vascular attenuation, and nodular opacities; however, chest radiograph is often normal or nonspecific. Standard CT is usually obtained at end-inspiration and may mask findings of BO. High-resolution end-expiratory images with 1-2 mm slice thickness will best demonstrate the geographic distribution of deceased attenuation due to localised air-trapping [4, 5]. Alveolar ventilation occurs from collateral air drift and relative obstruction of the alveoli connected to affected bronchioles. Oligaemia can be an associated finding, as sequela of reflexive local hypoxemic vasoconstriction. Additional supportive imaging features include subsegmental bronchial dilatation [6]. The primary treatment for BO in bone marrow transplant recipients is increased immunosuppression to counter the graft-versus-host response. Outcome is associated with the rate of onset. Patients with rapid onset BO and severe obstruction, typically have a poor outcome; in contrast, in patients with gradual onset BO, the outcome is improved, as the degree of obstruction may stabilise in about half of patients [7]. Teaching points:1- Bronchiolitis obliterans is the most common pulmonary manifestation of graft-versus-host-disease. 2- CT imaging should include end-expiratory images when the diagnosis is suspected.3- Bronchiolitis obliterans on end-expiratory HRCT is characterised by a mosaic attenuation pattern due to air trapped in the alveoli secondary to bronchiolar obstruction.4- Differential diagnosis includes viral or other infectious bronchiolitis and drug toxicity.",
    "differential_diagnosis": "Bronchiolitis, obliterans, from, pulmonary, graft-versus-host-disease, Viral, or, other, infectious, bronchiolitis, Chronic, bronchitits, Drug, toxicity, Collagen, vascular, disease, Toxic, inhalation, exposure, Small, vessel, vasculitis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009444/000001.jpg?itok=7DQoZxOK",
            "caption": "Frontal chest radiograph demonstrates mildly hyperinflated lungs with slight central bronchial wall thickening. No focal consolidations or pleural effusions are seen."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009444/000002.jpg?itok=5fv-qG4f",
            "caption": "Lateral chest radiograph demonstrates similar findings. An old compression deformity of the T8 vertebral body is incidentially noted."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009444/000003.jpg?itok=J-gsC0By",
            "caption": "Conventional non-contrast CT obtained upon expiration with 5  mm slices demonstrates mild mosaic attenuation and bilateral bronchial wall thickening."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009444/000004.jpg?itok=eBVYkOmq",
            "caption": "Adjacent 5 mm slice with annotations showing the different attenuation of lung parenchyma."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009444/000005.jpg?itok=wq3A3Pm7",
            "caption": "High-resolution CT images obtained at end-expiration with 1.25 mm slice thickness. Mosaic attenuation and mild bilateral bronchial wall thickening are better appreciated compared to the 5 mm thick conventional CT images."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009444/000006.jpg?itok=IHUp1Wkr",
            "caption": "Same image with annotations. Arrows show dilated and slightly thick walled central bronchi and areas of different attenuation are measured."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT",
      "CT-High Resolution"
    ],
    "link": "https://www.eurorad.org/case/9444",
    "time": "15.10.2011"
  },
  "9445": {
    "case_id": 9445,
    "title": "Bilateral pneumothoraces, pneumomediastinum and subcutaneous emphysema following spontaneous pneumomediastinum",
    "section": "Chest imaging",
    "age": "47",
    "gender": "female",
    "diagnosis": "Bilateral pneumothoraces, pneumomediastinum and subcutaneous emphysema following spontaneous pneumomediastinum",
    "history": "A 47-year-old woman admitted with sudden onset of shortness of breath, multiple body compartment swelling (orbital, thoracic and abdominal swelling) without history of forceful vomiting. On examination, subcutaneous emphysema was noted in orbit, thorax, both arms and abdomen. There was decreased air entry with hyper-resonant percussion bilaterally. She suffered from peripheral vascular disease, COPD, peripheral neuropathy. She was a heavy smoker and alcohol dependent.",
    "image_finding": "After admission chest radiograph was performed and showed extensive subcutaneous emphysema [Fig 1]. CT of the thorax  that followed [Fig.2] showed extensive mediastinal emphysema tracking into the neck and retroperitoneum with moderate right and mild left pneumothoraces. There was also consolidation of the left lung basae. Chest drain was inserted in the right side to release the pneumothorax. On the same day, water soluble contrast agent swallow [Fig. 3] showed free flow of contrast agent with no evidence of oesophageal leak.A series of chest radiographs was performed later and the patient made a good recovery. One week after admission he was discharged safely from the hospital being adviced to stop smoking and reduce alcohol consumtion.",
    "discussion": "Air within the mediastinum can originate from five sites: the lung, the mediastinal airways, the oesophagus, the neck and the abdominal cavity [1]. This can be categorised as spontaneous or traumatic. Spontaneous pneumomediastinum, described for the first time in 1939 by Louis Hamman, is usually seen in young, tall and thin men and unusually in women (as in this case), which is caused by rupture of peripheral pulmonary alveoli due to sudden increase in the intraalveolar pressure after exaggerated Valsalva maneuvers. Traumatic causes could be iatrogenic like barotrauma during mechanical ventilation or due to penetrating or blunt trauma to the chest. Also, it could occur as a complication of obstructive airway processes like foreign body inhalation or asthma [2]. Pneumomediastinum is usually a benign and self-limited condition, but is sometimes dangerous if the mediastinal pressure rises abruptly or decompression does not occur in the subcutaneous tissues. Life threatening complications are possible and include:1/ Pneumothorax2/ Tension pneumomediastinum leading to cardiac tamponade3/ Impedance of pulmonary vascular flow by air within the vascular sheaths.Pneumomediastinum is diagnosed clinically, the clinical diagnosis being based on the  triad of symptoms of chest pain, dyspnoea and subcutaneous emphysema.  The standard posteroanterior and lateral radiographs are usually sufficient for diagnosis, as posteroanterior chest radiograph typically demonstrates a radiolucent line between the mediastinal pleura and the left heart border. In the lateral view, air is visualised in the retrosternal space or as lucent streaks outlining the aorta and other mediastinal structures. Posteroanterior chest radiographs may be false positive in 50% of cases, and therefore lateral chest radiograph should always be performed increasing the sensitivity to nearly 100% [3].Other diagnostic procedures like oesophagoscopy, oesophagogram (with water-soluble contrast agent), bronchoscopy or chest CT are often performed following conventional radiographic imaging to rule out spontaneous or traumatic rupture of oesophagus and tracheobronchial tree or other secondary causes of pneumomediastinum.Spontaneous pneumomediastinum is  a self-limited condition and has a relatively benign clinical behaviour and air in the mediastinum is usually absorbed spontaneously within 2 to 4 days. Therefore conservative management with bed rest and analgesics is the first choice of treatment in most cases. Treatment with oxygen facilitates air absorption in the mediastinum in a similar way as in the spontaneous pneumothorax and is therefore recommended [4]. Decompression of mediastinal air is used in critically ill patients.",
    "differential_diagnosis": "Bilateral, pneumothoraces,, pneumomediastinum, and, subcutaneous, emphysema, following, spontaneous, pneumomediastinum, Spontaneous, pneumomediastinum, Ruptured, oesophagus, Iatrogenic",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009445/000003.jpg?itok=f0VYFErc",
            "caption": "CT thorax showing surgical emphysema."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009445/000006.jpg?itok=JzxgKMft",
            "caption": "CT thorax shows bilateral pneumothoraces and pneumomediastinum."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009445/000007.jpg?itok=GaU-3lNB",
            "caption": "Extensive surgical emphysema."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009445/000008.jpg?itok=xuvAHpaY",
            "caption": "Water-soluble contrast agent swallow to exclude oesophageal perforation."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009445/000009.jpg?itok=7kCgG61Q",
            "caption": "Water-soluble contrast agent swallow to exclude oesophageal perforation with contrast in the stomach."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax",
      "Contrast agents"
    ],
    "imaging_technique": [
      "CT",
      "Fluoroscopy"
    ],
    "link": "https://www.eurorad.org/case/9445",
    "time": "04.12.2011"
  },
  "9494": {
    "case_id": 9494,
    "title": "Primary mediastinal seminom",
    "section": "Chest imaging",
    "age": "40",
    "gender": "male",
    "diagnosis": "Primary mediastinal seminoma",
    "history": "A 40-year-old male patient complained of fatigue and worsening exertional dyspnoea followed by face oedema, dizziness and anorexia.Physical examination revealed increased volume of the face and neck, suggesting superior vena cava syndrome, without collateral circulation or palpable lymph nodes.Laboratory tests showed normal values of \u03b1-fetoprotein, \u03b2-HCG and LDH.",
    "image_finding": "The patient underwent a chest CT examination with intravenous contrast and a solid mass was depicted in the anterior and superior mediastinum. This lesion, measuring 8 x 7 x 9 cm, induced posterior deviation of mediastinal vascular structures and showed slight and heterogeneous enhancement with intravenous contrast. There were no intralesional calcifications. Superior vena cava (SVC) syndrome related to this mass was confirmed as clinically suspected, with SVC thrombosis associated to marked collateral circulation in the shoulder girdle and venous return to the heart conducted through the azygos system. The most probable differential diagnosis was a thymic lymphoma/ Hodgkin\u2019s lymphoma of the anterior mediastinum or an invasive thymoma. A surgical biopsy of the lesion was performed and the histologic diagnosis suggested a seminomatous type germ cell tumour \u2013 mediastinal seminoma. After this diagnosis, a testicular ultrasound was done to exclude a primary tumour, but no masses were found.",
    "discussion": "Only about 5-7% of germ cell tumours are located outside the gonads [1]. However, among the possible extra-gonadal locations, the mediastinum is the most common [2].Although 80% of these tumours are symptomatic, seminomas usually have a large volume at diagnosis. This, coupled with the high degree of malignancy often affects the possibility of surgical resection. The majority of cases occurs in young males (15-35 years old) [3] and is located mostly in the anterior mediastinum.In 30% of cases, these tumours are asymptomatic and are incidental findings on chest radiographs. However, symptoms may occur, usually nonspecific, such as sensation of pressure or local pain, exertional dyspnoea, cough, hoarseness and dysphagia. Systemic symptoms may also be present (e.g. weight loss), and in approximately 10% of cases there is superior vena cava syndrome at presentation [1]. The initial symptom is usually metastatic disease, often located in the chest (lung and regional lymph nodes) and bone [4]. The serum tumour markers, such as \u03b2-HCG, AFP and LDH, are essential for the diagnosis of primary mediastinal seminoma, which may be associated with low elevation of HCG (usually below 100 \u00b5L/L) levels, high LDH levels and normal AFP[2, 5].Imaging plays a very important role both in diagnosis and management. A chest radiograph may show widening of the mediastinum, but CT is the modality of choice and contrast enhanced CT helps characterise the lesion and also gives information concerning involvement of other structures and organs [2]. A testicular ultrasound should be performed to confirm primary extragonadal seminomatous tumour [6].Seminomas characteristically are smooth or lobulated masses of homogeneous tissue density [7]. This distinguishes them from other malignant germ cell tumours which tipically have a very heterogeneous appearance due to haemorrhage and necrosis but calcifications and fatty material are not seen. Criteria for malignancy are rapid growth, signs of local invasiveness, and the detection of distant metastases in regional lymph nodes, lung, pleura, bone or liver [4]. Although the direct invasion of surrounding structures is rare, obliteration of fat planes is common, and pleural or pericardial effusion may also occur.Radiographically, seminomas consist of well defined, lobulated masses, located in anterior mediastinum, that may extend to both sides of the midline. Calcifications are typically absent.On CT, seminomas appear as large and lobulated masses, with homogeneous attenuation and show a slight enhancement after contrast administration.MRI may be helpful in distinguish between fibrosis or residual tumour after therapy.",
    "differential_diagnosis": "Primary, mediastinal, seminoma, Thymoma, Thymic, carcinoma, Lymphoma, Mediastinal, metastasis, of, testicular, germ, cell, tumour",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009494/000003.jpg?itok=ni4vYyxI",
            "caption": "There is superior mediastinal widening (a), located in the anterior compartment (b)."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009494/000011.jpg?itok=M7tO-i-Q",
            "caption": "There is superior mediastinal widening (a), located in the anterior compartment (b)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009494/000005.jpg?itok=4O4FcInP",
            "caption": "Contrast-enhanced CT axial projection (a) and coronal  and sagittal CT reconstructions (b): The lesion induced posterior deviation of mediastinal vascular structures and showed slight and heterogeneous enhancement with intravenous contrast."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009494/000006.jpg?itok=FYbNpUfl",
            "caption": "Contrast-enhanced CT axial projection (a) and coronal and sagittal CT reconstructions (b): The lesion induced posterior deviation of mediastinal vascular structures and showed slight and heterogeneous enhancement with intravenous contrast."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009494/000009.jpg?itok=80rkqjRV",
            "caption": "Contrast-enhanced CT obtained after four cycles of combination chemotherapy with BEP (Bleomycin, Etoposide and Cisplatin). There was significant decrease in lesion size."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009494/000010.jpg?itok=cKoyumCR",
            "caption": "Fibrous stroma containing numerous inflammatory cells. There is proliferation of epithelioid cells with clear cytoplasm, round nucleus and evident nucleolus, which are arranged in clusters. These aspects are in favour of the diagnosis of seminoma."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Mediastinum",
      "Thorax"
    ],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/9494",
    "time": "02.09.2011"
  },
  "9496": {
    "case_id": 9496,
    "title": "Penetrating thoracic injury: the heart is the target",
    "section": "Chest imaging",
    "age": "16",
    "gender": "male",
    "diagnosis": "Laceration of right ventricular wall after a chest stab injury",
    "history": "A 16-year-old boy was referred to our emergency department three hours after a fight, with a penetrating stab wound above his left mammillary region. He was anxious, slightly dyspnoeic, but with good pulse and without jugular distension. His blood pressure, heart rate and electrocardiogram (ECG) were unremarkable.",
    "image_finding": "Chest radiograph showed a cardiac silhouette with the varying cardiac density sign, abnormal bulge of left cardiac contour and a translucent line delineating the left mediastinal superior border (Fig. 1). An unenhanced and enhanced non-ECG gated multidetector CT was performed. A small left pneumothorax was seen (Fig. 2). Linear air-bubbles in the third left intercostal space revealed the wound track. A dense heterogeneous effusion (50 HU) in superior pericardial recess was seen, consistent with haemopericardium (Fig. 3). Enhanced CT revealed a linear high density in haemopericardium in front of right ventricular apex suggesting myocardial perforation and contrast extravasation into pericardial sac (Fig. 4).Transthoracic echocardiogram confirmed a heterogeneous hyperechogenic pericardial effusion suggesting active hemorrhage. Cardiac contractility and function were normal (Fig. 5). Patient immediately underwent cardiac surgery, which confirmed right ventricular laceration and a blood clot sealing the wound. Rupture of the root of great vessels was excluded, confirming CT findings.",
    "discussion": "Penetrating wound of the chest wall is a relatively frequent type of injury in the emergency situation, usually a non life-threatening one [1]. However, when the heart is injured, less than 20% of patients reach the hospital alive [2] which requires a high index of suspicion [1] to diagnose cardiac perforation on time. Clinical presentation of cardiac trauma is extremely variable and can range from haemodynamic stability to profound shock, depending on the size and location of the damage [2, 3, 4]. Cardiac perforation can temporarily be sealed by a clot, but if displacement of the clot occurs, pericardial tamponade with exsanguination will seriously compromise cardiac function. If this happens, resuscitation is of limited value and cardiac surgery is the only lifesaving treatment [4]. In the presented case the clinical symptoms were unremarkable and the wound was diagnosed to be only superficial. A more severe situation was suspected based on the admission chest radiograph, which showed a varying cardiac density sign and a translucent line along the upper mediastinal border. Pericardial effusion and pneumothorax were suspected and further investigation was required. CT of the thorax turned out to be critical in order to guide treatment and to plan the surgical procedure. Multidetector thoracic CT, with and without intravenous contrast agent (even without cardiac ECG gating), defined hemorrhagic pericardial effusion and suggested myocardial perforation of the right ventricular apex and contrast extravasation into the pericardial sac. It also excluded involvement of the great vessels in the mediastinum.This clinical case points out the need for careful inspection of admission chest radiographs even when a superficial thoracic stab wound is thought to be the case. Thoracic CT confirmed the need of a life-saving surgical procedure.",
    "differential_diagnosis": "Laceration, of, right, ventricular, wall, after, a, chest, stab, injury, Rupture, of, ascending, aorta, or, pulmonary, trunk, Myocardial, contusion, without, myocardial, rupture",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009496/000008.jpg?itok=ItyZGSUO",
            "caption": "Left upper pneumothorax is noted."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009496/000021.jpg?itok=AEaGpN-l",
            "caption": "Pneumothorax in the left anterior costophrenic recess is seen (arrow)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_video/2018-08/0000009496/000009F.png?itok=ZyBQ0j1d",
            "caption": "Four chamber view shows hyperecogenic anterior pericardial effusion confirming haemopericardium."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009496/000012.jpg?itok=8oB0bJ9p",
            "caption": "High density pericardial effusion in front of mediastinal great vessels is seen."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009496/000011.jpg?itok=lHG7u-V1",
            "caption": "High density pericardial effusion presumed to be haemopericardium is noted."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009496/000022.jpg?itok=l1M46hIg",
            "caption": "Small transparent bubbles defining knife trajectory in the anterior left chest wall are seen (arrow)."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009496/000028.jpg?itok=3CgoelNg",
            "caption": "The contour of the great thoracic vessels was regular and well defined (arrow)."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009496/000018.jpg?itok=pfV_BLUI",
            "caption": "High density pericardial effusion presumed to be haemopericardium (open arrow)."
          },
          {
            "number": "Figure 4c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009496/000030.jpg?itok=Jw-B2nka",
            "caption": "Wound track seen in anterior thoracic wall to the left of internal mammary artery (arrow).\nHigh density pericardial effusion (55HU)."
          },
          {
            "number": "Figure 4d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009496/000023.jpg?itok=6mgpSzQE",
            "caption": "Linear high density in the haemopericardium in front of the right ventricular apex suggesting myocardial perforation and contrast extravasation (arrow)."
          },
          {
            "number": "Figure 4e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009496/000025.jpg?itok=xC6vVYHE",
            "caption": "Hyperdensity in pericardial fluid: extravasation of contrast medium into the pericardial sac (arrow)."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009496/000027.jpg?itok=emjJGwJN",
            "caption": "Anteroposterior chest radiograph shows a bulge of the left cardiac border (arrow) with varying cardiac density sign (double arrow). A translucent line outlining the mediastinal upper border was noted (arrow head).\nLateral projection was normal."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Cardiac",
      "Trauma",
      "Thorax",
      "Thoracic wall",
      "Soft tissues / Skin",
      "Mediastinum"
    ],
    "imaging_technique": [
      "Echocardiography",
      "Conventional radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/9496",
    "time": "04.12.2011"
  },
  "9517": {
    "case_id": 9517,
    "title": "Lipoma of the oesophagus",
    "section": "Chest imaging",
    "age": "65",
    "gender": "male",
    "diagnosis": "Lipoma of the oesophagus",
    "history": "Sixty-five year-old man complaining of minimal dysphagia and dyspepsia for many years. The clinical interview disclosed a history of hypertension, diabetes and a surgically removed groin lipoma. Physical examination revealed no abnormalities and laboratory data were normal.",
    "image_finding": "Frontal chest radiograph showed a right-sided, lobulated mass in superior mediastinum (figure 1) and lateral radiograph revealed increase in soft-tissue density behind the trachea (figure 2). A barium swallow of the upper gastrointestinal tract displayed a submucosal lesion at the T3-T8 level. The mass appeared like a filling defect in a dilated oesophagus and it could be falsely interpreted as achalasia with food retention (figure 3).Contrast-ehanced CT of the chest revealed an oblong-shaped fat-attenuating and submucosal mass which measured 4 x 3 x 11 cm, in upper oesophagus (figure 4). The lesion was encapsulated (surrounding thin rim of contrast). No significant mediastinal or hilar adenopathy, lung or liver metastasis was apparent.Upper gastrointestinal echo-endoscopy demonstrated an echogenic, smooth, mobile and ovoid lesion was encountered distal to the cricopharyngeus muscle surrounding the oesophagus (figure 5).Upper gastrointestinal endoscopy showed a submucosal, yellow, space-occupying mass with pliability and smooth surface without ulceration (figure 6).",
    "discussion": "Benign tumours of the oesophagus, especially lipomas, are uncommon. Lipomas have been found in all segments of the digestive tract. Oesophageal lipomas account for only 0,4% of benign tumours of the gut [1, 2]. They usually originate in the cervical and upper thoracic oesophagus. Lipomas are well-circumscribed mesenchymal tumours that originate from adipose tissue. These lesions are usually submucosal, slowly-growing and small. Solitary pedunculated large tumours often occur in adults, predominantly men [3]. These lesions can be classified as fibrovascular polyps.Many cases (>85%) are asymptomatic and are found incidentally, whereas symptoms include dysphagia (the most frequent complaint), epigastric pain, weight loss and bleeding (ulceration). These tumours can be associated with recurrent respiratory infections [1]. Death from asphyxia, related to laryngeal impaction of a regurgitated lesion (some develop a long pedicle and prolapse) has been described [3].Frontal chest radiography may reveal a right-sided, slightly lobulated, soft-tissue lesion in the superior mediastinum, while lateral film may demonstrate increased retro-tracheal soft-tissue density associated with compression and anterior bowing of the trachea [4].A barium swallow of the upper gastrointestinal tract shows a mass in relationship to the oesophagus, its smooth surface and the obtuse angle between the lesion and the oesophageal lumen suggest a submucosal mass.On CT, the finding of a homogeneous mass with Hounsfield units between -80 and -120 is virtually diagnostic of a lipoma [5]. It helps to plan better preoperatively the surgical approach for removal. MR imaging can also show the extent and confirm the fatty nature of the lesion.Endoscopic ultrasound may display a homogeneous hyperechogenic mass with smooth outer margins in oesophageal submucosa. Upper gastrointestinal endoscopy shows a yellow colour oesophageal lesion, pliability and smooth surface.Imaging is often diagnostic but the definitive diagnosis is made by the pathologist.Although the literature includes a single case of a pedunculated oesophageal lipoma with squamous cell carcinoma of the overlying mucosa [6], malignant degeneration of these tumours is thought to be extremely rare.Surgical or endoscopic resection should be recommended for all symptomatic cases [1].Lipoma of the oesophagus is an extremely rare and benign tumour.It is typically detected incidentally but it can present with local symptoms and rarely with life-threatening complications.The diagnosis is established based on the findings of CT or MR, endoscopic ultrasound examination and  upper gastrointestinal endoscopy, which  evaluate the origin, extent, surface and consistency of oesophageal lipoma.\tManagement options vary depending on the size and location of the mass.",
    "differential_diagnosis": "Lipoma, of, the, oesophagus, Oesophageal, lipomatosis, Gastrointestinal, stromal, tumour, Fibroma, Neuroma, Neurofibroma, Haemangioma, Spindle, cell, carcinoma, (carcinosarcoma), Duplication, cyst, Lymphoma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009517/000001.jpg?itok=77cV_dzy",
            "caption": "Posterioanterior conventional chest radiograph shows a right-sided, slightly lobulated mass in superior mediastinum."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009517/000002.jpg?itok=Ly6WAg-E",
            "caption": "Lateral chest radiograph shows a subtle increase in soft-tissue density behind the trachea."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009517/000003.jpg?itok=3hvWWZtq",
            "caption": "Axial contrast-enchanced chest CT reveals a well-demarcated sausage-shaped mass surrounding the upper thoracic oesophagus with fatty attenuation, consistent with lipoma."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009517/000009.jpg?itok=IqfJYTaI",
            "caption": "Sagittal contrast-enchanced chest CT reveals a well-demarcated sausage-shaped mass surrounding the upper thoracic oesophagus with fatty attenuation, consistent with lipoma."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009517/000010.jpg?itok=mL6_hpvZ",
            "caption": "Coronal contrast-enchanced chest CT reveals a well-demarcated sausage-shaped mass surrounding the upper thoracic oesophagus with fatty attenuation, consistent with lipoma."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009517/000006.jpg?itok=diDw_fP-",
            "caption": "Barium swallow study (single\u2013contrast oesophagogram). Right lateral oblique view shows a large intraluminal-mass like a filling defect extending from above aortic arch to lower third of oesophagus."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009517/000007.jpg?itok=EAOsgQ3q",
            "caption": "Upper gastrointestinal endoscopic ultrasoound demonstrates a sharply marginated, homogeneously hyperechoic and intramural tumuor in the thoracic oesophagus."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009517/000008.jpg?itok=E8xN3zLt",
            "caption": "Upper gastrointestinal endoscopy shows a yellow, submucosal and smooth mass in the wall of the upper oesophagus, occupying the lumen. The lesion was covered by normal mucosa."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Gastrointestinal tract",
      "Mediastinum"
    ],
    "imaging_technique": [
      "CT-High Resolution",
      "PACS",
      "Ultrasound",
      "Conventional radiography",
      "Fluoroscopy"
    ],
    "link": "https://www.eurorad.org/case/9517",
    "time": "28.09.2011"
  },
  "9538": {
    "case_id": 9538,
    "title": "Fat embolism sydrome: a case report",
    "section": "Chest imaging",
    "age": "18",
    "gender": "female",
    "diagnosis": "Fat embolism syndrom",
    "history": "We present a case of an 18-year-old woman with tibial and peroneal fractures, who presented clinical symptoms of confusion, dyspnoea, hypoxaemia, haemoptysis and petechial rash 24 hours after orthopaedic surgery.",
    "image_finding": "Chest radiograph showed ill-defined bilateral opacities with symmetrical distribution predominating in the middle and lower fields of both lungs.Contrast-enhanced chest CT showed ill-defined ground glass opacities associated with interlobular septal thickening with middle and lower lobe predominance. No filling defects were detected in the main lobar or segmental branches of the pulmonary arteries and no pleural effusions were present. Acute pulmonary embolism was therefore ruled out.",
    "discussion": "The concept of fat embolism syndrome (FES) refers to a clinical entity in which neurological, haematological, respiratory and skin symptoms are associated as a result of the release of fat droplets into the bloodstream [1]. Long bone fracture and orthopaedic surgery are often the main cause, although this syndrome may also develop in severe burns, acute pancreatitis, severe infections, acute decompression illness and sickle cell disease [2, 3, 4].Fat embolism occurs very frequently (up to 90% in bone fractures and orthopedic prosthetic surgery), but only very few patients (~4%) will present with FES with classical symptoms[2, 3, 4].The pathogenetic mechanism is unclear. There are many theories, but the most widely accepted are two: the mechanical theory which states that fat emboli are released from the intramedullar pressure increased (after trauma or orthopaedic manipulation) and the biochemical theory which postulates that fat embolism are a result of neutral lipids hydrolysis into free fatty acids by lipase activation during some stress situations. In any case, the harmful effect of fat embolism is not due to vascular occlusion, but instead the endothelial damage caused by these fatty acids [3, 4].Clinical manifestations often appear after a latency period of 24-72 hours, which is the time it takes to develop vasculitis. The respiratory clinical symptoms are usually the first to appear and include dyspnoea, tachypnoea, cyanosis and hypoxaemia. Neurological symptoms can present at the same time, ranging from headache, stupor, drowsiness, seizures or coma. Conjunctival petechiae can appear sometimes in the neck and trunk [1, 3, 4].The chest radiograph may be normal initially, the most common radiological finding being bilateral ill-defined opacities with a pattern similar to pulmonary edema. These opacities on CT may have variable density, ranging from ground-glass to condensation, but usually tend to clear within 7-14 days. Interlobular septal thickening and centrilobular nodules may also be seen on CT. Sometimes fat embolism is seen as a filling defect in the pulmonary arteries. Pleural effusion is an uncommon finding in fat embolism. In severe cases adult respiratory distress can appear [1, 2, 5].The diagnosis of FES requires a clinocoradiological correlation [1]. The radiological signs are nonspecific and may occur in other diseases that affect patients with multiple trauma (pulmonary contusion, inhalation of toxic gases etc) [2, 5]. The latency period between the trigger and the onset of clinical and radiological signs is of great importance for the diagnosis [1].",
    "differential_diagnosis": "Fat, embolism, syndrom, Pulmonary, contusion, Aspiration, Acute, pulmonary, embolism, Acute, pulmonary, edema",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009538/000001.jpg?itok=TddrBpRL",
            "caption": "The image shows tibial and peroneal fractures with displacement of bone fractures."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009538/000002.jpg?itok=oZE5vARx",
            "caption": "No filling defects were detected in the main pulmonary arteries, lobar or segmental branches. No pleural effusions were seen."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009538/000003.jpg?itok=aaYIHNDH",
            "caption": "No filling defects were detected in the main pulmonary arteries, lobar or segmental branches. No pleural effusions were seen."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009538/000004.jpg?itok=M7PcM-6q",
            "caption": "No filling defects were detected in the main pulmonary arteries, lobar or segmental branches. No pleural effusions were seen."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009538/000006.jpg?itok=A2u-XxBL",
            "caption": "Note the ill-defined ground glass opacities associated with interlobular septal thickening, which predominate in middle and lower fields of both lungs."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009538/000007.jpg?itok=Oqbjy7Px",
            "caption": "Note the ill-defined ground glass opacities associated with interlobular septal thickening, which predominate in middle and lower fields of both lungs."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009538/000008.jpg?itok=pTPHWCMC",
            "caption": "Note the ill-defined ground glass opacities associated with interlobular septal thickening, which predominate in middle and lower fields of both lungs."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009538/000009.jpg?itok=eDaPPTB3",
            "caption": "Ill-defined bilateral opacities with symmetrical distribution predominate in middle and lower fields of both lungs."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Bones",
      "Thorax",
      "Pulmonary vessels"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT",
      "CT-Angiography"
    ],
    "link": "https://www.eurorad.org/case/9538",
    "time": "22.01.2012"
  },
  "9549": {
    "case_id": 9549,
    "title": "Kartagener\u2019s syndrome",
    "section": "Chest imaging",
    "age": "47",
    "gender": "male",
    "diagnosis": "Kartagener\u2019s syndrome",
    "history": "47-year-old male patient presented with difficulty breathing for two weeks, low grade fever for 3 days and a chronic productive cough with yellow sputum. Lung auscultation revealed occasional bi-basilar rhonchi. WBC showed mild leukocytosis with leftward shift.",
    "image_finding": "Chest X-ray (panel A) demonstrated situs inversus totalis (dextrocardia, right-sided aortic arch, left-sided liver and right sided gastric bubble) with tram-tracking and left basilar consolidation. CT of the paranasal sinuses (panel B) demonstrated mucosal thickening and air fluid levels consistent with sinusitis. High-Resolution CT chest demonstrated situs inversus totalis, bilobed right lung and trilobed left lung, left middle lobe bronchiectasis with scattered \u201ctree in bud\u201d nodular pattern consistent with bronchiolitis and some patchy left basilar consolidation. High-Resolution CT chest (panel C) demonstrated left middle lobe bronchiectasis with scattered \u201ctree in bud\u201d nodular pattern consistent with bronchiolitis and some patchy left basilar consolidation.",
    "discussion": "Kartagener\u2019s syndrome is characterised by the triad of situs inversus, bronchiectasis and sinusitis [1]. It is an autosomal recessive disease due to mutations in genes (DNAI1 and DNAH5) that code for ciliary proteins (dynein) and also play a role in situs determination in the developing embryo (heterotaxy). Symptoms result from defective ciliary motility in the upper respiratory tract, eustachian tubes, spermatozoa and fallopian tubes. Patients present with chronic upper and lower respiratory tract disease resulting from ineffective mucociliary clearance. A typical presentation is that of rhinorrhoea and/or mucopurulent discharge since birth. Immotile spermatozoa result in male sterility.Sinus radiographs and CT typically demonstrate mucosal thickening, opacified sinus cavities, and hypoplastic frontal sinuses. Chest radiograph may include bronchial wall thickening, hyperinflation, atelectasis, bronchiectasis, and situs inversus (in 50% of patients with primary ciliary dyskinesia). The presence of situs inversus strongly suggests Kartagener syndrome [2]. Bronchiectasis occurs in the lower lobes in patients with Kartagener syndrome. High-resolution CT of the chest is the most sensitive modality for documenting early and subtle abnormalities within airways and pulmonary parenchyma when compared to routine chest radiographs. Consideration should be given to this imaging technique early in the presentation of primary ciliary dyskinesia (PCD) syndromes, when a chest radiograph may not be sensitive enough to identify disease processes or when another differential is being considered. The most common infectious organisms affecting children with primary ciliary dyskinesia (PCD) are Haemophilus influenza and Staphylococcus aureus. These patients should receive comprehensive immunisations, including the influenza A and pneumococcal vaccines. Continuous or intermittent antibiotics are used to treat upper and lower airway infections. Children with primary ciliary dyskinesia are good candidates for long-term low-dose preventative antibiotics. Obstructive lung disease should be treated with inhaled bronchodilators and aggressive pulmonary toilet. Mucolytics may be helpful. Surgical interventions to treat middle ear disease, maxillary sinusitis, and nasal polyposis may be necessary in a subset of patients. Surgical intervention for bronchiectasis is rarely recommended, but can be beneficial when the disease is localised. Bilateral lung transplantation is the therapy of choice in patients with end-stage respiratory insufficiency, although heart-lung transplantation or a modified surgical procedure is required in patients with situs inversus.",
    "differential_diagnosis": "Kartagener\u2019s, syndrome, Alpha1-Antitrypsin, deficiency, Immunosuppression",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009549/000002.png?itok=Gdctoats",
            "caption": "CT of the paranasal sinuses demonstrates mucosal thickening and air fluid levels consistent with sinusitis."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009549/000003.png?itok=07xq4iVn",
            "caption": "High-Resolution CT Chest demonstrates left middle lobe bronchiectasis with scattered \u201ctree in bud\u201d nodular pattern consistent with bronchiolitis and some patchy left basilar consolidation."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009549/000004.jpg?itok=4f2QwEcZ",
            "caption": "Chest x-ray  demonstrated situs inversus with dextrocardia and right-sided aortic arch. There is bronchiectatic change in the bases."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009549/000005.jpg?itok=BpGg45Gr",
            "caption": "Chest x-ray  demonstrated situs inversus totalis (dextrocardia, right-sided aortic arch, left-sided liver and right sided gastric bubble). There is bibasilar tram-tracking compatible with bronchiectasis."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009549/000006.jpg?itok=BoIFGlvE",
            "caption": "Axial CT image at the level of upper abdomen shows situs inversus with left sided liver and right sided spleen and stomach."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009549/000007.jpg?itok=NTdPuEeY",
            "caption": "Oblique CT image demonstrates major and minor fissures in the left lung and left sided liver. There are bonchiectatic changes with tree in bud nodules consistent with bronchiolitis."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Ear / Nose / Throat",
      "Lung",
      "Cardiac",
      "Education",
      "Anatomy"
    ],
    "imaging_technique": [
      "CT",
      "CT-High Resolution",
      "Conventional radiography"
    ],
    "link": "https://www.eurorad.org/case/9549",
    "time": "15.10.2011"
  },
  "9553": {
    "case_id": 9553,
    "title": "Localized Castleman\\&#039;s disease",
    "section": "Chest imaging",
    "age": "44",
    "gender": "female",
    "diagnosis": "Hyaline vascular Castleman's disease",
    "history": "Female patient, 44 years old, asymptomatic, with no relevant history of disease underwent a routine thoracic radiography.",
    "image_finding": "Chest radiography showed a nodular medium-density opacity, located in the superior segment of the left lower lobe (Fig. 1).To further investigate the mass, chest CT was performed. CT showed a well-defined paravertebral mass. The mass showed a rough central calcification and enhanced homogeneously and avidly after intravenous administration of contrast material. The mass invaded the adjacent rib (Fig. 2).The patient underwent mediastinoscopy and surgical biopsy was obtained. The histological examination classified the lesion as hyaline vascular Castleman\u2019s disease.A successful surgical resection was performed.",
    "discussion": "Castleman\u2019s disease, also known as angiofollicular or benign giant lymph node hyperplasia, is a rare benign lymphoproliferative disorder of unknown etiology [1-3].It can be classified morphologically in unicentric/localized and multicentric/disseminated disease based on the extent of local lymph node involvement. Histopathologically two major categories can be distinguished: hyaline vascular, accounting for 90% of cases and plasma cell type. The former manifests, in approximately 90% of cases, as unicentric disease and the latter usually shows multicentric involvement [1-4].Pathologically the hyaline vascular type is characterized by lymph node hyperplasia, involuted germinal centers and capillary proliferation with endothelial hyperplasia.Hyaline vascular type occurs predominantly in young adults (3rd or 4th decade) with female predominance and has a significant predilection for the thorax, especially mediastinum and hilum but unusual locations can be involved, including pericardium, pleura, intercostal space and lung [3-5]. The typical radiographic appearance of hyaline vascular Castleman disease is an asymptomatic solitary rounded mediastinal or hilar mass lesion [2-6].The classic CT findings include a solitary mass or lymphadenopathy with avid homogeneous enhancement after intravenous administration of contrast material.Based on CT, three different patterns have been described: 1) a solitary noninvasive mass; 2) an infiltrative mass with lymphadenopathy in the same compartment and 3) lymphadenopathy in a single compartment without mass. Characteristic hypervascularity of lesions is verified by their homogeneous and intense enhancement after administration of contrast material. Indeed the mass may show feeding vessels in its proximity. About 10% of the lesions can show internal calcifications, which are typically coarse and central or branchlike. Systemic involvement of hyaline vascular type is uncommon compared with plasma cell type [1, 3-8].Mediastinal masses may simulate lymphoma, sarcoma, thymoma and neurogenic tumors, although hilar masses can mimic bronchial adenomas. Pericardial disease may resemble pericardial cyst. Intercostal disease may show rib erosion and can be confused with other chest wall masses. Pleural disease can manifest as pleural effusion or well-defined interlobar mass [4-8].Definitive preoperative diagnosis usually requires mediastinoscopy or surgical biopsy.Complete surgical resection is the gold standard for unicentric disease. If it is not possible or if multicentric involvement is present, radiotherapy and/or steroid therapy may be indicated [3-5].",
    "differential_diagnosis": "Hyaline, vascular, Castleman's, disease, Neurogenic, tumours, (ganglioneuroma;, paraganglioma;, nerve, sheaths, tumours), Lymphoma, Neurenteric, cyst, Meningocele, Extramedullary, haematopoiesis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009553/000004.jpg?itok=CH71HNuQ",
            "caption": "Axial contrast-enhanced CT shows a well-defined hypervascular left paravertebral mass, which enhances avidly after intravenous administration of contrast material"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009553/000005.jpg?itok=PTNMKw4e",
            "caption": "Tha mass shows central rough calcification and invasion of the adjacent rib."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009553/000006.jpg?itok=hdPU9rJw",
            "caption": "The posteroanterior radiography of the chest shows nodular medium-density opacity obliterating the left upper heart edge."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009553/000007.jpg?itok=QZsPHWpJ",
            "caption": "The lateral radiography of the chest shows nodular opacity located in the superior segment of the left lower lobe."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "CT",
      "Conventional radiography"
    ],
    "link": "https://www.eurorad.org/case/9553",
    "time": "21.12.2011"
  },
  "9577": {
    "case_id": 9577,
    "title": "Mediastinal mass with air-fluid level",
    "section": "Chest imaging",
    "age": "55",
    "gender": "female",
    "diagnosis": "Bronchogenic cyst",
    "history": "This 55-year-old woman presented with history of intermittent chronic cough. Physical examination was unremarkable.",
    "image_finding": "Chest radiograph (Fig. 1) showed widened mediastinum with right paratracheal mass containing air-fluid level. Subsequent CT (Fig. 2) showed a hypodense non-enhancing mass in the right paratracheal region with extension into the subcarainal region. Air-fluid level was also demonstrated. A bronchogenic cyst was suspected; complicated in this case due to the presence of air-fluid levels. The cause for air-fluid level was not clearly evident in this case. Possibilities include infection or communication with the bronchial tree; the later being more likely as there were no clinical features to suggest infection. Histology results post excision confirmed the diagnosis of bronchogenic cyst. Follow up chest radiographs at 6 months and 1 year later showed reduction in the size of the mediastinum with a persistent small area of air-fluid level (Fig. 3).",
    "discussion": "Bronchogenic cysts are rare congenital malformations which result from abnormal budding of ventral foregut. They are usually mediastinal lesions, however, less common cysts may occur within lung parenchyma, pleura or diaphragm [1, 3]. They are lined by secretary respiratory epithelium and the wall is made of tissues similar to that of normal bronchial tree [3]. They do not usually communicate with bronchial tree and are therefore typically not air filled. Rather they contain fluid, variable amount of proteinaceous material, blood products and calcium oxalate [1]. These components result in increased attenuation mimicking solid lesions [3]. Possible complications of the cysts include fistula formation with the bronchial tree, superimposed infection, haemorrhage, malignant transformation and secondary bronchial atresia. Rarely, these cysts can lead to pleurisy, pneumothorax and air embolism [1, 3].Bronchogenic cysts are usually asymptomatic and are found incidentally. When large, mass effect may result in bronchial obstruction and lead to symptoms of dyspnoea and cough [2, 3]. An alternative presentation may occur when cyst become infective [1].On the plain radio-graphs, the cyst appears as soft tissue density rounded structures sometimes with air fluid level. CT is valuable in determining site, size and shape of cyst and typically shows well defined spherical mass of soft tissue or water attenuation. Most bronchogenic cysts can be confidentially diagnosed by using non-enhanced CT. However, administration of contrast material and MR help to differentiate it from surrounding structures and other masses. Variable attenuation on CT and signal intensity on MR with fluid levels have also been reported due to the presence of variable composition [3]. Definitive diagnosis is obtained by surgical excision and tissue biopsy [4].Surgical excision is recommended to establish diagnose, alleviate symptoms and prevent complications in all operable candidates [2]. Transbronchial and percutaneous aspirations have been proposed as alternative to operation but these methods are not widely accepted because of possible cyst recurrence [4].Teaching Point: Widened mediastinum on plain radiograph has a number of differentials. Most often, cross sectional imaging is required to narrow down the differential. Well defined rounded fluid density lesion with or without air fluid level in a relatively asymptomatic patient should prompt the diagnosis of bronchogenic cyst. As mediastinal abscess has high mortality, this must not be forgotten as a differential. Definitive diagnosis can be achieved with transbronchial or CT guided aspiration which are invasive and should ideally be planned after multidisciplinary team discussion.",
    "differential_diagnosis": "Bronchogenic, cyst, Other, congenital, cysts/, malformations, such, as, oesophageal, duplication, cyst, and, pericardial, cyst, Mediastinal, abscess",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009577/000001.jpg?itok=PRXDZ6eD",
            "caption": "Widened mediastinum with right paratracheal opacity containing air fluid level."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009577/000002.jpg?itok=X_m_Dm6s",
            "caption": "Contrast enhanced axial images through the thorax: Right paratracheal non-enhancing hypodense mass is demonstrated with air fluid level (fig 2a: upper extent of the mass)"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009577/000003.jpg?itok=VuxWlV6Z",
            "caption": "Contrast enhanced axial images through the thorax: Right paratracheal non-enhancing hypodense mass is demonstrated with air fluid level"
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009577/000004.jpg?itok=BaLX0VPC",
            "caption": "Contrast enhanced axial images through the thorax: Right paratracheal non-enhancing hypodense mass is demonstrated with air fluid level"
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009577/000014.jpg?itok=ycdqyJUh",
            "caption": "Contrast enhanced axial images through the thorax: Right paratracheal non-enhancing hypodense mass is demonstrated with air fluid level (lung windows)"
          },
          {
            "number": "Figure 2e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009577/000005.jpg?itok=vJ8J4SAw",
            "caption": "Contrast enhanced axial images through the thorax: Right paratracheal non-enhancing hypodense mass extends into the subcarinal space"
          },
          {
            "number": "Figure 2f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009577/000007.jpg?itok=E-_5_TFO",
            "caption": "Contrast enhanced axial images through the thorax: Right paratracheal non-enhancing hypodense mass extends into the subcarinal space (fig 2f: lower extent of the mass)"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009577/000012.jpg?itok=2UL_sVcT",
            "caption": "3 months post excision of mediastinal cyst"
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009577/000013.jpg?itok=BBLrh1MU",
            "caption": "12 months post excision of mediastinal cyst."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Mediastinum"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/9577",
    "time": "02.12.2012"
  },
  "9634": {
    "case_id": 9634,
    "title": "CT and MR Findings of an Giant Pancreatic Cyst on Ectopic Thoracic Pancreas",
    "section": "Chest imaging",
    "age": "23",
    "gender": "female",
    "diagnosis": "Ectopic Giant Pancreatic Cyst in the Thorax",
    "history": "A 23-year-old female without alcohol abuse history complained of chest pain and dyspnea. Chest radiograph revealed a huge lesion in the left hemithorax. Four liters of straw-yellow colour fluid were evacuated immediately and 2 additional liters one week later. The fluid had pH 7.33, glucose 180mg/dL, protein 3.3g/dL, amylase 342IU/L.",
    "image_finding": "Chest radiograph showed a giant opacity that extended to the whole left lung field, with contralateral shift of mediastinal structures and inferior displacement of the gastric bubble (Fig. 1).The contrast enhanced CT examination revealed a giant lesion located between the left lung and the diaphragm (Fig. 2). It was predominantly cystic (mean CT attenuation value of 12 Hounsfield unit), well-circumscribed, demonstrating slightly thickened septa. A soft-tissue elongated structure was noted in the anterolateral wall of the previously mentioned cystic mass, with a mean CT attenuation value of 92 HU in the CECT. Most of the left lung was compressed by the mass. Paraaortic and pericardial lymphnodes were observed, as well as a small amount of pleural and pericardial effusion.Chest MRI revealed a predominantly thoracic cystic lesion with slightly thickened septa and confirmed the presence of the soft-tissue elongated structure seen in the anterolateral wall of the cystic mass (Fig. 3).",
    "discussion": "Most pancreatic cystic lesions in the thorax originate in the abdomen, with continuity of anatomical and vascular structures of normal pancreas. In the case of pancreatic pseudocyst on ectopic thoracic pancreas, there is no connection. The pancreas is located anomalously since the embryonic development. Its histogenesis is unclear. There are currently two main theories to explain this phenomenon. The first one supports that cell differentiation in the ventral primary foregut may fail, resulting in pancreatic cells. The second theory argues for an abnormal migration of cells from the pancreatic bud [1]. Whatever the case may be, an ectopic pancreatic cystic lesion in the thorax is extremely rare.  Symptomatic thoracic pseudocysts can present with dysphagia, dyspnea, airway obstruction, cough, chest pain, fever and/or cardiac tamponade [2-5]. CT and MRI are useful imaging techniques characterizing the extent and the topographic relations of the entity for surgical planning. Both techniques show an intrathoracic giant lesion with cystic loculations, with a small soft-tissue structure [2-5]. This cystic enlargement may be due to the absence of a natural way of drainage of secretions [5].Due to the lack of pathognomonic imaging findings and the rarity of the entity, our patient was diagnosed after surgery, because the diagnosis of a thoracic ectopic pancreas depends mainly on its histologic appearance. Histological analysis iof the surgical specimen in the presented case demonstrated the presence of ectopic pancreatic tissue in the thorax.Differential diagnosis should include thoracic cystic lesions and tumors with cystic components such as mature cystic teratoma, dermoid cyst, lymphangioma, cystic degeneration of tumors or another congenital mediastinal cyst. The presence of amylase in the aspirated fluid favors the diagnosis of a pancreatic lesion, regardless of its aggressiveness. To our knowledge, there have been no reports of malignant transformation of ectopic pancreatic cells in the thorax.Surgery is an effective method to treat the symptomatic ectopic pancreas.More studies are warranted in order to establish the imaging findings and characteristics of complications of thoracic ectopic pancreas, however if a young patient is found to have large cystic mass in the thorax without any specific symptoms or underlying known history of pancreatic disease, ectopic pancreas should be included in the differential diagnosis.",
    "differential_diagnosis": "Ectopic, Giant, Pancreatic, Cyst, in, the, Thorax, Mature, cystic, teratoma, Dermoid, cyst, Lymphangioma, Cystic, degeneration, of, tumors, Other, congenital, mediastinal, cyst",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009634/000001.jpg?itok=4M2OQmUR",
            "caption": "Chest radiograph shows a giant opacity extending to the whole left lung field, with contralateral shift of mediastinal structures and inferior displacement of the gastric bubble."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009634/000004.jpg?itok=7V1FsyDB",
            "caption": "Axial contrast-ehnanced CT reveals a predominantly cystic lesion (C) occupying the whole left hemithorax with significant shifth of the mediastimun to the right. A soft-tissue elongated structure is seen in its anterolateral wall (arrow)."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009634/000005.jpg?itok=sapPRw-V",
            "caption": "Coronal view."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009634/000006.jpg?itok=l0Bg0BzF",
            "caption": "Coronal view of contrast-enhanced abdominal CT. Note the inferior displacement of gastric bubble (G), pancreas (P), liver (L) and spleen (S). Pancreas is normal."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009634/000007.jpg?itok=7V8LK6Lt",
            "caption": "Axial T1W MRI shows a thoracic cystic lesion with a solid component (arrow)."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009634/000008.jpg?itok=uih0-Rbv",
            "caption": "Axial T1W MRI of the upper abdomen shows no abnormalities."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009634/000009.jpg?itok=WeRZxuuM",
            "caption": "The axial T2W image at the level of midthorax shows the cystic (C) and solid (arrow) components of the lesion."
          },
          {
            "number": "Figure 3d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009634/000011.jpg?itok=LT8WnhTH",
            "caption": "Axial T2W image at the level of upper abdomen and pancreas. No abnormalities are detected."
          },
          {
            "number": "Figure 3e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009634/000010.jpg?itok=eXrWdoS8",
            "caption": "Sagital T1W image of the thorax and upper abdomen shows the giant cystic mass in the left hemithorax displacing the diaphragm and subdiaphragmatic organs inferiorly."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax",
      "Abdomen"
    ],
    "imaging_technique": [
      "CT",
      "MR"
    ],
    "link": "https://www.eurorad.org/case/9634",
    "time": "03.09.2012"
  },
  "9664": {
    "case_id": 9664,
    "title": "Hold your breath!",
    "section": "Chest imaging",
    "age": "65",
    "gender": "male",
    "diagnosis": "Air embolus post CT-guided lung biopsy",
    "history": "Surveillance of a 65-year-old male for pT3N1 rectal carcinoma showed suspicious lung nodules. He underwent a CT-guided biopsy and four cores were taken. Upon completion, he complained of severe chest pain. He became diaphoretic and his oxygen saturations dropped to 92% on room air.",
    "image_finding": "A suspicious lung nodule is noted in the right middle lobe on axial CT images (figure 1). The post lung biopsy CT reveals an air embolus within the right ventricle, peritumoural haemorrhage and a small pneumothorax (figures 2 and 3). A repeat CT scan thirty minutes later showed complete resolution of the air embolus. Our patient's symptoms were transient and fully resolved within minutes. He responded to conservative measures of 100% oxygen supplementation. Apart from the temporary drop in oxygen saturations, he remained haemodynamically stable throughout.",
    "discussion": "Air embolus is a rare and potentially fatal complication of CT-guided lung biopsies, reported in 0.02-0.07% of biopsies [1]. Air may gain access to the systemic circulation in one of three ways: 1) the needle tip may be placed into the pulmonary vein directly, 2) air introduced into the pulmonary arterial system may cross the microvasculature to the pulmonary venous system and 3) fistula may be created between an air-filled space and a pulmonary vein when a needle traverses both simultaneously. Subsequent coughing, straining or valsava manoeuvre may cause air embolisation to occur. Air entering the pulmonary venous network embolises primarily to coronary and cerebral arteries. A mere 0.5-1 ml of air in the coronary arteries may cause cardiac arrest and just 2 ml of air in the cerebral arteries is sufficient to cause death [2]. Risk factors have been identified which increase the risk of air embolus occurring. Higher risks are incurred in patients undergoing procedures for cystic or cavitary lesions, patients with vasculitis or those on positive pressure ventilation [3]. Some reports have suggested that using larger needles increases the risk of embolisation; however emboli have also been reported with smaller gauge needles [4]. Systemic air embolus should be suspected if there is an acute deterioration in the cardiovascular or neurological status of the patient and may be confirmed by post-procedural CT scanning. As with our case, immediate treatment is with 100% oxygen therapy. Hyperoxygenation can replace the nitrogen contained within the embolus with oxygen and expedite its reabsorption by blood and surrounding tissues. This process may be aided by the use of hyperbaric oxygen therapy which has been shown to reduce mortality in cerebral embolism by 7% [5]. While hyperbaric oxygen therapy is the only definitive treatment for systemic air emboli, in reality it is not always readily available. Some authors suggest placing the patient in the left lateral decubitus or Trendellenburg position if an air embolus is detected in the left ventricle to reduce the risk of cerebral artery embolisation [2, 4]. Others suggest the prone position is more appropriate as blood flow will inevitably overcome any benefit to be gained from the positional buoyancy of the air embolus within the ventricle [6]. For this rare, but potentially life threatening condition, radiologists should take the necessary steps to minimise the occurrence of systemic air embolism and be familiar with the signs and symptoms of air embolism.",
    "differential_diagnosis": "Air, embolus, post, CT-guided, lung, biopsy, Acute, coronary, event, Pneumothorax",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009664/000001.jpg?itok=xvBpLmT1",
            "caption": "Initial axial image.  Note the ill-defined lung nodule in the middle lobe.  Grid lines on the patient\\'s skin surface planning the biopsy.  Procedure performed using a 19/20 guage co-axial needle pairing"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009664/000002.jpg?itok=KEK_k3oz",
            "caption": "Note the air within the right ventricle (balck arrow).  The patient responded to conservative resuscitation of 100% oxygen supplementation.   There is a shallow surface pneumothorax and small volume peritumoural haemorrhage."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009664/000003.jpg?itok=cbqJHv50",
            "caption": "Coronal image showing the intracardiac air embolus (black arrow) and three lung nodules (white arrows)."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Respiratory system"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/9664",
    "time": "12.01.2012"
  },
  "9666": {
    "case_id": 9666,
    "title": "Tracheal diverticulum\u2019s invagination in a patient affected by tracheomalaci",
    "section": "Chest imaging",
    "age": "72",
    "gender": "female",
    "diagnosis": "Small single tracheal diverticulum in patient with tracheobroncomalacia",
    "history": "A 72 year old female, ex-smoker, with atypical mycobacterial infection, underwent chest multi-detector computed tomography (MDCT) for clinical follow-up due to persistence of dry cough, dyspnea and mild fever despite first-line medical therapy.",
    "image_finding": "High-Resolution CT volumetric axial images showed a small right-sided paratracheal ovoid air-filled structure, with a thick wall, originating from the pars membranacea of the trachea at the level of the thoracic inlet (Figure 1a). Performing multiplanar reconstruction, on sagittal plane we noticed the reduction of tracheal lumen due to a suboptimal inspiration of the patient (Figure 1b). We immediately repeated a volumetric CT, at maximum pulmonary inspiration, observing the posterior displacement of the small air-filled structure with a narrow connection with the postero-lateral wall of the trachea (Figures 2a and b). Tracheobroncomalacia was diagnosed measuring a tracheal lumen reduction >70% in the antero-posterior axial plane, in the expiratory scan.",
    "discussion": "Tracheal diverticulum is a benign lesion, single or multiple, congenital or acquired, characterised by single or multiple invaginations of the tracheal wall layers [1]. They may appear at any level of the trachea: the congenital outpouchings are located, generally, below the vocal cords or above the carina; acquired lesions may appear at any level. Most of the lesions are clinically asymptomatic.Computed tomography detects the presence of the diverticulum and gives informations about size, origin and location. Tracheobronchomalacia is a central airway disease due to weakness of the layers of the tracheal and mainstem bronchial wall, characterised by expiratory collapse of the airway and flow obstruction [2]. It can be congenital or acquired. In infants and children, it causes expiratory stridor and cough; in adults, main symptoms are cough, dyspnea, increased infections and poor secretion management. The dynamic evaluation of the airways is fundamental for diagnosis; tracheal and bronchial collapse during forced expiration is the key point and a cut-off of 70% narrowing in the antero-posterior axial plane (>50% expiratory reduction in cross-sectional area) is accepted to establish the diagnosis.Fibrobronchoscopy is still considered to be the gold standard. Dynamic multidetector computed tomography is emerging as a very useful technique allowing imaging of the entire airways in a few seconds and is the technique of choice for the evalutation of central and peripheral airways. Maximum pulmonary inspiration during the acquisition is mandatory for correct evaluation. Multiplanar reconstruction (MPR) in coronal, sagittal and oblique views are useful to assess the exact position of the airways, evaluate the surrounding structures and even control the correct inspiration of the patient during the examination.",
    "differential_diagnosis": "Small, single, tracheal, diverticulum, in, patient, with, tracheobroncomalacia, pharyngocele, laryngocele, Zenker, diverticulum, blebs, pneumomediastinum",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009666/000001.jpg?itok=IOyGwvwP",
            "caption": "Figure 1. a) Axial image: a small air-filled structure within the pars membranacea of the trachea is seen (white arrow); b)sagittal image: normal reduction of tracheal lumen due to expiratory acquisition is noted (black arrowhead)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009666/000002.jpg?itok=YqI7Lwn2",
            "caption": "Figure 2 a) oblique image: posterior displacement of the lesion behind the tracheal lumen (white arrow). b) sagittal reconstruction: enlargement of tracheal lumen (black arrowhead) and the extraluminal site of diverticulum (black arrow)  are seen."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT-High Resolution"
    ],
    "link": "https://www.eurorad.org/case/9666",
    "time": "04.12.2011"
  },
  "9668": {
    "case_id": 9668,
    "title": "Cavitary invasive adenocarcinom",
    "section": "Chest imaging",
    "age": "30",
    "gender": "male",
    "diagnosis": "Invasive mucinous adenocarcinoma with predominant lepidic growth",
    "history": "A 30-year-old man, smoker, asymptomatic and without relevant medical history, underwent a chest radiograph that showed a large well-circumscribed, thick-walled (>4mm) cavitary lesion in the left lower lobe (LLL). Physical examination and routine laboratory investigations, including tuberculin and HIV tests, were negative, as well as previous chest radiographs.",
    "image_finding": "Chest radiograph shows a large thick-walled cavitary lesion in the LLL, adjacent to the posterior chest wall (Figs. 1a and 1b). Chest CT scans (axial images and multiplanar reconstructions) (Fig. 2) confirm the presence of a 10 cm cavitary lesion, with irregular and thick inner wall (9mm maximum), internal septa and normal bronchial structures entering the lesion (Fig. 2b) (arrow). Ground-glass opacities (GGO) (Figs. 2a, 2d) are shown around the cavity and one cavitated nodule (Fig. 2c) is evident in the surrounding lung parenchyma. No inner air-fluid level is present in the cavity. Sagittal image at lung window setting (Fig. 3) better depicts the longitudinal extension of the lesion. No hilar and mediastinal lymphadenopathy is detected. No abnormalities in the brain, abdomen and pelvis are found. 18F-FDG PET demonstrates low tracer uptake in the lesion wall (Fig. 4). No other abnormal uptake of 18F-FDG is detected.",
    "discussion": "Adenocarcinoma is the most common histologic type of lung cancer and it has been recently demonstrated that it is more common among younger patients (age \u226440 years) than in older patients (57.5% versus 45.2%; p<0.0001) [1, 2]. Invasive adenocarcinomas represent more than 70 to 90% of surgically resected lung cases among adenocarcinoma subtypes. Histologically, invasive mucinous adenocarcinoma (IMA) shows tumor cells having intracytoplasmatic mucin and alveolar spaces containing mucin. IMA usually shows one or more of the following criteria: size >3cm, amount of invasion >0, 5cm and multiple nodules. IMA may have different growth patterns including lepidic predominant. In imaging studies IMA presents as a spectrum ranging from nodules to lobar replacement by a variety of patterns (GGO, mixed GGO/solid foci, or consolidation). The GGO component typically corresponds to lepidic pattern and the solid component to invasive pattern. In our case, the lesion appeared as a 10 cm thick-walled cavity, with irregular inner wall and internal septa. The surrounding lung parenchyma showed ground-glass opacities and one cavitating satellite nodule. Main differential diagnoses of lung lesions with cavitation include aspergilloma, bacterial abscess, post-primary tuberculosis and cavitary squamous cell carcinoma. Cavitation in aspergilloma and bacterial abscess generally presents smooth internal contour and wall thickness <4mm, while features that characterize tuberculosis are predilection of upper lobes and absence of internal septa [3]. Squamous cell carcinoma commonly shows central mass and tendency to cavitate (81%) due to necrosis. Hilar lymph node involvement and intense 18F-FDG uptake are typically observed in bacterial abscess, tuberculosis and cavitary squamous cell carcinoma. Cavitation is rare in adenocarcinoma. The pathogenetic mechanisms of cavitation may include conducting bronchus check-valve obstruction by tumour cells, alveolar wall rupture due to tumour cell proliferation or mucus retention [4]. In our case, the diagnosis was mainly suspected on the basis of the peripheral location, the ground-glass component surrounding the cavity and the low grade 18F-FDG uptake, which are more common in adenocarcinoma. Bronchoalveolar lavage demonstrated the presence of malignant cells. A left lower lobectomy was performed. The resected specimen (Fig. 5) showed lung parenchyma massive destruction with central cavity and focal translucent thickening of the wall (mucin) with internal septa of normal stroma. Specimen from the cavity wall (Fig. 6) demonstrated invasive mucinous adenocarcinoma with predominant lepidic growth. A cavitary lesion showing thick-wall, irregular inner margin and surrounding GGO that occurs in a young patient might include invasive adenocarcinoma as a possible diagnostic option.",
    "differential_diagnosis": "Invasive, mucinous, adenocarcinoma, with, predominant, lepidic, growth, Aspergilloma, Bacterial, abscess, Tuberculosis, Cavitary, squamous, cell, carcinoma, Cavitary, invasive, adenocarcinoma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009668/000001.jpg?itok=vi2gtDDF",
            "caption": "Chest radiograph (frontal and lateral view) shows a large thick-walled cavitary lesion in the LLL."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009668/000002.jpg?itok=E5o3QWU-",
            "caption": "Note a cavitary lesion with irregular, thick inner wall, internal septa and normal bronchial structures flowing into the lesion (b). Ground-glass opacities (a, d) and one satellite nodule in the surrounding lung (c) are noted."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009668/000003.jpg?itok=RdzLJ6Sk",
            "caption": "Sagittal reconstruction better depicts the longitudinal extension of the lesion."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009668/000004.jpg?itok=Q1QrHjtV",
            "caption": "18F-FDG PET demonstrates low uptake in the lesion wall."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009668/000006.jpg?itok=c4FXtL87",
            "caption": "Resected specimen shows massive destruction of lung parenchyma with central cavity and focal translucent thickening (2 cm) of the wall and internal septa."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009668/000007.jpg?itok=c4ttI-xy",
            "caption": "Specimen stained with hematossilin-eosin demonstrates the presence of mucin within the alveolar spaces and a lepidic growth along intact alveolar septa."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "Image manipulation / Reconstruction",
      "CT",
      "PET"
    ],
    "link": "https://www.eurorad.org/case/9668",
    "time": "22.01.2012"
  },
  "9750": {
    "case_id": 9750,
    "title": "Asymptomatic broncho-esophageal fistula due to tuberculous cavitatory lesion",
    "section": "Chest imaging",
    "age": "25",
    "gender": "female",
    "diagnosis": "Tuberculous bronchoesophageal fistula",
    "history": "A 25 year-old female attended the outpatient clinic complaining of cough, expectoration and fever. Her sputum analysis showed acid fast bacilli (AFB) positive for Mycobacterium tuberculosis and chest radiograph showed a cavitatory lesion. She was negative for HIV. She was put on antituberculous treatment and was shceduled for follow up.",
    "image_finding": "Her initial chest radiograph showed a cavitatory lesion. Although she was put on antituberculous treatment she discontinued it after one-month initial recovery. She returned with exacerbation of her symptoms and her sputum still showed AFB positive for Mycobacterium tuberculosis. Her CECT thorax (high resolution, 1 mm reconstruction and post processed images) revealed in axial, sagittal and coronal planes multiple thin fibrotic bands with consolidation in right lower lobe basal segments (Figure 1, 2, 3). There were multiple cavities and focal nodular opacities. One large cavity showed suspicious communication with the right lateral wall of oesophagus. Mediastinal lymphnodes were present. She underwent thin barium swallow study, which conclusively showed pooling of contrast in the cavity and presence of bronchoesophageal fistula (Figure 4). Ultrasound (USG) of abdomen was unremarkable. Her follow-up barium swallow was normal suggesting healing of fistulous track without any surgical repair and remarkable recovery both radiologically and clinically.",
    "discussion": "Tuberculosis is a disease with protean manifestations. It is still a huge burden in terms of prevalence and cost on healthcare in developing countries. In India it has been a challenge to deal with tuberculosis due to non-compliance and socio-economic factors. Despite of several programs and initiatives, results are not satisfactory. With increasing cases of drug resistant tuberculosis and conjunction with HIV cases the situation becomes more confounding [1]. Increasing number of cases with complications in young population is a serious issue [2]. Low socio-economic status, literacy, religious factors make treatment of TB difficult. There are many unusual complications and spectrum of disease that are diagnosed retrospectively [3]. A variety of complications can occur in patients. These include tuberculoma, aspergilloma, bronchiectasis, tracheobronchial stenosis, broncholithiasis, vascular lesions, lymph nodes, esophagomediastinal or esophagobronchial fistula. Scenario becomes complicated due to defaulters and gives rise to drug resistant tuberculosis [4]. The disease becomes more complicated in female patients. Incidence of gastrointestinal and tubercular salpingitis is high in the Indian population. Awareness is a major issue. Social factors are hard to overcome. Indiscriminate use of ATT without confirmation is an area of concern. The incidence of complicated pulmonary as well as extrapulmonary tuberculosis is bound to increase if these issues are not addressed. ATT if taken regularly can avoid complications and obviate surgery in the majority of cases.",
    "differential_diagnosis": "Tuberculous, bronchoesophageal, fistula, Malignant, bronchoesophageal, fistula, Traumatic, bronchoesophageal, fistula",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009750/000011.jpg?itok=2dwGjTNn",
            "caption": "Barium meal showing cavity and bronchoesophageal fistula."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009750/000012.jpg?itok=SHnQqnsp",
            "caption": "CONTIGUOUS SECTIONS SHOWING CONSOLIDATION AND CAVITATORY LESION IN TH ERIGHT LOWER LOBE ABUTTING THE LATERAL WALL OF ESOPHAGUS (A, B, C, D)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009750/000016.jpg?itok=11IKKk2i",
            "caption": "CORONAL SECTION OF CAVITY ABUTTING THE MEDIASTINUM"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009750/000018.jpg?itok=CADqKg0_",
            "caption": "SAGITTAL SECTION FOCUSSING ON CAVITY AND MEDIASTINUM."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Oesophagus",
      "Lung"
    ],
    "imaging_technique": [
      "Fluoroscopy",
      "CT-High Resolution"
    ],
    "link": "https://www.eurorad.org/case/9750",
    "time": "16.03.2012"
  },
  "9756": {
    "case_id": 9756,
    "title": "Relapsing polychondritis",
    "section": "Chest imaging",
    "age": "23",
    "gender": "male",
    "diagnosis": "Relapsing polychondritis",
    "history": "A 23-year-old Italian male patient came to our department with worsening dyspnoea, which arose about six months before. He also complained of recent-onset wheezing, stridor and left hypoacusia.",
    "image_finding": "The patient underwent a chest radiograph, which showed no parenchymal lesions but detected tracheal and main left bronchial narrowing (Fig. 1). A chest CT without contrast medium was subsequently performed to study the tracheobronchial tree. CT detected severe airway involvement and structural abnormalities: subglottic stenosis, tracheal and main left bronchial lumen narrowing, tracheobronchial wall thickening, disruption and calcifications of airway cartilage. CT also revealed calcifications of costal cartilages and findings related to arthritis of the third and fourth chondro-sternal joint (Fig. 2, 3). Expiratory CT was not performed to avoid excessive X-ray exposure in a young patient. A PET scan that showed low metabolic hyperactivity (SUV 3-5) of costal cartilages, and high metabolic hyperactivity of the left part of cricoid cartilage (Fig. 4). These findings were compatible with an inflammatory process in the above mentioned areas.",
    "discussion": "Relapsing polychondritis is a rare, chronic, systemic inflammatory disease and is classified as an autoimmune connective tissue disorder. It has no age or sex prediliction, but it generally occurs between the fourth and fifth decades of life [1].It is characterised by recurrent and diffuse inflammation of cartilaginous structures that can lead to progressive degeneration and destruction of cartilage; cicatricial fibrosis, calcifications and sometimes malacia can be severe outcomes of this chronic inflammatory process. The disease frequently involves external ear, nose, larynx, tracheobronchial tree and joints [2]. Aetiopathogenesis is still unknown, even though an immune-mediated mechanism is hypothesized: chronic inflammation is probably due to an autoimmune response, since antibodies against type II collagen are found in these patients [3]. The most frequent clinical features are dyspnoea, wheezing and stridor, cough and dysphonia, due to upper and lower airways chondritis (70% of patients) [4]; in fact, chronic inflammation causes airway narrowing and cartilaginous collapse that lead to respiratory distress. Respiratory failure and pneumonia are the two major causes of death [1].Other clinical findings consist of recurrent inflammation with pain and swelling of nose and external ear, which can gradually result in deformities (auricular and nasal chondritis), hypoacusia (audiovestibular damage), ocular inflammation and inflammatory arthropathy of peripheral joints. Patients can sometimes present cardiovascular involvement as systemic vasculitis, aortic and mitral valvular insufficiency, aortic aneurysm [5].CT is the most important imaging technique; typical findings are tracheobronchial wall thickening and luminal narrowing, unusual calcifications and cartilaginous disruption. Functional airway abnormalities like malacia and air-trapping can manifest in patients with normal inspiratory CT, and can represent the only signs of disease at early stages; these findings can be detected only with dynamic expiratory CT, that is why expiratory CT should become routine in the evaluation of these patients. Multiplanar reconstruction and three-dimensional renderings are also very informative[6, 7]. The following differential diagnosis should be considered: amyloidosis (narrowing due to multifocal or diffuse submucosal infiltrates), sarcoidosis (external compression caused by enlarged lymph nodes or granulomas of the trachea and main-stem bronchi) and tracheopathia osteochondroplastica (calcified nodules protrude into airway lumen causing thickening and narrowing) [8]. Therapeutic options include steroids and more aggressive immunosuppressors; therapy should be started at early stages in order to delay disease progression, especially in patients with respiratory involvement that portends a worse prognosis. Unfortunately early diagnosis is quite uncommon. In case of severe tracheobronchial narrowing, a metallic stent can be placed [9].",
    "differential_diagnosis": "Relapsing, polychondritis, Amyloidosis, Sarcoidosis, Tracheopathia, osteochondroplastica",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009756/000001.jpg?itok=ehcukVIH",
            "caption": "Chest radiograph does not show pleural-parenchymal lesions, but reveals tracheal and main left bronchial narrowing instead."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009756/000002.jpg?itok=5iXVqryH",
            "caption": "Axial CT shows disruption and calcifications of the cricoid cartilage and upper airway lumen narrowing."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009756/000003.jpg?itok=GMQiILH5",
            "caption": "This image underlines the tracheal wall thickening."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009756/000017.jpg?itok=IUojxX9Y",
            "caption": "This image shows the difference between left and right main bronchial lumen with the left one being exteremely narrow."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009756/000005.jpg?itok=InQ0eTwQ",
            "caption": "Coronal MPR reconstruction shows the main left bronchial lumen stenosis, that reaches a diameter of 4.4 mm at the most narrow point."
          },
          {
            "number": "Figure 2e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009756/000006.jpg?itok=0KeBPrpF",
            "caption": "Coronal MPR reconstruction shows the tracheal narrowing."
          },
          {
            "number": "Figure 2f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009756/000007.jpg?itok=otqlA8jQ",
            "caption": "This sagittal MPR reconstruction shows subglottic stenosis."
          },
          {
            "number": "Figure 2g",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009756/000015.jpg?itok=kzEcf2-O",
            "caption": "This sagittal MPR reconstruction highlights main left bronchus narrowing."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009756/000008.jpg?itok=a482rPQW",
            "caption": "3D reconstruction of trachea and main-stem bronchi underlines main left bronchus narrowing compared to the right one."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009756/000009.jpg?itok=CPqPljf8",
            "caption": "This image shows an overview of lungs and tracheobronchial tree. It underlines narrowing of the left main bronchus ."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009756/000010.jpg?itok=md-KinNV",
            "caption": "This 3D reconstruction helps visualise the involvement of costal cartilages and chondro-sternal joints."
          },
          {
            "number": "Figure 3d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009756/000016.jpg?itok=62hdMl5M",
            "caption": "MIP reconstruction highlights calcifications of costal cartilages."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009756/000011.jpg?itok=8am_DFL0",
            "caption": "The red area suggests a high metabolic hyperactivity of the left part of cricoid cartilage."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009756/000012.jpg?itok=d088KoOH",
            "caption": "The image shows a high metabolic hyperactivity corresponding to the glottic area and to the airway lumen narrowing."
          },
          {
            "number": "Figure 4c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009756/000013.jpg?itok=McGgQjT0",
            "caption": "Yellow and red areas along the course of the left main bronchus underline its metabolic hyperactivity."
          },
          {
            "number": "Figure 4d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009756/000014.jpg?itok=OOMuHn4P",
            "caption": "This image shows metabolic hyperactivity of costal cartilages, especially in the left hemithorax."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax",
      "Head and neck"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT",
      "PET-CT"
    ],
    "link": "https://www.eurorad.org/case/9756",
    "time": "02.02.2012"
  },
  "9783": {
    "case_id": 9783,
    "title": "Idiopathic spontaneous pneumomediastinum",
    "section": "Chest imaging",
    "age": "9",
    "gender": "female",
    "diagnosis": "Idiopathic spontaneous pneumomediastinum",
    "history": "A 9 year-old previously healthy female patient presented with right ear pain and odynophagia, ipsilateral parotid swelling of sudden onset with no history of trauma, coughing or straining.On clinical examination subcutaneous emphysema was confirmed in right temporoparietal region, neck and upper chest with good air entry in both lungs.",
    "image_finding": "Air in the retropharyngeal soft tissue and perilaryngeal and subcutaneous tissue was noted in the thoracic outlet. Submandibular soft tissue was enlarged. The body of the hyoid was moved forward (Fig. 1).The chest radiograph showed interstitial air juxtahilar between the left main pulmonary artery and the mediastinal pleura and subcutaneous emphysema in the soft tissues of the neck (Fig. 2, 3).Neck CT showed dissection of the different compartments due to the presence of interstitial air, with no evidence of rupture of organs (Fig. 4 - 7). Chest CT revealed air dissecting supraaortic and subaortic mediastinal structures.  Subcutaneous emphysema was noted in the presternal region without concomittant pneumothorax (Fig. 8, to 13).Skull CT was normal except for presence of gas in subcutaneous tissue of the right frontotemporoparietal area without associated bone lesions (Fig. 14).",
    "discussion": "Spontaneous pneumomediastinum is characterized by the presence of air in the mediastinum in a patient without known underlying cause and is benign and self-limited. The first report was made by Hamman in 1939 [4, 6]. The incidence is unknown.The mediastinum is connected to the submandibular space, retropharyngeal space, neck vessels, gastrointestinal tract, retroperitoneum (through periesophageal and periaortic fascial) and pelvis through the flank [5, 6]. The retropharyngeal space and prevertebral space communicate with the mediastinum neck. The prevertebral space continues down to the coccyx [7]. The pathophysiology of the mechanism consists of 3 steps: the terminal alveoli rupture, the air dissection along the peribronchovascular sheaths and the extent of interstitial emphysema in the mediastinum (Macklin effect) [6]. The alveolar rupture is a sudden increase in intraalveolar pressure, associated with cough or valsalva, exceeding the pressure in the pulmonary vasculature, releasing the air produced by interstitial emphysema, peribronchovascular sheaths dissected and interlobar septa. On the pressure gradient, the air can produce progress to pneumomediastinum or hilum to the periphery and produce pulmonary subpleural bullae and pneumothorax. The rupture of the alveoli in the pleural space can cause pneumothorax with no evidence of mediastinal emphysema. Finally, it can extend into the subcutaneous tissues of the chest wall and anterior cervical region, following the fascial planes and into the spinal canal [1].The main symptoms are chest pain and dyspnoea [1], odynophagia [8], cough, nausea, vomiting [3] secondary to the dissection of tissues over the air or compression [9]. Retrosternal chest pain worsens with movement or breathing. Dysphagia and dysphonia are present if the air dissects retropharyngeal or perilaryngeal spaces [10]. Hamman's sign (pericardial crunch synchronous with the heart) is not pathognomonic [11]. Treatment is conservative. Pneumomediastinum evolves smoothly and resolves in 3 to 15 days without sequelae. No fatalities have been reported. In 32% of cases it may be complicated by pneumothorax [2, 3, 4, 8, 9, 11, 12].Spontaneous pneumomediastinum is rare in children. A high index of suspicion is necessary in young patients with chest pain and signs of subcutaneous emphysema. A chest and lateral neck radiograph are initial tools for the initial diagnosis and should be supplemented by chest CT to rule out underlying lung disease or other causes of secondary pneumomediastinum and assess its extent.Supportive therapy and clinical observation is sufficient in most cases as pneumomediastinum is self-limited (Fig. 15, 16).",
    "differential_diagnosis": "Idiopathic, spontaneous, pneumomediastinum, Secondary, pneumomediastinum, Cardiac, ischaemia, Pericarditis, Pneumothorax, Mallory-Weiss, syndrome, Boerhaave, syndrome, Asthma, in, children, Respiratory, infections",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009783/000001.jpg?itok=9E57wytD",
            "caption": "Air in the retropharyngeal soft tissue and perilaryngeal and subcutaneous tissue are introduced into the thoracic outlet. Submandibular soft tissue shows augmentation. The body of the hyoid is moved forward."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009783/000002.jpg?itok=8GNj9hCP",
            "caption": "Interstitial air is displayed in the region of the left lung juxtahilar between the left main pulmonary artery and the mediastinal pleura. Subcutaneous emphysema is shown in the soft tissues of the neck."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009783/000003.jpg?itok=32S-HiTF",
            "caption": "Interstitial air in the region of the left lung juxtahilar between the left main pulmonary artery and the mediastinal pleura."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009783/000016.jpg?itok=WMGk8Z7c",
            "caption": "Follow-up radiograph is normal after 2 weeks."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009783/000018.jpg?itok=2dqEjWQd",
            "caption": "Dissection of the different compartments due to the interstitial air, with no evidence of rupture of organs (parotid and masticator space right retropharyngeal, prevertebral, anterior cervical visceral space and deep cervical space)."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009783/000019.jpg?itok=6jDr8btK",
            "caption": "Dissection of the different compartments due to the interstitial air, with no evidence of rupture of organs (parotid and masticator space right retropharyngeal, prevertebral, anterior cervical visceral space and deep cervical space)."
          }
        ]
      },
      {
        "number": "Figure 7",
        "subfigures": [
          {
            "number": "Figure 7",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009783/000020.jpg?itok=vt556K8i",
            "caption": "Dissection of the different compartments due to the interstitial air, with no evidence of rupture of organs (parotid and masticator space right retropharyngeal, prevertebral, anterior cervical visceral space and deep cervical space)."
          }
        ]
      },
      {
        "number": "Figure 8",
        "subfigures": [
          {
            "number": "Figure 8",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009783/000021.jpg?itok=W7JEtoGe",
            "caption": "Dissection of the different compartments due to the interstitial air, with no evidence of rupture of organs (parotid and masticator space right retropharyngeal, prevertebral, anterior cervical visceral space and deep cervical space)."
          }
        ]
      },
      {
        "number": "Figure 9",
        "subfigures": [
          {
            "number": "Figure 9",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009783/000022.jpg?itok=2vn5dmtb",
            "caption": "Air is dissecting supra-aortic and subaortic mediastinal structures. The presternal subcutaneous emphysema is noted  without associated pneumothorax."
          }
        ]
      },
      {
        "number": "Figure 10",
        "subfigures": [
          {
            "number": "Figure 10",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009783/000023.jpg?itok=2didVgRR",
            "caption": "Air is dissecting supra-aortic and subaortic mediastinal structures. The presternal subcutaneous emphysema is noted  without associated pneumothorax."
          }
        ]
      },
      {
        "number": "Figure 11",
        "subfigures": [
          {
            "number": "Figure 11",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009783/000024.jpg?itok=LH4R1yY-",
            "caption": "Air is dissecting supra-aortic and subaortic mediastinal structures. The presternal subcutaneous emphysema is noted  without associated pneumothorax."
          }
        ]
      },
      {
        "number": "Figure 12",
        "subfigures": [
          {
            "number": "Figure 12",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009783/000025.jpg?itok=5vYbYEWC",
            "caption": "Air is dissecting supra-aortic and subaortic mediastinal structures. The presternal subcutaneous emphysema is noted  without associated pneumothorax."
          }
        ]
      },
      {
        "number": "Figure 13",
        "subfigures": [
          {
            "number": "Figure 13",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009783/000026.jpg?itok=WzNszlTs",
            "caption": "Air is dissecting supra-aortic and subaortic mediastinal structures. The presternal subcutaneous emphysema is noted  without associated pneumothorax."
          }
        ]
      },
      {
        "number": "Figure 14",
        "subfigures": [
          {
            "number": "Figure 14",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009783/000027.jpg?itok=ybSzzMSw",
            "caption": "The CT of the skull is normal except for presence of gas in subcutaneous tissue of the right frontotemporo-parietal area, without associated bone lesions."
          }
        ]
      },
      {
        "number": "Figure 15",
        "subfigures": [
          {
            "number": "Figure 15",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009783/000028.jpg?itok=rRSxIKou",
            "caption": "Follow-up chest CT is normal after two weeks."
          }
        ]
      },
      {
        "number": "Figure 16",
        "subfigures": [
          {
            "number": "Figure 16",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009783/000029.jpg?itok=l9cexH5F",
            "caption": "Air is dissecting supra-aortic and subaortic mediastinal structures. The presternal subcutaneous emphysema is noted  without associated pneumothorax."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Anatomy",
      "Bones",
      "Education"
    ],
    "imaging_technique": [
      "CT",
      "Conventional radiography"
    ],
    "link": "https://www.eurorad.org/case/9783",
    "time": "18.03.2012"
  },
  "9801": {
    "case_id": 9801,
    "title": "Pneumorrhachis in Spontaneous Pneumomediastinum",
    "section": "Chest imaging",
    "age": "21",
    "gender": "female",
    "diagnosis": "Pneumorrhachis in spontaneous pneumomediastinum",
    "history": "A 21-year-old girl was admitted for investigation of a sudden onset of chest pain, dyspnoea and cough. She had a previous history of severe asthma.There was subcutaneous emphysema of the neck and upper part of the chest.Lung auscultation revealed wheezes. The remainder of general and neurological examination was normal.",
    "image_finding": "The admission chest radiograph showed signs of pneumomediastinum and extensive subcutaneous emphysema in the neck and upper thorax (figure 1).To better delineate the extent of air dissection into the neck and mediastinum the patient underwent computed tomography, which confirmed the presence of pneumomediastinum and subcutaneous emphysema (figure 2a). It also depicted air dissecting the neural foramen into the epidural space of the spinal canal (pneumorrhachis) at the cervicothoracic region (figure 2b, c).A follow-up CT showed considerable resolution of pneumomediastinum, subcutaneous emphysema and pneumorrhachis, with no evidence of mediastinitis.",
    "discussion": "Pneumorrhachis is the presence of air in the epidural space which can be seen in various situations, the most common causes being iatrogenic or traumatic. Pneumorrhachis secondary to spontaneous pneumomediastinum is rare, with less than 50 cases having been reported in the literature [1]. The typical patient is a male adolescent or young adult with bronchial asthma or a very recent history of hyperpnoea, illicit drug inhalation, vomiting, coughing or air travel. In all these cases, the primary aetiology suggested is alveolar rupture with secondary passage of air into the mediastinum [2].It is well known that because of the absence of a fascial barrier between the posterior mediastinum and retropharyngeal space, the air may dissect along fascial planes from these spaces into the spinal canal through the neural foramina, which is not protected by a true fascial envelope. Our observation of air distending the cervical neural foramen supports this view.Superiorly, the space is anatomically closed at the foramen magnum where the spinal dura attaches to the endosteal dura of the cranium, therefore air cannot extend intracranially [3].Of 42 recently published cases of pneumomediastinum documented by CT, pneumorrhachis was observed in four (9.5%), suggesting that in spontaneous pneumomediastinum, pneumorrhachis is uncommon but not exceptional [4]. Pneumorrhachis is known to be a benign complication, and more importantly, in patients with spontaneous pneumomediastinum, pneumorrhachis is neurologically asymptomatic, as in our case, and self-limited in 98% of the cases [2].",
    "differential_diagnosis": "Pneumorrhachis, in, spontaneous, pneumomediastinum, Traumatic, pneumorrhachis, Iatrogenic, pneumorrhachis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009801/000001.png?itok=SDBtRqM4",
            "caption": "Posteroanterior chest radiograph demonstrates extraalveolar air as a thin linear band parallel to the heart and interposition of air between the heart and diaphragm. Subcutaneous neck and superior chest wall emphysema is also depicted."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009801/000002.png?itok=bvUiBzHC",
            "caption": "Pulmonary window axial CT image shows pneumomediastinum without pneumothorax. Subcutaneous emphysema is also present."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009801/000003.png?itok=LmNsxEog",
            "caption": "Axial CT shows the presence of air lying in the right neural exit foramen, depicting the probable site of entry for causing pneumorrhachis. Widespread subcutaneous emphysema is also present."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009801/000004.png?itok=k5xcBeFX",
            "caption": "A further axial CT image clearly shows the presence of air within the epidural space."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Mediastinum",
      "Spine"
    ],
    "imaging_technique": [
      "CT",
      "Conventional radiography"
    ],
    "link": "https://www.eurorad.org/case/9801",
    "time": "02.02.2012"
  },
  "9815": {
    "case_id": 9815,
    "title": "Tracheal bronchus and partial anomalous pulmonary venous return.",
    "section": "Chest imaging",
    "age": "27",
    "gender": "female",
    "diagnosis": "Right-sided tracheal bronchus and partial anomalous pulmonary venous return.",
    "history": "A 27-year-old woman presented with mild but recurrent respiratory distress.",
    "image_finding": "The initial chest radiograph (Fig. 1) showed enlargement of the right cardiac cavities and an additional vascular structure on right middle pulmonary field. The possibility of vascular anomaly was raised and the patient underwent thorax CT (General Electric LightSpeed VCT scan; post IV contrast). This confirmed the presence of a short supernumerary tracheal bronchus and the right upper lobe partial anomalous pulmonary venous drainage emptying into the superior vena cava. Coronal average reconstruction (Fig. 2), MIP and MinIP algorithms (Fig. 3) and the volume rendering images (Fig. 4) better depicted the bifurcation of the tracheal bronchus distally, the anatomy of the rest of the bronchial and the anomalous pulmonary drainage. We also show a virtual bronchoscopy image of the carina.",
    "discussion": "The prevalence of tracheal bronchus (TB) is about 0.1% - 2% for right side [1]. It is called displaced/ectopic if it totally supplies one of the pulmonary segments and is called supernumerary when there is a normal branching of the right upper lobe. TB may occur in isolation or in association with tracheoesophageal fistula, hypoplastic lung, pulmonary sequestration, cardiac anomalies, asplenism, and Down syndrome [3]. There is a partial anomalous pulmonary venous return (PAPVR) when one or more of the pulmonary veins drains into the right atrium or a systemic vein (SVC, IVC, azygos vein, right atrium or coronary sinus). An isolated PAPVR is most frequent. However, the anomalous drainage is common in patients with sinus venosus type of atrial defect. The overall incidence is 0.5% [2].The association of TB and PAPVR is scarcely reported in the literature, so we think that it can be underdiagnosed because of the low incidence of symptoms and subtleties of detection.Regarding the pathogenesis, the primitive lung begins as an outgrowth from the foregut, and the venous drainage is via a vascular plexus that communicates with the cardinal venous system. A single pulmonary vein will grow from the left atrium to join this primitive venous plexus and the connections with the cardinal venous system will be largely obliterated. [3] If this pulmonary venous plexus is only partially involute, a PAPVR will result. Over the same period, the trachea appears as an outpouching of the ventral wall of the foregut that subsequently divides into the main bronchi. The pathogenesis of TB is yet unknown. The growth and development depend on interplay of physical factors, such as the resistance and trophic mediation by the surrounding tissue [4]. Although the relationship between PAPVR and TB is unclear, both of them appear to occur at a similar developmental stage.All PAPVR are usually haemodynamically insignificant left-to-right shunts [3], and can be an incidental finding. The TB may also be asymptomatic or it may be the underlying cause in recurrent infections, respiratory distress, cough, haemoptysis or stridor [1]. Management of TB complications is conservative; excision of the supplied segment is advised. It is important to be aware of the presence of TB before intubation, as it may be inadvertently intubated causing respiratory collapse [4]. The importance of diagnosing PAPVR is emphasised by the risk of contralateral lung resection, leading to right ventricular failure.",
    "differential_diagnosis": "Right-sided, tracheal, bronchus, and, partial, anomalous, pulmonary, venous, return., Normal, chest, Pulmonary, varix",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009815/000001.jpg?itok=ihVtZ3Xd",
            "caption": "Enlargement of the right cardiac cavities and an additional vascular structure on right middle pulmonary field."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009815/000002.jpg?itok=ZrLr7kIw",
            "caption": "Enlargement of the right cardiac cavities and an additional vascular structure on right middle pulmonary field."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009815/000003.jpg?itok=9WYiv_yP",
            "caption": "The short supernumerary TB arises from the right lateral wall of the trachea. The right upper lobe PAPVR empties into the superior vena cava. Note the normal bronchial branching for the upper lobe."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009815/000004.jpg?itok=8fjXchKR",
            "caption": "The short supernumerary TB arises from the right lateral wall of the trachea. The right upper lobe PAPVR empties into the superior vena cava. Note the normal bronchial branching for the upper lobe."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009815/000006.jpg?itok=NRVLEbRr",
            "caption": "The short supernumerary TB arises from the right lateral wall of the trachea. The right upper lobe PAPVR empties into the superior vena cava. Note the normal bronchial branching for the upper lobe."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009815/000007.jpg?itok=g-hZvoEA",
            "caption": "The short supernumerary TB arises from the right lateral wall of the trachea. The right upper lobe PAPVR empties into the superior vena cava. Note the normal bronchial branching for the upper lobe."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009815/000008.jpg?itok=b3mHt_uG",
            "caption": "(a) MIP image: right upper lobe PAPVR to the superior vena cava. (b) MinIP image: bronchial tree with the TB, that only supplied the medial aspect of the upper lobe."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009815/000009.jpg?itok=igqbJqPD",
            "caption": "(a) MIP image: right upper lobe PAPVR to the superior vena cava. (b) MinIP image: bronchial tree with the TB, that only supplied the medial aspect of the upper lobe."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009815/000010.jpg?itok=lC-12wzl",
            "caption": "(a) The VR reconstruction shows the PAPVR to the superior vena cava."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009815/000011.jpg?itok=ejxeKuWc",
            "caption": "(b) The surface reconstruction shows the bronchial tree with the TB"
          },
          {
            "number": "Figure 4c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009815/000012.jpg?itok=dHjvCjrP",
            "caption": "(c) Virtual bronchoscopy image of the carina and the TB."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax",
      "Cardiovascular system"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/9815",
    "time": "12.03.2012"
  },
  "9819": {
    "case_id": 9819,
    "title": "Solitary fibrous tumour of the ple",
    "section": "Chest imaging",
    "age": "45",
    "gender": "male",
    "diagnosis": "Solitary fibrous tumour of the pleura.",
    "history": "A 45-year-old man with no relevant medical history was admitted to our hospital to have a medical check up. In the routine posteroanterior and lateral chest radiographs (RX), an incidental opacity in the left lung was discovered.",
    "image_finding": "Posteroanterior and lateral chest radiographs show an extrapaulmonary, well defined, solid mass in the lower third of the left lung (Fig. 1). No other abnormalities were seen.Chest CT with intravenous contrast medium administration was performed to characterise the incidentally discovered mass (Fig. 2). A little enhancing (50 UH, similar to adjacent muscle), heterogeneous, solid, well-circumscribed lobulated mass with a broad base to the left posterior pleura was discovered. The extrapleural fat was largely respected and adjacent bones were not compromised. The imaging findings were consistent with an extrapulmonary location of the mass. Ultrasound-guided biopsy was subsquently performed and histological results were compatible with a solitary fibrous tumour of the pleura.Surgical removal of the mass (Fig. 3, 4) was performed and confirmed the diagnosis.",
    "discussion": "Solitary fibrous tumour of the pleura (SFTP) is a rare tumour which originates from the mesenchymal cells below the mesothelial lining of the pleura, being the visceral pleura the most affected. SFTP is usually histologically benign. It appears between the sixth and seventh decades of life, with no sex preference and it hasn't`t been shown to be related to asbestos exposure [1] . About 50% of the patients with SFTP are asymptomatic and the lesion is discovered as an incidental finding. However, patients may present cough, chest pain, dyspnea, haemoptysis or fever. Sometimes, para-neoplastic syndromes such as hypertrophic pulmonary osteoarthropathy or severe symptomatic hypoglycemia (4% of patients) may be found [2, 3].On plain chest radiogrpah, SFTPs appear as well-circumscribed, extraparenchymal, solid masses. They could be round or lobed, stalked or sessile and they may associate pleural effusion [4]. Chest CT with intravenous contrast is the imaging modality of choice to diagnose SFTP. Iodinated contrast is used to differentiate between benign and malignant disease, to establish local invasion and to confirm the solid nature of the tumor. CT findings may be important for a working-up diagnosis in patients with poor performance status who do not accept, or are unfit for, invasive biopsy procedures [1, 5]. They usually appear as well-circumscribed, slight enhancing, homogeneous solid masses which sometimes present tiny calcifications [1]. Benign SFTPs spare extrapleural fat in their growth and they don't affect or erode adjacent bone structures. Malignant pleural mesothelioma and pleural metastases are the most important malignant tumours which must be excluded [4].The first one is associated to asbestos exposure. Pleural metastases are the most common cause of malignant pleural mass, and sometimes it is impossible to differentiate them from SFTPs [6]. The biopsy before resection is an important initial step in the differential diagnosis [3], and it is doesn't seem to be associated with spread of the tumor [3]. The recurrence after biopsy is rare [7]. Other benign entities as encapsulated pleural effusion have been reported in the differential diagnosis of SFTPs [3]. The most practical approach is to evaluate serial radiographs, as the liquid collections can vary rapidly (vanishing tumour), whereas SFTPs will always have the same size and shape [4].Complete surgical resection is usually required, although conservative treatment is possible in small lesions [6]. Recurrence of the tumour is infrequent (approximately 2% for pedunculated and 8% for sessile tumours) [3].",
    "differential_diagnosis": "Solitary, fibrous, tumour, of, the, pleura., Malignant, pleural, mesothelioma, Pleural, metastasis, Encapsulated, pleural, effusion",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009819/000002.jpg?itok=wB7A6szJ",
            "caption": "Contrast-enhanced chest CT shows a mildly and  heterogenously enhancing, solid, well-circumscribed mass broadly based to the left posterior pleura."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009819/000003.jpg?itok=6eSGFBz4",
            "caption": "Intraoperative image shows a pedunculated, well-defined, pleural, solid mass."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009819/000004.jpg?itok=bmKeNvV1",
            "caption": "Completely resected surgical specimen with a stalk."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009819/000005.jpg?itok=kKbZgtao",
            "caption": "Chest radiogrpah shows well defined, solid mass in the lower lung field (mostly appreciated in the lateral projection)."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Thorax"
    ],
    "imaging_technique": [
      "Digital radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/9819",
    "time": "11.08.2012"
  },
  "9825": {
    "case_id": 9825,
    "title": "Tree-in-bud pattern \u2013 Pulmonary TB",
    "section": "Chest imaging",
    "age": "53",
    "gender": "male",
    "diagnosis": "Pulmonary tuberculosis",
    "history": "A 53-year-old African male was referred to our institution with non-resectable oesophageal squamous cell carcinoma - diagnosed 3 months before - for radiotherapy. He developed onset symptoms of dysphagia and weight-loss when endoscopic procedure with biopsy confirmed the diagnosis. Laboratory tests revealed anaemia (Hg=9, 6g/L), low albumin and elevated PCR.",
    "image_finding": "CT-scout-view showed opacity of the right upper lobe associated with bronchiectasis resembling necrotic pneumonia. No pleural effusion or large lymph node involvement was depicted.CT/HRCT (high-resolution-CT) showed extensive bronchiectasis along with parenchymal disruption in the right upper lobe. The remaining pulmonary parenchyma demonstrated scattered tree-in-bud pattern with lower lobe predominance and without pleural effusion. The patient had an oesophageal lesion below the carina extending longitudinally 6 cm. There are no criteria for invasion of the aorta or the bronchial tree. Lymph node involvement at the carina level were noted. Patient underwent bronchoscopy and cough sputum sample was sent to bacteriological analysis with subsequent confirmation of positive Koch's bacilus specimen on direct examination.",
    "discussion": "The World Health Organization (WHO) estimates that 2 billion people have latent TB and that globally in 2009 it killed 1.7 million people. Active pulmonary TB may present as asymptomatic, mild to progressive dry cough or cough with bloody sputum often accompanied by fever, weight loss, and night sweats. A definitive diagnosis based on bacteriological culture remains challenging because M. tuberculosis is a slow-growing microorganism [1, 2, 4].Primary tuberculosis can manifest as four main entities: parenchymal disease, lymphadenopathy, miliary disease and pleural effusion. The earliest finding in parenchymal disease is patchy, poorly-defined consolidation, particularly in the apical and posterior segments of the upper lobes. Furthermore, bilateral disease can be seen in one third to two thirds of cases [1]. Postprimary tuberculosis usually refers to both reinfection and reactivation of tuberculosis. Primary tuberculosis is usually self-limiting, whereas postprimary tuberculosis is progressive. Cavitation is the hallmark, resulting in hematogenous dissemination and spread throughout the lungs. The cavities are usually multiple and occur within consolidation areas, typically with thick, irregular walls, which become smoother and thinner after successful treatment [2].Lymphadenopathy and pneumothoraces are less often seen as in this case lymph node involvement was more related with the oesophageal tumour [1]. Our patient presented without pleural effusion or lymphadenopathy. CT showed predominantly airway disease with endobronchial spread of infection, namely tree-in-bud opacities. These findings usually noted in the lung periphery resemble a branching-tree with buds at the tips of the branches, in this case highly suggestive of active tuberculosis [3]. Although there was clinical uncertainty of previous TB-infection, the patient might have previously contacted with M. tuberculosis and subsequently resolved the infection, or hosted the microorganism without typical healing fibrosis or calcification but with pulmonary parenchymal distortion of the right upper lobe that predisposed the extensive bronchiectasis. Primary and postprimary tuberculosis somehow overlap; the distinguishing features of postprimary tuberculosis include a predilection for the upper lobes, cavitation and absence of lymphadenopathy. Normal radiographic findings may be seen in up to 15% of patients with proved tuberculosis or show only mild or nonspecific findings in patients with active disease.CT provides accurate diagnosis in pulmonary TB in 91% of patients and correctly excludes it in 76% of patients [4]. CT/HRCT are particularly helpful in the detection of small foci of cavitation, tree-in-bud pattern and in pleural evaluation, namely tuberculous effusion, empyema, and bronchopleural fistula.",
    "differential_diagnosis": "Pulmonary, tuberculosis, Atypical, pneumonia, Lung, cancer, Bronchiectasis, Aspergillosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009825/000001.png?itok=eilEOmer",
            "caption": "This image showed opacity of the upper right lobe and bronchiectasis resembling necrotic pneumonia. No pleural effusion is noted."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009825/000002.jpg?itok=Ch_bjouQ",
            "caption": "In the mediastinum an oesophageal lesion below carina was detected extending longitudinally 6 cm without aorta or bronchial tree invasion. Lymph node involvement at the carina level is seen.  No pleural effusion."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009825/000003.jpg?itok=9zFnzHRq",
            "caption": "In the mediastinum an oesophageal lesion below carina was detected extending longitudinally 6 cm without aorta or bronchial tree invasion. Lymph node involvement at the carina level is seen.  No pleural effusion."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009825/000004.jpg?itok=NZAWPFZu",
            "caption": "In the mediastinum an oesophageal lesion below carina was detected extending longitudinally 6 cm without aorta or bronchial tree invasion. Lymph node involvement at the carina level is seen.  No pleural effusion."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009825/000005.jpg?itok=Znwjdi50",
            "caption": "In the mediastinum an oesophageal lesion below carina was detected extending longitudinally 6 cm without aorta or bronchial tree invasion. Lymph node involvement at the carina level is seen.  No pleural effusion."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009825/000006.jpg?itok=ygjGwlXu",
            "caption": "CT showed extensive bronchiectasis along with parenchymal disruption in the right upper lobe probably communicating with the upper right bronchus."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009825/000007.jpg?itok=9THkalNH",
            "caption": "CT showed extensive bronchiectasis along with parenchymal disruption in the right upper lobe probably communicating with the upper right bronchus."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009825/000008.jpg?itok=QGMQiHj7",
            "caption": "CT showed extensive bronchiectasis along with parenchymal disruption in the right upper lobe probably communicating with the upper right bronchus."
          },
          {
            "number": "Figure 3d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009825/000009.jpg?itok=bfDuJv3m",
            "caption": "Peribronchial patchy nodular ground-glass opacities and tree-in-bud pattern are noted bilaterally. No pleural effusion."
          },
          {
            "number": "Figure 3e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009825/000010.jpg?itok=zZcvxje0",
            "caption": "Peribronchial patchy nodular ground-glass opacities and tree-in-bud pattern are noted bilaterally. No pleural effusion."
          },
          {
            "number": "Figure 3f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009825/000011.jpg?itok=mhoHekJw",
            "caption": "Peribronchial patchy nodular ground-glass opacities and tree-in-bud pattern are noted bilaterally. No pleural effusion."
          },
          {
            "number": "Figure 3g",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009825/000012.jpg?itok=l_abuAYw",
            "caption": "Peribronchial patchy nodular ground-glass opacities and tree-in-bud pattern are seen in the right lung base. No pleural effusion."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009825/000013.jpg?itok=rHSjytdZ",
            "caption": "The HRCT images demonstrate poorly defined small centrilobular nodules and branching linear opacities of similar calibre originating from a single stalk - the tree-in-bud pattern scattered bilaterally with slight lower lobe predominance."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009825/000014.jpg?itok=C7QtqNte",
            "caption": "The HRCT images demonstrate poorly defined small centrilobular nodules and branching linear opacities of similar calibre originating from a single stalk - the tree-in-bud pattern scattered bilaterally with slight lower lobe predominance."
          },
          {
            "number": "Figure 4c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009825/000015.jpg?itok=LLBeAubj",
            "caption": "The HRCT images demonstrate poorly defined small centrilobular nodules and branching linear opacities of similar calibre originating from a single stalk - the tree-in-bud pattern scattered bilaterally with slight lower lobe predominance."
          },
          {
            "number": "Figure 4d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009825/000016.jpg?itok=S0vzcM9u",
            "caption": "The HRCT images demonstrate poorly defined small centrilobular nodules and branching linear opacities of similar calibre originating from a single stalk - the tree-in-bud pattern scattered bilaterally with slight lower lobe predominance."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009825/000017.jpg?itok=DhnGyrXP",
            "caption": "Bronchial irregular wall thickening of the right-upper-lobe with traction bronchiectasis and scattered areas of tree-in-bud pattern are seen bilaterally."
          },
          {
            "number": "Figure 5b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009825/000018.jpg?itok=N7R4-utb",
            "caption": "Bronchial irregular wall thickening of the right-upper-lobe with traction bronchiectasis and scattered areas of tree-in-bud pattern are seen bilaterally."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "CT",
      "CT-High Resolution"
    ],
    "link": "https://www.eurorad.org/case/9825",
    "time": "26.06.2012"
  },
  "9838": {
    "case_id": 9838,
    "title": "Paraspinal abscess following traumatic haematoma of vertebral column",
    "section": "Chest imaging",
    "age": "63",
    "gender": "male",
    "diagnosis": "Para-spinal abscess following a T7-T8 vertebral body fracture.",
    "history": "A 63-year-old diabetic man presented with a 2 week history of worsening thoracolumbar back pain following trivial blunt trauma. His pain was not improving with analgesia. On examination he was febrile and complaining of tenderness in the thoracic spine and thoracic paraspinal region, and was found to have a neutrophilia.",
    "image_finding": "A posteroanterior chest radiograph following the episode of trauma was reported as normal (Fig. 1a). Follow-up study after 3 weeks showed lateral displacement of both paraspinal lines (Fig. 1b) - in keeping with a posterior mediastinal collection. Multiplanar reformatted CT showed cortical irregularity at the lower endplate of T7 (Fig. 2) surrounded by fluid collection (Fig. 3a). Repeat CT following conservative management (Fig. 3b) showed that this posterior mediastinal fluid collection contained gas bubbles. Findings were therefore highly suggestive of a posterior mediastinal abscess. Selected images from a reformatted coronal CT in mediastinal (Fig. 4a) and bone window (Fig. 4b) settings showed progression of the posterior mediastinal fluid collection, with extension in both pleural spaces. Note is also made of well circumscribed intrapulmonary lesions, some of which were cavitating and with a \u2018feeding vessel\u2019 sign - findings highly suggestive of septic emboli. Follow-up CT showed complete resolution following treatment.",
    "discussion": "Paraspinal infection is an uncommon condition. Diagnostic delays may result in neurological deficits, paralysis and even death [1]. Compression of the spinal cord or cauda equina can lead to neurological signs with varying degrees of weakness, numbness and bladder dysfunction. Another uncommon complication, seen in this case, is that of hematogenous pulmonary septic emboli. Paraspinal abscesses mostly occur in the setting of invasive procedures, including transcutaneous infection by needles [2], catheters and orthopedic surgery. Other causes include blunt trauma and hematogenous spread from distant sites [3]. Our patient sustained trauma with T7 vertebral body endplate fractures. The resultant paraspinal hematoma was subsequently infected, with paraspinal abscess formation. Previous case reports of paraspinal abscess have indicated back pain as a common presenting symptom, with 50% of patients exhibiting concomitant pyrexia during the initial presentation [1]. Our patient presented with back pain and decreased range of motion due to muscle spasm. Initial imaging is generally based on plain radiography. Displacement of the paraspinal lines, may be indicative of a paraspinal collection, but it is not a very sensitive finding. Further imaging is usually undertaken when displaced paraspinal lines are seen on radiographs or when there is a high degree of clinical suspicion for paraspinal abscess formation [4]. MRI has been found to be an optimal tool in identifying paraspinal abscess formation [5, 6]. CT can be useful both for the diagnosis of paraspinal abscess formation and also to guide aspiration of pus for therapeutic and laboratory diagnostic purposes.Identifying the causative microorganism is of paramount importance with regards to targeted antimicrobial therapy. Peripheral blood cultures may also identify the responsible microorganism. Staphylococcus aureus infection is the most common cause of paraspinal abscesses [7]. Rarer microorganisms such as coagulase-negative staphylococci and streptococci, Mycobacterium tuberculosis and Brucella spp. are other possible aetiologies, depending on the geographical area [8]. In our patient, Enterobacter Cloacae (ESBL+), E.Coli and Proteus Mirabilis were cultured.If image-guided drainage of the abscess is not enough, surgical drainage is usually considered, especially when there is associated neurological deficit or protracted course of disease. In our patient, serial imaging showed non-resolution of the abscess despite antibiotic therapy. He therefore underwent left-sided thoracotomy with insertion of two pigtail drains for adequate drainage.This case report highlights the importance of prompt diagnosis of paraspinal abscess as delay in diagnosis of a widened middle mediastinum lead to delay in appropriate management of the patient and worse prognosis.",
    "differential_diagnosis": "Para-spinal, abscess, following, a, T7-T8, vertebral, body, fracture., Post-traumatic, para-spinal, abscess, Vertebral, body, osteomyelitis, Discitis, Empyema",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009838/000001.jpg?itok=eCTqaKJm",
            "caption": "Initial chest radiograph showing a subtle abnormality - subchondral sclerosis at the lower endplate of T7.  No further abnormalities were reported."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009838/000003.jpg?itok=dHPEi9Wn",
            "caption": "Repeat chest radiograph 3 weeks following the one shown in Figure 1a.  Evident widening of both paraspinal lines is seen, in keeping with a posterior mediastinal mass/fluid collection."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009838/000004.jpg?itok=Ypmc_dc3",
            "caption": "Following insertion of a pigtail catheter, the para-spinal lines are now almost normal.  Around 1200 mL of pus was drained in total."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009838/000005.jpg?itok=Trufiex8",
            "caption": "Selected imaged from a sagittal CT in bone window settings showing an end-plate defect at the lower border of T7.  Note is also made of a posterior mediastinal fluid collection."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009838/000006.jpg?itok=ZWyp1ZmB",
            "caption": "Coronally reconstructed CT showing the posterior mediastinal fluid collection."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009838/000007.jpg?itok=A5RZ1uyV",
            "caption": "Follow-up coronally reconstructed CT (done three weeks following that in figure 3a) showing progression of the posterior mediastinal fluid collection.  Gas bubbles are also seen, in keeping with abscess formation."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009838/000008.jpg?itok=5s6h18VU",
            "caption": "Selected imaged from a coronal CT in mediastinal window settings following surgical thoracotomy shows residual fluid and a left sided empyema."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009838/000009.jpg?itok=BrQs35yq",
            "caption": "Selected coronal CT image at the same level as the CT displayed in Figure 4a in bone window settings.  Endplate irregularity and sclerosis with mild loss of vertebral body height is seen at T7-T8."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_video/2018-08/0000009838/000010F.png?itok=qFgiqry2",
            "caption": "Axial CT in lung window settings.  Cavitating pulmonary lesions are seen on both sides, together with a left sided empyema.  These were not seen on previous imaging, and are in keeping with septic emboli."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Musculoskeletal bone"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/9838",
    "time": "26.07.2012"
  },
  "9846": {
    "case_id": 9846,
    "title": "Cardiogenic bronchus",
    "section": "Chest imaging",
    "age": "40",
    "gender": "male",
    "diagnosis": "Cardiogenic bronchus",
    "history": "A 40-year-old male patient underwent a CT examination of the chest to check a previous bronchopneumonia after antibiotic therapy. Chest examination was negative as there were no respiratory symptoms such as cough and fever.",
    "image_finding": "CT examination of the chest was performed without injection of iodinated contrast medium. It showed a small accessory bronchus originating from the medial wall of the middle right bronchus and extending downward and medially to the mediastinum (figure 1).Axial scans and MPR-MinIP reconstructions showed also a small portion of poorly ventilated pulmonary parenchyma around the bronchus, but no bronchopneumonia foci were found (figure 2).",
    "discussion": "Cardiogenic accessory bronchus is a rare anatomical variant with an incidence of 0.1% in the general population. It consists of a developmental aberration of bronchial branching occurring between the 4th and 6th weeks of embryonic life. It is lined by endobronchial mucosa, presenting cartilaginous rings within its walls [1, 2].It originates from the medial wall of the right middle or lower bronchus and can extend caudally 1-5 cm towards the pericardium or it can be a short dead-end abutment without presenting alveolar ventilated tissue [3]. The associated alveolar tissue can be more or less ventilated so even if in most cases this anatomical variant is asymptomatic, sometimes it can be associated with chronic infections and haemoptysis.",
    "differential_diagnosis": "Cardiogenic, bronchus, Bronchial, diverticulum, Other, anatomical, variants, Bronchial, fistula",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009846/000001.png?itok=ehPw0WjS",
            "caption": "Axial image and MPR-MinIP reconstructions. A small accessory bronchus originating from the medial wall of the middle right bronchus and extending downward and medially to the mediastinum."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009846/000002.png?itok=yGpHQEeC",
            "caption": "The bronchus shows a short dead-end abutment."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009846/000003.png?itok=x-MqcnI5",
            "caption": "The bronchus shows a short dead-end abutment."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009846/000004.png?itok=xpqlWBUz",
            "caption": "Associated poorly ventilated alveolar tissue around the bronchus."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Anatomy"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/9846",
    "time": "02.02.2012"
  },
  "9927": {
    "case_id": 9927,
    "title": "Huge solitary fibrous tumor of the ple",
    "section": "Chest imaging",
    "age": "45",
    "gender": "female",
    "diagnosis": "Solitary fibrous tumour of the pleura",
    "history": "A 45-year-old female non-smoker with back pain and no relevant clinical history performed a plain film of the dorsal spine suggesting the presence of a huge para-vertebral mass.",
    "image_finding": "Chest radiograph showed a well-defined, large paramediastinal lesion in the right lung(Fig 1). Contrast-enhanced CT confirmed the presence of a single, well-defined, lobulated,  solid mass, 12x7cm, with heterogeneous enhancement. The mass exhibited smoothly tapering margin at the junction with visceral pleura that extended from subcarinal mediastinum to the posterolateral right lung base, causing compression on heart, mediastinum and oesophagus and subsegmental atelectasis of the surrounding parenchyma, without ipsilateral pleural effusion (Fig 2). No hilar or mediastinal lymphadenopathy was detected. CT guided cutting-needle biopsy was negative for malignant cells and revealed  the presence of inflammatory and fibrotic cells. Subsequent angiography showed vascular afferences from right bronchial and intercostal arteries (Fig 3), which were promptly embolised. Surgery confirmed the presence of a huge soft-tissue highly vascularized mass, (Fig 4) in the right pleural cavity compressing without infiltrating the adjacent structures. One and two years follow-up CT showed no recurrence.",
    "discussion": "Solitary Fibrous Tumour of the Pleura (SFTP) is a benign mesenchymal tumour that arises, usually, from the pleura. The term benign mesothelioma was abandoned when the origin from mensenchymal tissue was determined allowing to distinguish SFTP from diffuse, aggressive epithelial mesothelioma [1-3]. Although the tumor is more commonly intrathoracic, rarely can it be described as extrathoracic, taking origin from peritoneum or pericardium, or with a nonserosal origin from meninges, thyroid, salivary glands, breast and kidney [1, 4]. Fibrous tumour occurrence is more common in the fifth decade, but epidemiology is not clear, due both to the rarity of this tumour and to the lack of symptoms at the early stages of the disease. However, recently, with improvements in diagnostic imaging techniques, the rate of diagnosis is increasing [1, 5]. Any SFTP shall undergo surgical removal followed by histological analysis. Our patient, preoperatively, underwent endoarterial embolisation to decrease hypervascular afflux and facilitate surgery. The diagnosis was confirmed at the anatomic-pathological evaluation. Macroscopically the SFTP is a dense fibrous tissue, arising from the visceral pleura to which is stuck by a peduncle, with possible areas of haemorrhage and necrosis. Microscopically, the typical pattern is a \"patternless pattern\", with hypercellularity and fibrotic areas [6]. A preoperative diagnosis is possible through a cutting-needle biopsy. Imaging has a crucial role for diagnosis, not only for the detection of the mass, but also for determining the pleural origin of the tumour and the relationship with the surrounding parenchyma, the mediastinum and the chest wall. SFTP usually appears on chest radiograph as a well-defined, sometimes lobulated, extrapulmonary solitary mass, of homogeneous opacity, in broad contact with the chest wall; it can be associated with reactive ipsilateral pleural effusion. At CT, the SFTP looks like an inhomogeneous solitary bulky well-defined solid mass, originating from the visceral pleura, occasionally compressing adjacent mediastinal structures, and with inhomogeneous contrast enhancement. Preoperative CT is useful in surgical planning and in evaluating the features that are associated with poor prognosis (malignant behaviour of SFTP), such as ipsilateral pleural effusion and involvement of the parietal pleura.",
    "differential_diagnosis": "Solitary, fibrous, tumour, of, the, pleura, Bronchogenic, carcinoma, Thymoma, Neurogenic, tumor, Mesothelioma, Lipoma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009927/000001.jpg?itok=2UzkpN0t",
            "caption": "Frontal chest radiograph showing the right para-mediastinal homogeneous opacity characterised by a maximum diameter of twelve centimetres."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009927/000002.jpg?itok=3S_Hb-wr",
            "caption": "Lateral chest radiograph showing the posterior homogeneous opacity characterised by a maximum diameter of twelve centimetres."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009927/000003.jpg?itok=Xkh6ZQpi",
            "caption": "Axial contrast-enhanced CT on mediastinal window shows a well-defined, solid mass, with inhomogeneous enhancement, causing compression (arrowheads) of the mediastinal structures."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009927/000004.jpg?itok=B52Vno3K",
            "caption": "Coronal contrast-enhanced CT on lung windowing shows the right paravertebral well-defined, solid mass."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009927/000005.jpg?itok=3gDPF3EL",
            "caption": "Pre-embolisation angiography shows the hypertrophic bronchial artery (arrow) feeding the highly vascularised mass."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009927/000006.jpg?itok=umNdNzmB",
            "caption": "Post embolisation angiography reveals the decreased vascularisation of the mass."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000009927/000007.jpg?itok=UPefgjNd",
            "caption": "Surgical specimen confirms the large size, the high vascular supply  and the presence of the capsule of the tumour."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Respiratory system"
    ],
    "imaging_technique": [
      "CT",
      "Catheter arteriography",
      "Experimental"
    ],
    "link": "https://www.eurorad.org/case/9927",
    "time": "21.03.2012"
  },
  "10009": {
    "case_id": 10009,
    "title": "Imaging in extramedullary haematopoiesis (ECR 2011 Case of the Day)",
    "section": "Chest imaging",
    "age": "31",
    "gender": "male",
    "diagnosis": "Extramedullary haematopoiesis",
    "history": "A 31-year-old man with a known history of \u03b2-thalassemia major, thoracic diffuse pain, dyspnoea, and migraine, was referred to our department for a standard chest evaluation followed by a thoracic and brain CT. After 1 year, a MRI cervico-thoracic spine evaluation was for paresthesia and medullar compression with a thoracic T3-T4 level.",
    "image_finding": "Poster-anterior chest radiography (Fig. 1) and lateral chest radiography (Fig. 2) followed by a thoracic CT (Fig. 3-4) and a brain CT (Fig. 5-6) were performed. After 1 year magnetic resonance imaging evaluation of the cervical and the upper part of thoracic spine in sagittal and axial plane T1 weighted was performed (Fig. 7-8). Findings on chest radiographies consists in bilateral, smooth, sharply delineated, lobulated paraspinal masses without erosion of the vertebral bodies or ribs (Fig. 1, 2). Computed tomography of the thorax and head revealed marked medullary expansion of the bony structures with the ribs showing the most pronounced involvement (Fig. 3, 4), but also skull base thickening (Fig. 5, 6). MRI of the spine releved paravertebral and epidural mass with mass effect and compression of the thoracic spinal cord (Fig. 7, 8).",
    "discussion": "Extramedullary haematopoiesis (EMH) occurs as a compensatory mechanism for abnormal haematopoiesis, due to the proliferation of haematopoietic cells outside of the bone marrow in response to production of too few blood cells to satisfy the body's demand [1, 2]. EMH occurs in haemoglobinopathies, myeloproliferative disorders, or bone marrow infiltration. Myeloproliferative disorders include chronic myelogenous leukaemia, polycythemia vera, essential thrombocytosis, and myelofibrosis with myeloid metaplasia. Haemoglobinopathies include sickle cell disease and thalassaemia [3]. EMH mainly involves the RE system (liver, spleen, and lymph nodes) but is also known to occur in every organ of the body, including the thyroid, prostate, pericardium, kidney, and lungs [1]. Rarely, it can cause cord compression, pleural effusion, massive haemothorax, and respiratory failure [3-6]. EMH should be considered in the differential diagnosis in a patient with chronic severe anaemia and a paraspinal mass [6, 7]. Chest radiography reveals a sharply outlined, lobulated paraspinal and rib masses (Fig. 1-2). The thoracic CT examination revealed well-defined bilateral paraspinal and rib masses with intralesional fine linear calcifications (Fig. 3-4). The posterior parts of the ribs showed increased trabeculation and dimensions (Fig. 4). CT of the brain showed a sphenoid osteolytic mass (Fig. 5-6). Conventional spin echo T1 MRI demonstrated that the right paravertebral masses and the mass of the epidural posterior space have the same signal characteristics with the marrow of the adjacent vertebral body (Fig. 7-8). The epidural thoracic mass compress the adjacent thoracic spinal cord (Fig. 8). Patients with haemoglobinopathies are more likely to have EMH in paraosseous locations, whereas patients with myeloproliferative disorders are more likely to have extraosseous masses [11]. More commonly observed areas of EMH include the paraspinal regions of the thorax, liver, and spleen, but it has been reported in other locations, including the adrenal gland, bowel, dura mater, and breast [11-14]. Only a few cases of perirenal and pelvicaliceal EMH have been reported in the literature [11].Intrathoracic EMH is a rare cause of paraspinal mass and should be differentiated from other costovertebral angle masses, such as neurogenic tumours, lymphoma, metastasis, paravertebral abscess [1, 8]. EMH usually regresses or disappears after treatment with blood transfusion and hydroxyurea, splenectomy in cases of spherocytosis or radiation therapy [1, 9, 10]. The paraspinal thoracic regions, the spine, and the skull base are common sites of involvements by EMH, and familiarity with its radio-imaging findings and knowledge of the patient's clinical history are essential to avoid misdiagnosis.",
    "differential_diagnosis": "Extramedullary, haematopoiesis, Myeloma, Lymphoma, Multiple, ganglioneuroma, Metastasis, Multiple, abscesses",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010009/000001.jpg?itok=KwYBCmGk",
            "caption": "Bilateral, smooth, sharply delineated, often lobulated paraspinal masses without erosion of the vertebral bodies or ribs."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010009/000002.jpg?itok=Ce3SKkDx",
            "caption": "Lobulated paraspinal masses along the entire length of the vertebral column."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010009/000003.jpg?itok=ODywNe-I",
            "caption": "Marked medullary expansion of the bony structures with the ribs showing the most pronounced involvement."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010009/000004.jpg?itok=QDqpCnGp",
            "caption": "Marked medullary expansion of the bony structures with the ribs showing the most pronounced involvement."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010009/000005.jpg?itok=PKIcdwJx",
            "caption": "Skull base thickening and sphenoidal mass."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010009/000006.jpg?itok=lnBdVkMb",
            "caption": "Skull base thickening and sphenoidal mass."
          }
        ]
      },
      {
        "number": "Figure 7",
        "subfigures": [
          {
            "number": "Figure 7",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010009/000007.jpg?itok=s0eWsGyO",
            "caption": "Paravertebral thoracic mass."
          }
        ]
      },
      {
        "number": "Figure 8",
        "subfigures": [
          {
            "number": "Figure 8",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010009/000008.jpg?itok=QQPgqlSb",
            "caption": "Paravertebral and epidural mass with mass efect and compresion of the thoracic spinal cord."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Education"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT",
      "MR"
    ],
    "link": "https://www.eurorad.org/case/10009",
    "time": "12.04.2012"
  },
  "10026": {
    "case_id": 10026,
    "title": "ndobronchial carcinoi",
    "section": "Chest imaging",
    "age": "37",
    "gender": "female",
    "diagnosis": "Endobronchial carcinoid",
    "history": "A 37-year-old female non-smoking patient presented with recurrent pneumonia. She felt tired, sometimes pain in the chest but without cough or difficulty with breathing. Lung auscultation revealed no additional phenomena. Laboratory data included slightly elevated C-reactive protein and leukocytosis.",
    "image_finding": "Chest radiographs demonstrated recurrent consolidation predominantly in the right lower lobe (Fig. 1). After antibiotic therapy, CT examination was recommended to exclude malignancy. Post contrast thorax CT showed almost complete collapse of the right lower lobe and a hyperattenuated nodule in the bronchus intermedius (Fig. 2). The finding was confirmed by bronchoscopic biopsy. Follow up PET CT and octreotid scan revealed no signs of metastasis (Fig. 3). Right-side bilobectomy was done with the minimal postoperative pneumothorax apically. There were no signs of recurrence or metastasis at control after 4 months (Fig. 4).",
    "discussion": "Bronchial carcinoids are slow-growing low-grade malignant neuroendocrine tumours that represent 1-4 % of all bronchial neoplasms [1]. The gastrointestinal tract is the most frequently involved site while lung is the second most common. There are two different types of carcinoids \u2013 nearly 90% are typical carcinoids, atypical carcinoids occur rarely.Bronchial carcinoids affect mainly young patients. There is no relationship to smoking, inhalation of carcinogens, radiation or environmental factors [2].Clinical symptoms manifest as cough, chest pain, haemoptysis, wheezing or recurrent pneumonia. Carcinoid syndrome is very rare. A certain proportion of patients may be asymptomatic.Radiography is a method of first choice. Because most bronchial carcinoids are located in central airways, radiologic findings are usually related to bronchial obstruction [3]. Atelectasis and air trapping are among some of the most common findings. Other findings involve pneumonitis, bronchiectasis or mucoid impaction, rarely abscess can occur. CT gives more detailed information and helps define the cause of obstruction. This method is also used for staging, planning the extent of surgery and patient\u2019s follow-up. PET CT is used for further characterisation of pathological lesions and detecting local and extrathoracic metastases. Carcinoids don\u2019t uptake contrast as other malignant tumours. FDG uptake on PET CT is quite variable and depends on mitotic figures and tumour proliferation [4]. Therefore PET doesn\u2019t allow to clearly distinguish between benign and malignant lesions. Octreotid scan shows if carcinoid has somatostatin receptors and consequently if the tumour is sensitive to chemotherapy.Prognosis depends on histological finding. Typical bronchial carcinoids have better prognosis, whereas survival for atypical carcinoids is significantly worse. The 5-year survival is 87% for typical and 56% for atypical carcinoids [5].Therapy is primary based on surgical resection of the tumour. Chemotherapy and radiation therapy can be used in case of cancer dissemination.",
    "differential_diagnosis": "Endobronchial, carcinoid, Endobronchial, tumours, like, adenoid, cystic, or, mucoepidemoid, carcinoma, Foreign, body, granuloma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010026/000001.jpg?itok=F4H1KocJ",
            "caption": "Posteroanterior chest radiograph demonstrates basal paracardial consolidation on the right side"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010026/000002.jpg?itok=FvmstP8W",
            "caption": "Lateral chest radiograph showing dorsobasal consolidation."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010026/000003.jpg?itok=yIb1kAAA",
            "caption": "Posteroanterior chest radiograph after 1 month and 3 months revealed persistent paracardial consolidation on the right side."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010026/000013.jpg?itok=AyviVKae",
            "caption": "CT demonstrates a hyperattenuating nodule in the bronchus intermedius."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010026/000005.jpg?itok=keEDoO9I",
            "caption": "CT demonstrates volume reduction of the right hemithorax and elevation of the diaphragm on the right side. Right lower lobe atelectasis. The cause of collapse is a hyperattenuating nodule in the bronchus intermedius."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010026/000006.jpg?itok=nninAxMp",
            "caption": "CT demonstrates atelectasis because of a hyperattenuating nodule  in the bronchial lumen."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010026/000007.jpg?itok=a2HNEXae",
            "caption": "Virtual bronchoscopy confirmed diagnose of the intrabronchial tumour."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010026/000008.jpg?itok=K-jeFmKk",
            "caption": "Hyperattenuating lesion on the right side was detected with PET CT. No metastasis in the thorax or abdomen."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010026/000009.jpg?itok=Fgtxj8Hf",
            "caption": "Octreotid scan confirmed diagnosis of tumour with somatostatin receptors."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010026/000010.jpg?itok=EvMXxuo9",
            "caption": "Chest radiograph after operation with minimal pneumothorax apically."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010026/000011.jpg?itok=Wb3V8e9k",
            "caption": "Control after 4 month shows usual postoperative finding, without suspicion for recurrence or metastasis."
          },
          {
            "number": "Figure 4c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010026/000012.jpg?itok=sPn6jfVI",
            "caption": "Control after 4 month shows usual postoperative finding, without suspicion for recurrence or metastasis."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Thorax",
      "Respiratory system"
    ],
    "imaging_technique": [
      "PET-CT",
      "Nuclear medicine conventional",
      "Digital radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/10026",
    "time": "15.07.2012"
  },
  "10027": {
    "case_id": 10027,
    "title": "Opportunistic pulmonary nocardiosis, an uncommon tuberculosis mimic",
    "section": "Chest imaging",
    "age": "45",
    "gender": "male",
    "diagnosis": "Pulmonary nocardia infection in HIV",
    "history": "A middle-aged, 45-year-old male patient with longstanding history of Human Immunodeficiency Virus (HIV) infection and severe immunosuppression (4 CD+ cells/mmc) unresponsive to antiretroviral therapy, was hospitalised because of malaise, diarrhoea, weight loss and metabolic acidosis, without specific respiratory symptoms.",
    "image_finding": "Initial chest radiographs (Fig. 1) disclosed a 3 cm right infraclavicular subpleural cavitary consolidation, confirmed HRCT with associated pleural adhesion, retraction and thickening (Fig. 2). Negative results of tuberculin skin test, acute phase reactants, sputum culture and QuantiFERON\u2122 assay did not confirm suspected tuberculosis. Empiric treatment was started with antituberculous and broad-spectrum antibiotics, including staphylococcal coverage: early radiographs after 3 weeks (Fig. 3) suggested initial regression with persistent cavitation. Radiographic follow-up at two months (Fig. 4) showed enlarging lesion with resolution of central cavity. Repeat HRCT (Fig. 5) confirmed growing, noncavitary mass with central hypodensity, satellite nodules, linear densities and peripheral \u201chalo sign\u201d ground-glass. Percutaneous aspirate excluded malignant changes, but failed to reveal causative organism. Nocardia infection was diagnosed on the basis of bronchial lavage cultures and treated with cotrimoxazole plus linezolid. Three months after admission, chest radiographs (Fig. 6) and HRCT (Fig. 7) detected resolution of the pulmonary opportunistic lesion.",
    "discussion": "Pulmonary or systemic infection by Nocardia species is an uncommon, often severe opportunistic condition, increasingly recognised because of the growing number of immunosuppressed patients with reduced cellular immunity and improvements in laboratory techniques. Most cases occur in the setting of Human Immunodeficiency Virus (HIV), whereas in other patients predisposing factors include chronic obstructive lung disease, organ transplantation, antineoplastic chemotherapy, collagen vascular disease and corticosteroid treatment [1, 2]. Although with low incidence, Nocardia infections usually occur at an advanced stage of HIV disease with severe immunosuppression (mean CD4+ count 35 cells/mmc). Nocardia asteroides represents the most common (70% of cases) causative organism. Notably, nocardiosis may also develop during cotrimoxazole prophylaxis, because of drug resistance or infection by different Nocardia species [2, 3]. Nonspecific clinical manifestations indicate a subacute pneumonia, with malaise and possible respiratory failure, often suggesting Mycobacterium tuberculosis infection. The diagnosis is usually confirmed by sputum culture or bronchial lavage, and is usually delayed because of the very low prevalence, variable and nonspecific clinical features and radiologic findings, lack of serologic tests, difficulties and slowness of culture growth [3]. Chest radiographic appearances include lobar consolidations, large irregular nodules or solitary masses, or reticulonodular infiltrates: these abnormalities most commonly involve the upper lobes, are associated with cavitation in 62% of cases and with pleural effusion in one third of patients [4, 5]. CT confirms airspace consolidation/infiltrates or masses with internal low attenuation or cavitation, or multiple noncavitating nodules. AIDS patients are more likely to display a greater number of lesions and cavitations in 80% of cases [6, 7].Although usually showing a chronic course, Nocardiosis is a life-threatening infection in severely immunocompromised patients, with mortality rates approaching 50% unless promptly diagnosed and treated with appropriate antibiotic therapy [1-3]. Awareness of Nocardiosis and a high clinical suspicion index should prompt its inclusion in the differential diagnosis of pulmonary consolidations or nodular lesions in immunocompromised or chronically ill patients, particularly those showing central hypoattenuation or cavitation, upper lobe infiltrates negative to tuberculous tests, or unresponsive to usual antibacterial or antituberculous treatment. Suspected Nocardia infection should be notified when requesting culture, to optimise its identification [4, 6, 7].",
    "differential_diagnosis": "Pulmonary, nocardia, infection, in, HIV, Tuberculosis, Bacterial, pneumonia, Actinomycosis, Other, fungal, infections, Lung, abscess, Septic, emboli, Primary, lung, carcinoma, Cavitating, metastases, Sarcoidosis, Wegener\u2019s, granulomatosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010027/000001.jpg?itok=E2DOy2iZ",
            "caption": "Normally aerated lungs with a 3-cm subpleural consolidation in the right infraclavicular region, showing central cavitation (detailed view in C), suggesting a possible diagnosis of tuberculosis."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010027/000002.jpg?itok=JoeqVogg",
            "caption": "Normally aerated lungs with a 3-cm subpleural consolidation in the right infraclavicular region, showing central cavitation (detailed view in C), suggesting a possible diagnosis of tuberculosis."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010027/000016.jpg?itok=bizhuZTj",
            "caption": "Normally aerated lungs with a 3-cm subpleural consolidation in the right infraclavicular region, showing central cavitation (detailed view in C), suggesting a possible diagnosis of tuberculosis."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010027/000003.jpg?itok=zjqA6-I9",
            "caption": "HRCT confirms, as the sole abnormality, a cavitary peripheral nodule in the right upper lobe, with focal adhesion to the moderately thickened and retracted pleura (detailed view in C)."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010027/000004.jpg?itok=sIa2jHvD",
            "caption": "HRCT confirms, as the sole abnormality, a cavitary peripheral nodule in the right upper lobe, with focal adhesion to the moderately thickened and retracted pleura (detailed view in C)."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010027/000017.jpg?itok=2cO0Cipe",
            "caption": "HRCT confirms, as the sole abnormality, a cavitary peripheral nodule in the right upper lobe, with focal adhesion to the moderately thickened and retracted pleura (detailed view in C)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010027/000005.jpg?itok=wjoRSquf",
            "caption": "Three weeks after therapy initiation, early follow-up radiographs suggest initial reduction of the right upper lobe consolidation, with persistently identifiable cavitation (detailed view in C)."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010027/000006.jpg?itok=Kbwbk6tl",
            "caption": "Three weeks after therapy initiation, early follow-up radiographs suggest initial reduction of the right upper lobe consolidation, with persistently identifiable cavitation (detailed view in C)."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010027/000018.jpg?itok=e8keVVkd",
            "caption": "Three weeks after therapy initiation, early follow-up radiographs suggest initial reduction of the right upper lobe consolidation, with persistently identifiable cavitation (detailed view in C)."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010027/000007.jpg?itok=4jNt3K0n",
            "caption": "Two months after treatment initiation, further radiographic follow-up disclose size increase of the upper right lobe subpleural consolidation with resolution of the central cavitation (detailed view in C)."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010027/000008.jpg?itok=vx6xRgfQ",
            "caption": "Two months after treatment initiation, further radiographic follow-up disclose size increase of the upper right lobe subpleural consolidation with disappeared central cavitation (detailed view in C)."
          },
          {
            "number": "Figure 4c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010027/000019.jpg?itok=9BvHLpDh",
            "caption": "Two months after treatment initiation, further radiographic follow-up disclose size increase of the upper right lobe subpleural consolidation with disappeared central cavitation (detailed view in C)."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010027/000009.jpg?itok=YTfTutm9",
            "caption": "Repeat HRCT confirms enlarged right upper lobe mass without appreciable cavitation, with increased pleural adhesion and thickening, appearance of satellite nodules, some linear densities and peripheral ground glass \u201chalo sign\u201d opacities."
          },
          {
            "number": "Figure 5b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010027/000010.jpg?itok=btT-3PI1",
            "caption": "Repeat HRCT confirms enlarged right upper lobe mass without appreciable cavitation, with increased pleural adhesion and thickening, appearance of satellite nodules, some linear densities and peripheral ground glass \u201chalo sign\u201d opacities."
          },
          {
            "number": "Figure 5c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010027/000020.jpg?itok=iuFiI5LC",
            "caption": "Repeat HRCT confirms enlarged right upper lobe mass without appreciable cavitation, with increased pleural adhesion and thickening, appearance of satellite nodules, some linear densities and peripheral ground glass \u201chalo sign\u201d opacities."
          },
          {
            "number": "Figure 5d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010027/000011.jpg?itok=DALB2Czt",
            "caption": "On HRCT images viewed at soft tissue window settings, the lung mass appears centrally hypodense (detailed view in E)."
          },
          {
            "number": "Figure 5e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010027/000021.jpg?itok=nOAh6-nT",
            "caption": "On HRCT images viewed at soft tissue window settings, the lung mass appears centrally hypodense (detailed view in E)."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010027/000012.jpg?itok=0nSu8wY8",
            "caption": "Three months after initial admission, chest radiographs disclose regressed right upper lobe mass (detailed view in C)."
          },
          {
            "number": "Figure 6b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010027/000013.jpg?itok=rNMfvrkj",
            "caption": "Three months after initial admission, chest radiographs disclose regressed right upper lobe mass (detailed view in C)."
          },
          {
            "number": "Figure 6c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010027/000022.jpg?itok=qcsix-FY",
            "caption": "Three months after initial admission, chest radiographs disclose regressed right upper lobe mass (detailed view in C)."
          }
        ]
      },
      {
        "number": "Figure 7",
        "subfigures": [
          {
            "number": "Figure 7a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010027/000014.jpg?itok=WzGMqHKo",
            "caption": "Repeat HRCT at treatment termination confirms resolution of right upper lobe mass lesion, with residual fibrotic bands (detailed view in C)."
          },
          {
            "number": "Figure 7b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010027/000015.jpg?itok=RBan39BN",
            "caption": "Repeat HRCT at treatment termination confirms resolution of right upper lobe mass lesion, with residual fibrotic bands (detailed view in C)."
          },
          {
            "number": "Figure 7c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010027/000023.jpg?itok=ixj_8ADm",
            "caption": "Repeat HRCT at treatment termination confirms resolution of right upper lobe mass lesion, with residual fibrotic bands (detailed view in C)."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/10027",
    "time": "09.05.2012"
  },
  "10037": {
    "case_id": 10037,
    "title": "A case of  chronic eosinophilic pneumoni",
    "section": "Chest imaging",
    "age": "54",
    "gender": "female",
    "diagnosis": "Chronic eosinophilic pneumonia",
    "history": "A 54-year-old female patient presented to the outpatients asthma clinic with a few months history of cough, fatigue, shortness of breath on minimal exertion and wheezing. Blood investigations included an elevated erythrocyte sedimentation rate and eosinophilia at 2.0 X109 / L. No fever was documented.",
    "image_finding": "The initial chest radiograph at presentation was normal. After a few weeks of worsening symptoms, the repeat chest radiograph showed patchy areas of airspace shadowing mostly worse on the left. No pleural effusions were present. The patient was admitted for further investigations. Bronchoalveolar lavage studies revealed a 55% differential eosinophilic count. Subsequent radiograph showed an increase in airspace shadowing with a peripheral distribution. A chest CT was organised. This confirmed the patchy airspace shadowing with a characteristic \"photographic negative of pulmonary oedema\". In addition there were areas of ground glass shadowing but no mediastinal lymphadenopathy. The patient was treated with high dose steroids after which a remarkable clinical improvement was observed after few days. Follow-up HRCT 1 month post treatment were completely normal. As the dose of steroids was being tapered down, the patient relapsed a few months later.",
    "discussion": "Pulmonary eosinophilic diseases are a group of disorders characterised by lung opacities and tissue or peripheral eosinophilia. The diagnosis is confirmed with the presence of pulmonary opacities associated with peripheral eosinophila, parenchymal eosinophilia confirmed by open lung biopsy or transbronchial biopsy, or a high eosinophil differential on brochoalveolar lavage studies [1].Chronic eosinophilic pneumonia is commoner in women. Nonspecific symptoms of malaise, fever, weight loss and night sweats are amongst the clinical manifestations. Chest symptoms include cough and dyspnoea, which are always present, while wheezing occurs in around 50% of patients. Dyspnoea severe enough to require ventilation is rarely present except in the presence of idiopathic acute eosinophilic pneumonia. Asthma is also a common occurrence in these patients. Extra thoracic manifestations are never present [2, 3].Laboratory findings invariably demonstrate a high erythrocyte sedimentation rate and eosinophilia usually in excess of 1000/mm3. Bronchoalveolar lavage findings reveal high eosinophil levels in the region of 12 - 95% of the total cell count. This is an important differential finding in comparison to cryptogenic organising pneumonia, which shares many clinical and radiological characteristics. In the latter, lymphocyte counts are higher than eosinophils. Pulmonary function tests are an unreliable diagnostic factor. They are normal in a third of patients while both restrictive and obstructive patterns have been documented [3].Typical findings on chest X-ray include non-segmental patchy areas of airspace shadowing involving the lung periphery and mostly the upper lobes. This pattern may however be seen in less than 50% of cases. CT demonstrates similar features. Less common findings are the presence of ground glass change, nodules and reticulation. CT performed after more than 2 months from beginning of symptoms will show linear opacities parallel to the pleural surface. Only 9% of cases have a pleural effusion [1].The basis of treatment of chronic eosinophilic pneumonia is oral steroids. A dramatic response in blood results is noted within hours while radiographs return to normal within a few days. There is no consensus on the dose and duration of treatment. Initial prednisone doses of 0.5 and 1 mg/kg/day tapering down the dose for a total of 6 - 12 months. Relapse is observed in 50% of patients. The response to higher doses of steroids is similar to that of the first episode [3].",
    "differential_diagnosis": "Chronic, eosinophilic, pneumonia, Drug-associated, pulmonary, infiltrates, Allergic, bronchopulmonary, aspergillosis, Parasitic, infection",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010037/000001.jpg?itok=XQ4bc5K_",
            "caption": "Normal chest radiograph at presentation."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010037/000002.jpg?itok=5n_HXnmB",
            "caption": "Chest radiograph after worsening of symptoms. Bilateral areas of patchy airspace shadowing, worse on the left."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010037/000003.jpg?itok=TeA0zPPB",
            "caption": "Chest radiograph prior to starting steroid therapy showing increasing areas of airspace shadowing."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010037/000004.jpg?itok=GpGwaW7Q",
            "caption": "CT image showing patchy areas of airspace shadowing with a peripheral distribution."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010037/000005.jpg?itok=btDdSaEQ",
            "caption": "CT image showing subpleural parallel lines."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010037/000006.jpg?itok=0SwGJENT",
            "caption": "HRCT after treatment showing complete resolution."
          }
        ]
      },
      {
        "number": "Figure 7",
        "subfigures": [
          {
            "number": "Figure 7",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010037/000007.jpg?itok=Ut4Ygr9J",
            "caption": "CT Chest after tapering down of treatment. Notice the peripheral distribution characteristically termed \\\"photographic negative of pulmonary oedema\\\"."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Respiratory system"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT",
      "CT-High Resolution"
    ],
    "link": "https://www.eurorad.org/case/10037",
    "time": "09.05.2012"
  },
  "10071": {
    "case_id": 10071,
    "title": "Pulmonary nocardiosis",
    "section": "Chest imaging",
    "age": "47",
    "gender": "female",
    "diagnosis": "Nocardiosis",
    "history": "A 47-year-old female patient presented with fever, chest pain, coughing  blood-streaked sputum and swelling of right axillary. She had a history of chronic lymphocytic leukaemia and thrombocytopenic purpura treated with platelet concentrates and high-dose steroids, after that she had presented a haematoma on the volar surface of the right wrist.",
    "image_finding": "Chest radiographs showed multiple nodules, partially cavitated, distributed in both lungs (Figure 1).CT images using lung window presented multiple bilateral nodular lesions in all lobes, ranging from a few millimeters to 2.5 cm in size, characterised by cavitation and homogeneously or irregularly thickened walls (Figure 2). There were also some mediastinal lymph nodes with short axis less than a centimeter and a right axillary lymph node of about 3.7x2.6 cm. These imaging findings were consistent with an opportunistic infection.Definitive diagnosis was obtained by micro-organism isolation in sputum.Follow-up CT after three months of therapy (Cotrimoxazole and Amikacina) showed a general reduction in size of all lesions (Figure 3).Follow-up CT after nine months of therapy showed complete resolution of the lesions (Figure 4).",
    "discussion": "Nocardia are filamentous, aerobic, Gram-positive and partially acid-fast bacteria; they are ubiquitous saprophytes that live in the soil and stagnant water. The most common pathogenic species is Nocardia asteroides and transmission usually occurs through inhalation, sometimes by percutaneous route. Nocardiosis can be localised or disseminated (two or more organs involved), giving both suppurative and granulomatous infection. Clinical evolution can be acute, subacute or chronic and potentially life-threatening, especially because it is an opportunistic infection mainly affecting immunocompromised patients (AIDS, neoplasms, transplantation, chronic pulmonary disease, haematological malignancies, long-term corticosteroids therapy); it rarely occurs in immunocompetent hosts. Mortality rate increases in disseminated infections (40-60%) and in very debilitated patients (45%) [1, 2, 3].Lungs are the most common infection site (75-80%), with frequent haematogenous dissemination to central nervous system (44%) and skin. Clinical presentation is quite nonspecific, but associated respiratory, cutaneous and neurological symptoms should be suggestive for diagnosis. Pulmonary involvement manifests with dyspnoea, chest pain, productive cough, haemoptysis, fever and gradual weight loss (possible complications: empyema, mediastinitis, necrotising pneumonia). Signs of skin infection include cellulitis, ulceration, pustules, subcutaneous nodules and abscesses. Neurological manifestations vary according to the brain site affected and to infection severity (from cerebritis to abscess): difficulty in speaking or swallowing; lateralised weakness; compromised consciousness; headache, nausea and vomiting [3, 4, 5].Radiologic profile is also nonspecific and pleomorphic. Chest imaging findings are similar both in chest radiograph and CT (CT being more accurate in localising alterations and determining their extension) and consist of: irregular masses, cavitated nodules, pulmonary consolidation, reticular infiltrates and pleural effusion (upper lobes more frequently affected). Brain involvement is documented by contrast-enhanced CT and MRI, both showing parenchymal conglomerate ring-enhancing lesions with surrounding oedema. Abscesses have a necrotic centre and a peripheral colagenous capsule that respectively appear hypointense and hyperintense on T1-weighted sequences and hyperintense and hypointense on T2-weighted sequences [5, 6].Definitive diagnosis is obtained by micro-organism isolation in sputum, bronchoalveolar lavage fluid or bioptic specimens, and following bacterial culture. Unfortunately diagnosis is often delayed because of nonspecific clinico-radiological presentation, lack of diagnostic serological tests, long culturing time and hard differential diagnosis. This one includes tubercolosis, aspergillosis and sarcoidosis for similar organ involvement and imaging features; necrotising neoplastic lesions should be also taken into account [1].Antibiotic treatment of choice is cotrimoxazole (alternatively amikacin, imipenem, ceftriaxone, ampicillin); therapy duration depends on site of infection (6-12 months). Surgery must be considered in severe and refractory brain involvement [1, 7].",
    "differential_diagnosis": "Nocardiosis, Tubercolosis, Aspergillosis, Sarcoidosis, Neoplastic, disease",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010071/000007.png?itok=jBU_ieSu",
            "caption": "Chest radiograph shows resolution of the lesions.\nThere are some fibrotic striae in the right upper field peripherally."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010071/000019.png?itok=BIoTkhTL",
            "caption": "Axial CT images shows resolution of the lesions bilaterally distributed in all lobes leaving some residual scars."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010071/000020.png?itok=bIbmk_l5",
            "caption": "Axial CT images shows resolution of the lesions bilaterally distributed in all lobes leaving some residual scars."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010071/000009.jpg?itok=cEFh4ReI",
            "caption": "The posteroanterior chest radiograph shows multiple bilateral nodular lesions with central cavitation distributed in all lobes."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010071/000010.jpg?itok=GV3xaJiT",
            "caption": "The lateral chest radiograph reveals multiple nodular lesions with central cavitation."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010071/000011.png?itok=z7rB6y9L",
            "caption": "The axial CT images on lung windowing show multiple bilateral cavitated nodules of variable size with homogeneously or irregularly thickened walls, randomly distributed. A big right axillary lymph node is also noted."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010071/000012.png?itok=p3x2HriN",
            "caption": "The axial CT images on lung windowing show multiple bilateral cavitated nodules of variable size with homogeneously or irregularly thickened walls. They are randomly distributed in all lung lobes."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010071/000013.png?itok=7UqGx6Lz",
            "caption": "The axial CT images on lung windowing show multiple bilateral cavitated nodules of variable size with homogeneously or irregularly thickened walls. They are randomly distributed in all lung lobes."
          },
          {
            "number": "Figure 3d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010071/000014.png?itok=qJ8ygUyj",
            "caption": "The coronal and oblique lung CT images confirm the presence of multiple bilateral cavitated nodules of variable size with homogeneously or irregularly thickened walls. They are randomly distributed in all lung lobes."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010071/000015.png?itok=StYSG0Zc",
            "caption": "Axial images show a general reduction in size of the lesions in the posterior segment of the RUL.\nThey have irregular margins without central cavitation.\nThe big right axillary lymph node is no more visualised."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010071/000016.png?itok=UryzOWiO",
            "caption": "Axial images show a general reduction in size of the lesions bilaterally distributed. \nThey have irregular margins without central cavitation."
          },
          {
            "number": "Figure 4c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010071/000017.png?itok=z3Sp80c_",
            "caption": "Axial images show a general reduction in size of the lesions bilaterally distributed. \nOnly the lesion in the lateral basal segment of the LLL presents increase in size.\nThey have irregular margins without central cavitation."
          },
          {
            "number": "Figure 4d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010071/000018.png?itok=Q5tbsuM7",
            "caption": "Coronal-oblique lung CT images show a general reduction in size of the lesions.\nOnly the lesion in the lateral-basal segment of the LLL presents increase in size.\nThey have irregular margins without central cavitation."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax",
      "Lung"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/10071",
    "time": "25.06.2012"
  },
  "10080": {
    "case_id": 10080,
    "title": "Metastatic pulmonary calcification",
    "section": "Chest imaging",
    "age": "29",
    "gender": "female",
    "diagnosis": "Pulmonary metastatic calcification secondary to haemodialysis",
    "history": "A 45-year-old female patient with polycystic kidney disease started with haemodialysis programme due to a chronic renal failure.A chest radiograph was performed and showed poorly-defined small nodules in the upper and middle lung zones.",
    "image_finding": "Chest radiograph shows poorly-defined small nodules in the upper and middle lung zones (Figure 1).High-resolution CT examination of right lung shows fluffy, poorly defined nodules in right upper lobe (Figure 2). Several nodules exhibited calcification (arrows) on mediastinal window (Figure 3, 4).",
    "discussion": "Metastatic pulmonary calcification (MPC) is a complication arising in patients with untreated renal failure, failed renal transplantation and during haemodialysis treatment. It is found in 60% to 75% of postmortem examinations of patients who received chronic haemodialysis [1, 2].The clinical classification of pulmonary calcification includes metastatic calcification with deposits of a calcium magnesium phosphate complex accumulating in normal interstitial and bronchovascular tissue and dystrophic calcification, which occurs in previously injured lung [1, 2].The mechanism is not entirely clear but is believed to be related to the secretion of free ions, this produces an alkaline medium in which calcium salts may precipitate [1]. The lung is one of the first sites of deposition of calcium being affected by 75% of cases. It affects with more frequency the apices because the pH is 7.5, compared to the bases, where it is 7.3. The deposit occurs primarily in the alveolar septa and bronchial walls and to a lesser extent in pulmonary and bronchial arterioles. Other organs susceptible to metastatic calcification are the stomach and kidneys [1, 3].Several conditions can cause disbalance of the metabolism of calcium and phosphorous e.g. patients who are in haemodialysis programs, primary and secondary hyperparathyroidism or hypervitaminosis D. In the case of chronic renal failure with secondary hyperparathyroidism, a significant association has been found between lung calcium content, elevated phosphate level and the calcium-phosphate product [4]. Although most of the patients are asymptomatic, typical symptoms can include dyspnoea, chronic non productive cough and even fulminate respiratory failure or death [2, 4]. The chest radiograph can be normal or shows poorly defined nodules. Involvement of the lung can be unilateral or bilateral typically in the upper lobes [4]. They may simulate airspace disease, such as pulmonary oedema or infection [4]. Chest CT examination is a more sensitive technique than radiography in detecting the nodules and make a correct diagnosis. Chest HRCT shows poorly defined small nodules of 2-12 mm diameter, some of them calcified. Other findings are ground-glass attenuation and patchy consolidation. Calcifications of the vessels of the chest wall are better seen on the mediastinal window [5]. Technetium-99m-MDP SPECT can help with the diagnosis. This technique has demonstrated radiotracer deposition in MPC in the absence of radiographic findings [4, 6]. The differential diagnosis includes primary and secondary hyperparathyroidism, hypervitaminosis D, dystrophic calcification (TBC) sarcoidosis, silicosis or idiopatic ones (alveolar microlithiasis) [7].",
    "differential_diagnosis": "Pulmonary, metastatic, calcification, secondary, to, haemodialysis, Primary, and, secondary, hyperparathyroidism, Tubeculosis, Sarcoidosis, Alveolar, microlithiasis, Paraneoplastic, syndrome",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010080/000001.jpg?itok=Nr5bYpAn",
            "caption": "Chest radiograph shows poorly-defined nodules in the upper and middle lobes."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010080/000002.jpg?itok=Ft-acgzy",
            "caption": "High-resolution CT examination shows poorly-defined nodules in the right upper lobe."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010080/000003.jpg?itok=WgiFgEhq",
            "caption": "Several nodules were calcified (arrows) on mediastinal windows."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010080/000004.jpg?itok=NsSNy-4n",
            "caption": "Several nodules were calcified in the right upper and middle lobes on mediastinal windows."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT",
      "CT-High Resolution",
      "Teleradiology"
    ],
    "link": "https://www.eurorad.org/case/10080",
    "time": "27.05.2012"
  },
  "10098": {
    "case_id": 10098,
    "title": "Paraquat induced pulmonary fibrosis",
    "section": "Chest imaging",
    "age": "36",
    "gender": "male",
    "diagnosis": "Pulmonary fibrosis induced by paraquat poisoning",
    "history": "An alcoholic 31-year-old man, otherwise healthy, was admitted to the Emergency Department 4 hours after ingesting an herbicide to commit suicide. Digestive decontamination and haemodialysis were immediately performed and the patient survived. He was discharged 2 months later. One year later he gradually became increasingly breathless on effort.",
    "image_finding": "The chest radiograph at the time of admission was clear. Seven days later there was a diffuse pattern of consolidation on radiography (Fig. 1) but the patient remained asymptomatic.He missed all follow up chest radiographs and medical appointments until the day he started to experience shortness of breath. He underwent radiography (Fig. 2) that disclosed a reticular appearance.Subsequently performed high resolution CT demonstrated extensive lung fibrosis with alveolar destruction, distributed predominantly in the central regions of the lung. The honeycombing resulted in thick walled, air-filled cysts measuring not more than 1cm and arranged in several layers (Fig. 3).",
    "discussion": "Paraquat is an herbicide highly toxic used in agriculture and causes damage to the lungs, liver and kidneys [1]. Exposure usually results in death, either due to gastrointestinal caustic lesions, shock, acute respiratory distress syndrome or related to the progressive development of pulmonary fibrosis associated with refractory hypoxemia. The cytotoxic effects of paraquat have been attributed to the generation of superoxide radicals after reduction of paraquat by intracellular oxidases [2]. Ingestion of a large quantity of paraquat leads to rapid onset of pulmonary edema. Ingestion of smaller doses results in delayed onset of pulmonary abnormalities, which may progress to respiratory failure. The radiographic appearance of paraquat pneumonitis varies widely and is non-specific [1]. On chest radiographs, initially there is diffuse air-space consolidation (first 7 days) indicative of pulmonary edema, followed by diffuse cystic and linear shadows (next 7 days). Consolidation or diffuse haziness evolves later to a pattern of focal interstitial opacities that contained small cysts \u2013 honeycombing (one month after paraquat ingestion) [2, 3]. Pneumomediastinum occurs frequently and may result from pulmonary interstitial emphysema or esophageal perforation.On high resolution CT early abnormal findings include thickening of alveolar walls and septa, microatelectasis and alveolar hemorrhage that appear as bilateral and diffuse areas of ground-glass attenuation and evolves into consolidation with bronchiectasis, irregular lines, and traction bronchiectasis. Late findings are pulmonary fibrosis and microcyst formation. In this stage lung structure is entirely disorganized and replaced by many small (0.5- 2.0 mm) cysts lined by fibrous tissue [2, 3]. An interesting finding is that in most cases paraquat-induced pulmonary fibrosis involves the central regions of the lung, whereas idiopathic pulmonary fibrosis primarily involves the lung periphery.At pathologic analysis, an exudative phase of diffuse alveolar damage is often initially seen in individuals who survive for several days, followed by interstitial fibrosis in the later phase [1]. Paraquat poisoning should be considered in the differential diagnosis of patients who have unexplained renal failure or progressive pulmonary changes, particularly if there is a history of a persistent sore throat or unexplained painful dysphagia [4]. Paraquat toxicity in the lung is more severe than in other organs because of the delayed effect of paraquat [3]. Its concentration is high in the lungs for 7 days, whereas in other organs there is a rapid decrease in concentration 24-36 hours after ingestion.There is no specific treatment for paraquat poisoning. The goal is to relieve symptoms and treat complications.",
    "differential_diagnosis": "Pulmonary, fibrosis, induced, by, paraquat, poisoning, Idiopatic, pulmonary, fibrosis, Drug-related, pulmonary, fibrosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010098/000001.jpg?itok=aAR2ydTr",
            "caption": "Chest radiograph obtained in the first to weeks after admission began to show focal opacities."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010098/000002.jpg?itok=D03d05zR",
            "caption": "Follow up radiograph obtained after one year shows diffuse reticular-nodular opacities in both lungs with decreased lung volume."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010098/000003.jpg?itok=Dlpp7ner",
            "caption": "Established pulmonary fibrosis"
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010098/000004.jpg?itok=K2pZzOWi",
            "caption": "Reticular attenuation with interlobular septal thickening, architectural distortion with associated traction bronchiectasis and a honeycomb pattern."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010098/000005.jpg?itok=Vd_yi-93",
            "caption": "The abnormalities are predominantly central in distribution allowing distinction from idiopatic pulmonary fibrosis."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT-High Resolution"
    ],
    "link": "https://www.eurorad.org/case/10098",
    "time": "18.07.2012"
  },
  "10123": {
    "case_id": 10123,
    "title": "Asymptomatic Bochdalek\\&#039;s hernia in elderly woman",
    "section": "Chest imaging",
    "age": "82",
    "gender": "female",
    "diagnosis": "Bochdalek's hernia",
    "history": "An elderly lady, widow for several years, no children or kin, was admitted in a retirement home for the initial symptoms of dementia. During the routine examinations a chest radiograph showed a few anomalies.",
    "image_finding": "The frontal chest radiograph showed a large opacity, with a central air-fluid level in the retrocardiac region suggestive of a sliding hiatal hernia and a rounded parenchymal consolidation above the right diaphragm. This parenchymal consolidation was not visible on the lateral chest radiograph.An unenhanced CT examination was performed for further investigation of the radiographic findings.This confirmed the large sliding hiatal hernia and showed a rounded mass with a homogeneous fat density in the right posterior lower thorax, caused by herniation of retroperitoneal fat through an interruption of right diaphragmatic musculature. The findings were suggestive of Bochdalek's hernia (BHs).",
    "discussion": "Sliding hiatal hernia is a common finding. This is an acquired condition in which a portion of the stomach protrudes into the chest cavity through the oesophageal hiatus. Much less common is the detection, in adulthood, of Bochdalek's hernia (BH).This is the most common type of congenital defect of the diaphragm through which the abdominal contents may switch into the chest cavity [1]. The defect results from delay or failure of closure of the embryonic pleuroperitoneal membrane [1-2]. First described by Bochdalek in 1848, BH most frequently arises on the left side but can also be bilateral.BH may be found in patients of any age, however, normally this condition is diagnosed in neonatal and postnatal patients who present acute symptoms of respiratory distress and cyanosis due to a large herniation of abdominal organs.The defect of diaphragmatic musculature can vary in size as well as the contents of the herniation. The small size of diaphragmatic defect and the herniation solely of peritoneal fat can be asymptomatic and this condition, undiagnosed in childhood, can be incidentally discovered in adulthood.The true prevalence of BH is unknown, estimations vary between 0.17% and 6%. Nevertheless, the identification of BH in adults occurs most frequently than before CT era due to the increase of patients undergoing CT examinations for other reasons [3].Presentation of BH in adults varies, often asymptomatic, some patients can present chest pain, difficulty in breathing, abdominal pain or intestinal obstruction. The diagnosis can be established using various imaging techniques. Chest radiograph is usually the first procedure, showing a soft-tissue opacity or a solitary rounded lesion at the lung base. Other imaging methods such as barium studies, radionuclide imaging and ultrasound may also be useful but are of limited value.CT examination and especially multislice CT with multiplanar reformatting of the images is the most accurate method of diagnosing and evaluating the diaphragmatic hernias [4].CT findings are the following: 1) a low-attenuated mass neighbouring the posterior portion of the diaphragm, 2) the discontinuity of the diaphragmatic musculature adjacent to the mass and 3) the continuity of the subdiaphragmatic and supradiaphragmatic densities through the diaphragmatic defect.Small and asymptomatic BH have poor clinical relevance and require no treatment, however, can create problems of differential diagnosis with several lung diseases [5].Surgery is the treatment of choice in symptomatic cases.",
    "differential_diagnosis": "Bochdalek's, hernia, Lung, or, pleural, neoplasm, Diaphragmatic, lipoma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010123/000003.jpg?itok=mMMN2HLO",
            "caption": "The frontal chest radiograph shows a large opacity, with an air-fluid level in the retrocardiac region (red arrow) and a rounded opacity above the right diaphragm (white arrow)"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010123/000004.jpg?itok=uzr5GrBo",
            "caption": "The lateral chest radiograph shows the large opacity, with area of radiolucency, in the retrocardiac region. The rounded opacity is not visible."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010123/000005.jpg?itok=Gne3dSAO",
            "caption": "Axial unenhanced CT examination confirmed the large sliding hiatal hernia (arrow)."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010123/000006.jpg?itok=IkRB421k",
            "caption": "Axial unenhanced CT examination shows a rounded fat mass in the posterior inferior right intrathoracic area (arrow)."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010123/000007.jpg?itok=HBdHrri5",
            "caption": "Axial unenhanced CT examination shows a small defect of the right diaphragm (arrow)."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010123/000009.jpg?itok=ckuxb51x",
            "caption": "Coronal MPR image shows the small defect of the right diaphragm (red arrow) with herniation of retroperitoneal fat."
          },
          {
            "number": "Figure 2e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010123/000011.jpg?itok=6Q5KHc7n",
            "caption": "Sagittal MPR image shows the small defect of the right diaphragm (red arrow) with herniation of retroperitoneal fat (white arrow)."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT",
      "Image manipulation / Reconstruction"
    ],
    "link": "https://www.eurorad.org/case/10123",
    "time": "25.06.2012"
  },
  "10143": {
    "case_id": 10143,
    "title": "Scimitar syndrome with horseshoe kidney and portal vein thrombosis: A case report",
    "section": "Chest imaging",
    "age": "17",
    "gender": "male",
    "diagnosis": "Scimitar syndrome with horseshoe kidney and portal vein thrombosis.",
    "history": "A 17-year-old male patient presented with 2-year history of right chest pain and mild shortness of breath. On clinical examination there were decreased breath sounds on right side of chest.",
    "image_finding": "Chest radiograph revealed small right hemithorax with elevated dome of right hemidiaphragm. Contrast enhanced CT examination demonstrated small right hemithorax with hypoplastic right lung and elevated right hemidiaphragm (Figure 1). The right lung was drained by an aberrant vein draining into the inferior vena cava (Figure 2). The right lung was supplied by an anomalous artery arising from abdominal aorta at the level of renal hilum with absent normal right pulmonary artery (Figure 3, 4). Multiple vertebral anomalies were disclosed (Figure 5). Aberrant right subclavian artery was also seen passing posterior to the oesophagus (Figure 6). Abdominal CT revealed horseshoe kidney (Figure 7) and hypoplastic right lobe of liver with thrombus in right branch of portal vein (Figure 8, 9), which are unusual associated anomalies. Subsequent echocardiography was performed in order to investigate any associated cardiac anomalies but it was unremarkable.",
    "discussion": "Scimitar syndrome or pulmonary venolobar syndrome is a syndrome of unknown aetiology [1]. The first reported case of Scimitar syndrome was published in 1836 by Cooper [2]. The most constant and defining components of scimitar syndrome are hypogenetic lung and partial anomalous pulmonary venous return [3]. The name comes from this anomalous pulmonary vein which may be visible on chest radiograph in 1/3 of cases as a curvilinear shadow just above the right hemidiaphragm said to resemble a \"scimitar\" or Persian sword, \u201cshimshir\u201d [4]. It is also characterised by other major components of absent pulmonary artery, systemic arterialisation of lung, pulmonary sequestration, absent/interrupted inferior vena cava and duplication of diaphragm and minor components include tracheal trifurcation, eventration of diaphragm, partial absence of diaphragm, phrenic cyst, horse shoe lung, oeseophageal/gastric lung, anomalous superior vena cava and absent left pericardium. Other associated anomalies are hemivertebra, scoliosis and congenital heart diseases including septal defects, PDA, tetralogy of fallot and hypoplastic left heart [1]. The age of presentation can be between neonatal period and adulthood. Prognosis of the disease depends on age of presentation and associated anomalies. Based on age of presentation two forms of scimitar syndrome are identified: infantile form presenting within 1 year of life with rapidly progressing congestive heart failure and adult form diagnosed after 1 year of age and presents with mild symptoms or remains asymptomatic for life. The infantile form has poor prognosis and needs early surgical repair while adult form has better prognosis even without surgical correction [5]. Diagnosis is suggested by radiographic findings of hypoplastic right hemithorax and scimitar shaped curvilinear vein along right cardiac border. Traditionally angiography has been the modality of choice to demonstrate vascular anomalies but now multislice helical CT with multiplanar reconstruction allows delineation of complex anomalies seen in pulmonary venolobar syndrome [6]. Echocardiography is recommended for detecting associated cardiac anomalies. Meandering pulmonary vein, dextrocardia, hypoplastic lung and swyer james syndrome should be considered in differential of scimitar syndrome.Our patient presented at age 17 with 2 years history of shortness of breath and right chest pain, demonstrating hypoplastic right lobe of liver with thrombus in the right branch of the portal vein on contrast enhanced CT, which are unusual associated anomalies in scimitar syndrome.",
    "differential_diagnosis": "Scimitar, syndrome, with, horseshoe, kidney, and, portal, vein, thrombosis., Meandering, pulmonary, vein, Swyer, james, syndrome",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010143/000001.jpg?itok=bsASBODd",
            "caption": "Axial image showing lack of normal right pulmonary venous drainage into left atrium."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010143/000002.jpg?itok=i2jkgp-q",
            "caption": "Multiplanar reconstruction image demonstrating right pulmonary vein    draining into inferior vena cava."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010143/000003.jpg?itok=riMgUpUy",
            "caption": "Axial image demonstrating absent normal right pulmonary artery."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010143/000004.jpg?itok=qhEH6l_B",
            "caption": "Multiplanar reconstruction image showing aberrant right pulmonary artery originating from abdominal aorta."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010143/000005.jpg?itok=deIvHoUv",
            "caption": "Coronal image demonstrating multiple vertebral anomalies in dorsal spine."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010143/000006.jpg?itok=rEXiyUSQ",
            "caption": "MPR image showing aberrant right subclavian artery."
          }
        ]
      },
      {
        "number": "Figure 7",
        "subfigures": [
          {
            "number": "Figure 7",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010143/000007.jpg?itok=1Pt74TOT",
            "caption": "Axial image showing horseshoe kidney with connecting\nisthmus just below inferior mesenteric artery."
          }
        ]
      },
      {
        "number": "Figure 8",
        "subfigures": [
          {
            "number": "Figure 8",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010143/000008.jpg?itok=5LKJRtAU",
            "caption": "MPR image demonstrating right branch of portal vein with right lobar atrophy."
          }
        ]
      },
      {
        "number": "Figure 9",
        "subfigures": [
          {
            "number": "Figure 9",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010143/000009.jpg?itok=FS-jso_t",
            "caption": "Axial image showing thrombus in right portal vein."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Arteries / Aorta",
      "Abdomen",
      "Cardiovascular system",
      "Pulmonary vessels",
      "Computer applications"
    ],
    "imaging_technique": [
      "CT",
      "Image manipulation / Reconstruction"
    ],
    "link": "https://www.eurorad.org/case/10143",
    "time": "18.07.2012"
  },
  "10176": {
    "case_id": 10176,
    "title": "Mounier-Kuhn syndrome",
    "section": "Chest imaging",
    "age": "42",
    "gender": "male",
    "diagnosis": "Mounier-Kuhn Syndrome (tracheobronchomegaly)",
    "history": "A 42-year-old male patient presented to outpatients respiratory clinic with a long standing history of cough productive of sputum and regular chest infections.",
    "image_finding": "The initial chest radiograph revealed multiple intrapulmonary cavities, a dilated trachea and a well defined right hilar opacity (Figure 1). The right lateral chest radiograph detected an area of airspace shadowing at the right lung base (Figure 2). In view of the hilar mass, a conventional CT chest was requested rather than an HRCT. However, the hilar shadow turned out to be one of the dilated bronchi which was filled with fluid. Axial CT images confirmed the presence of a dilated trachea which also contained posterior tracheoceles made up of prolapsed mucosa (Figure 3). Multiple sacculations, all connected to the bronchial tree could be seen, some of which contained an air/fluid level (Figure 4, 5). The coronal reformatted images shows absence of the cavities at the lung periphery (Figure 6). Follow-up chest radiograph taken 17 months post diagnosis revealed an increase in both the size and number of the cavities.",
    "discussion": "Tracheobronchomegaly was first described by Mounier-Kuhn in 1932. The syndrome's characteristics include dilatation of the trachea and bronchi together with recurrent chest infections. Its cause is unknown but a decrease in the amount of elastic and muscle fibres has been reported. Mounier-Kuhn itself is a congenital disease however tracheobronchomegaly may also occur as a result of Ehlers-Danlos syndromes, severe upper lobe fibrosis as in sarcoidosis and cystic fibrosis and in chronic airway inflammation as in allergic bronchopulmonary aspergillosis. The disease is commoner in males and usually diagnosed in the 40 - 50 year age group. [1, 2]The clinical presentation is nonspecific with symptoms overlapping those of chronic bronchitis and bronchiectasis. Some patients are asymptomatic having been diagnosed incidentally. Most patients present with a chronic cough, recurrent chest infections, haemoptysis and shortness of breath. An increase in the dead space and tidal volume is seen on pulmonary function tests. [3]Tracheobronchomegaly is subdivided into three. Type 1 is subtle diffuse enlargement of the trachea and major bronchi, while type 2 is more obvious bizarre enlargement which may include sacculations in the major bronchi. In type 3, the diverticula and sacculations extend into the distal bronchi. [3]The widened and corrugated trachea can usually be diagnosed on plain radiography, however, this can be missed if it is not specifically looked for. Specific measurements for diagnosis have been set. Tracheobronchomegaly is confirmed once the trachea exceeds 3cm in diameter, the right main bronchus exceeds 2.4cm while the left main exceeds 2.3cm. HRCT confirms the dilatation and allows more accurate measurements. The dilatation and sacculation of distal bronchi can also be appreciated. [2]No treatment is advocated in asymptomatic patients while smoking cessation is actively encouraged. Intense broad spectrum antibiotics are administered in acute infection and postural physiotherapy for drainage is advised. Surgery has minimal role in treatment. [2]Mounier-Kuhn syndrome is a diagnosis to consider in patients presenting with chronic cough, recurrent infections and sputum production. The tracheal diameter should be included as one of the review areas when interpreting a plain chest radiograph.",
    "differential_diagnosis": "Mounier-Kuhn, Syndrome, (tracheobronchomegaly), Bronchiectasis, Williams-Campbell, syndrome, Chronic, airway, inflammation, or, infection, with, tracheomalacia, Allergic, bronchopulmonary, fungal, disease",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010176/000001.jpg?itok=nZU4o5uW",
            "caption": "Plain radiograph showing multiple intrapulmonary cavities and right hilar opacity. Note the dilated trachea."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010176/000002.jpg?itok=Eu7yBUJl",
            "caption": "Lateral view confirms the intrapulmonary location of the cavities as well as right basal airspace shadowing."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010176/000003.jpg?itok=xRFeDOyx",
            "caption": "Note widened trachea with multiple posterior diverticula."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010176/000004.jpg?itok=RFVmk9Uk",
            "caption": "Dilated main left bronchus and bronchus intermedius. Multiple intrapulmonary cavities which connect to the bronchial tree."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010176/000005.jpg?itok=nrnllORx",
            "caption": "Few of the cavities containing air/fluid levels."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010176/000006.png?itok=uDlISjhx",
            "caption": "Note the relative apical and peripheral sparing."
          }
        ]
      },
      {
        "number": "Figure 7",
        "subfigures": [
          {
            "number": "Figure 7",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010176/000007.jpg?itok=dknZA2Xo",
            "caption": "Follow-up chest x-ray taken 17 months later reveals an increase in the number and size of intrapulmonary cavities as well as visible air/fluid levels."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/10176",
    "time": "15.07.2012"
  },
  "10197": {
    "case_id": 10197,
    "title": "Traumatic false aneurysm of an intercostal artery",
    "section": "Chest imaging",
    "age": "34",
    "gender": "male",
    "diagnosis": "Traumatic false aneurysm of an intercostal artery",
    "history": "A 34-year-old male patient was admitted to the ER with left posterior thoracic penetrating trauma (stabbing); the patient was haemodynamically stable.",
    "image_finding": "After admission, a chest radiograph was performed (Fig. 1) and showed an opacity of the middle and lower third of the left lung. Thorax CT was performed (Fig. 2) and showed a left posterior subcostal fluid collection, adjacent to the site of injury, showing progressive contrast enhancement, compatible with a false intercostal artery aneurysm.Thoracic surgery was performed, with aneurysmectomy, and the patient was discharged without further complications.",
    "discussion": "False aneurysm is a rupture of the arterial wall with subsequent haematoma formation bounded by neighbouring tissues. Its causes are varied, highlighting surgery, catheterization or trauma [1]. Chest pain is present in most cases. The initial assessment takes place with a chest radiograph, usually followed by CT [2]. CT angiography is the gold standard technique for diagnostic purposes; subcostal fluid collection, showing progressive contrast enhancement, is the most frequent and characteristic finding [2, 3].Treatment is usually surgical although occasionally endovascular embolisation may be considered [3].TEACHING POINTS: The intercostal pseudoaneurysm is a potentially fatal cause of haemothorax and is extremely rare. Imaging, particularly with CT, is of great importance to characterise and define size and extension of the lesion to nearby structures and evaluate the best therapeutic approach either surgical or endovascular.",
    "differential_diagnosis": "Traumatic, false, aneurysm, of, an, intercostal, artery, Intercostal, artery, aneurysm, Haemorrhage, of, neoplastic, pleural, lesions",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010197/000001.jpg?itok=BSrfZDHP",
            "caption": "Left lower lobe opacity is noted."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010197/000008.jpg?itok=vHgjifpX",
            "caption": "Left lower lobe opacity is noted."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010197/000002.jpg?itok=qqavqzQo",
            "caption": "Biconcave loculated subcostal fluid collection, adjacent to the site of injury, showing a focal area of progressive contrast enhancement."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010197/000006.jpg?itok=pqHbD-Jc",
            "caption": "Biconcave loculated subcostal fluid collection, adjacent to the site of injury, showing a focal area of progressive contrast enhancement."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010197/000007.jpg?itok=WP76rVhd",
            "caption": "Biconcave loculated subcostal fluid collection, adjacent to the site of injury, showing a focal area of progressive contrast enhancement."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax",
      "Thoracic wall"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/10197",
    "time": "06.08.2012"
  },
  "10206": {
    "case_id": 10206,
    "title": "Chronic granulomatous disease revealed by a pulmonary aspergillosis complication in an adult",
    "section": "Chest imaging",
    "age": "42",
    "gender": "male",
    "diagnosis": "Chronic granulomatous disease, with pulmonary aspergillosis complication.",
    "history": "42-year-old healthy man presented with cough and flu symptoms for several months. In absence of satisfactory clinical improvement after antibiotic therapy, CT, laboratory investigations and bronchoscopy were performed, suggesting a sarco\u00efdosis. Despite corticosteroid treatment, symptoms persisted. The patient was hospitalised for further investigation.",
    "image_finding": "First ambulatory chest CT examination revealed a bilateral disseminated centrilobular and a septal distribution of micronodular infiltrates, associated with bilaterally enlarged mediastinal lymph nodes, concluding a diagnosis of probable stage II Sarcoidosis (fig. 1-4). Chest CT done at the hospital showed an evolution of the diffuse micronodular distribution associated with area of alveolar condensation predominant in the hilar regions and the upper lobes (fig. 5). The broncho-alveolar lavage and biopsy highlighted histological non-necrotising granulomatous infiltration, with presence of mycelial filaments (Aspergillus fumigatus). In the absence of known immunosuppression, a flow cytometry was performed and revealed strongly reduced activity of NADPH (oxidative activity of neutrophils), compatible with a chronic granulomatous disease (CGD), and confirmed by sequencing the complex NADPH genes.",
    "discussion": "Chronic granulomatous disease (CGD) is a rare type of primary immunodeficiencies, involving dysfunction of the NADPH oxidase system and inability of phagocytes to generate superoxide to fight pathogenic organisms. It is characterised by repeated infections with bacterial and fungal pathogens, as well as the formation of granulomas in tissues [1]. Pulmonary changes are present in as many 60% of patients with primary immunodeficiency [3].The clinical manifestations of CGD usually occur during childhood as repeated and severe bacterial or fungal necrotising infections. The diagnosis affects approximately 1/250, 000 individuals and it can occur late in adult age, as in our clinical case [1]. Pneumonia is the most common complication (in about 80% of CGD), with descriptions of Aspergillus infection as the major cause of morbidity and mortality [2].Medical imaging, especially CT, plays an important role in monitoring the response to therapy. Indeed, granulomatosis is an indicator of uncertain prognosis, developing a terminal respiratory failure in 24% of cases [3]. Some authors have described a semiology of sarco\u00efd or sarco\u00efdlike pattern to characterise granulomas in patients with primary immunodeficiency (present in as many as 8% of patients with common variable immunodeficiency), which occurs as well-defined nodules with perilymphatic distribution (which can be associated with areas of pulmonary fibrosis in advanced-staged disease), and it can be associated with bilateral mediastinal lymphadenopathies (58% of patient with both primary immunodeficiency and granulomatosis) [3, 4]. Such imagery suggests a differential diagnosis of sarcoidosis, tuberculosis infection, opportunistic infections or lymphoproliferative disease. CGD should also be suggested in the differential diagnosis in a clinical context of immunodeficiency [2].The final diagnosis of CGD is made by histology, with pattern of non-necrositing granulomatous infiltration, and is confirmed by both flow cytometry and DNA sequencing of the NADPH oxidase system (dysfunctional in CGD) [1].",
    "differential_diagnosis": "Chronic, granulomatous, disease,, with, pulmonary, aspergillosis, complication., sarco\u00efdosis, tuberculosis, infection, opportunistic, infection, lymphoproliferative, disease, chronic, granulomatosis, disease",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010206/000001.jpg?itok=2bfQ6bx5",
            "caption": "Diffuse bilateral micronodular infiltrate is noted."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010206/000002.jpg?itok=UpjyB7N6",
            "caption": "Diffuse bilateral micronodular infiltrate with both centrilobular and perilymphatic distribution is seen."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010206/000003.jpg?itok=6znBP4z3",
            "caption": "Diffuse bilateral micronodular infiltrate with both centrilobular and perilymphatic distribution is seen."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010206/000004.jpg?itok=F6C7fXtv",
            "caption": "Enlarged bilateral hilar lymphadnodes are noted."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010206/000005.jpg?itok=yfwlQisc",
            "caption": "Appearance of alveolar condensations in the hilar regions and the upper lobes."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/10206",
    "time": "18.12.2012"
  },
  "10214": {
    "case_id": 10214,
    "title": "Lusory artery",
    "section": "Chest imaging",
    "age": "66",
    "gender": "male",
    "diagnosis": "Lusory artery",
    "history": "A 66-year-old male, asymptomatic, performs elective CT for staging follicular thyroid carcinoma.",
    "image_finding": "CT scan revealed a retro-esophageal right subclavian artery (lusoria).",
    "discussion": "The right subclavian artery arises from the bifurcation of the brachiocephalic trunk at the level of the sternoclavicular articulation. It is superficially located in the right omoclavicular triangle of the neck, directed towards the axilla, and then changing its name at the level of first rib to the right axillary artery.A left aortic arch with aberrant right subclavian artery (ARSA or lusory artery) is the most common congenital anomaly of the aortic arch (0.5 to 2% of the population) [1]. This anomaly might be an isolated defect or concurrent with congenital heart defects. ARSA occurs as a result of abnormal regression of the fourth aortic arch and persistence of patency of the right eight dorsal aortic segment. Sixty percent of patients with ARSA, have Kommerell's diverticulum and aneurysm of the diverticulum have been observed in 3\u20138% of these patients [2]. Lusory artery arises as last branch of the aortic arch with a retro-oesophageal disposition. In most cases it is asymptomatic, representing an imaging finding, and not more than 10% of the cases, dysphagia is reported. However, although less frequent, but with higher prevalence of symptoms (e.g. dyspnea), it may arise between the esophagus and the trachea or even anterior to it [3]. The presence of an aneurysm or Kommerell's diverticulum at its aortic origin, is more likely to produce symptoms from esophageal compression [4].It is associated with an anatomical variation of the lower right laryngeal nerve, an aspect of great importance in cervical surgery in order to avoid iatrogenic injuries [5].In symptomatic cases of dysphagia or any other mediastinal structure compression, the treatment is surgical [1]. Transluminal placed stent-grafts offer an alternative approach to aneurysms of Kommerell's diverticulum [2].",
    "differential_diagnosis": "Lusory, artery, other, vascular, malformations, esophageal, disease, adenopathy, other, prevertebral, lesions",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010214/000001.jpg?itok=v8D48kde",
            "caption": "No significant alterations"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010214/000003.jpg?itok=ip_keQWp",
            "caption": "Lusory artery"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010214/000004.jpg?itok=zTERj66Y",
            "caption": "Lusory artery"
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010214/000005.jpg?itok=eglnA4WG",
            "caption": "Lusory artery"
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010214/000006.jpg?itok=hccVKCjG",
            "caption": "Lusory artery"
          },
          {
            "number": "Figure 2e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010214/000007.jpg?itok=AGfXvAtJ",
            "caption": "Lusory artery"
          },
          {
            "number": "Figure 2f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010214/000008.jpg?itok=cREMAFFb",
            "caption": "Lusory artery"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010214/000009.jpg?itok=iHnz-A-s",
            "caption": "Schematic image - Right retroesophageal subclavian artery."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010214/000010.jpg?itok=91FUj5jH",
            "caption": "Angiography - Aberrant right subclavian artery."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax",
      "Anatomy",
      "Vascular"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT",
      "Image manipulation / Reconstruction",
      "Catheter arteriography"
    ],
    "link": "https://www.eurorad.org/case/10214",
    "time": "14.08.2012"
  },
  "10219": {
    "case_id": 10219,
    "title": "Non-Hodgkin\\&#039;s Lymphoma presenting as a chest wall mass",
    "section": "Chest imaging",
    "age": "58",
    "gender": "male",
    "diagnosis": "Non-Hodgkin's Lymphoma (diffuse large B-cell subtype)",
    "history": "A 58 year old male patient with history of anaemia and Crohn's disease was admitted complaining of right flank pain for 2 months. Physical exam showed decreased lung sounds in the right chest. A palpable mass was noted at the posterior right thoracic wall without overlying skin changes.",
    "image_finding": "Chest radiograph revealed an opacity in the right mid lung zone extending peripherally (Fig. 1). Chest CT with and without contrast enhancement revealed a heterogeneously enhancing necrotic mass in the right posterior chest wall, measuring 15 x 7.5 x 8 cm causing complete destruction of the 8th rib, as well as pathological fracture of the 7th rib (Fig. 2). PET-CT scan showed avid uptake of the radiotracer by a right supraclavicular lymph node as well as heterogeneous uptake of the chest wall mass with central necrosis (Fig. 3). A CT-guided biopsy of the chest wall mass followed and established the diagnosis of Non-Hodgkin\u2019s Lymphoma-diffuse large B-cell subtype (Fig. 4). A small right paravertebral soft tissue density was also noted, which was attributed to lymph node tissue (fig. 4).",
    "discussion": "Lymphomas are divided into Hodgkin lymphoma (HL) and non-Hodgkin lymphoma (NHL). NHL represents 85% to 90% of all lymphoma cases (1, 2). There are multiple subtypes of NHL, including diffuse large B-cell, follicular, marginal zone, small B-cell, mantle cell, marginal zone, Burkitt and pyothorax-associated lymphomas (1, 3). The majority of newly diagnosed NHL (in the United States) consist of diffuse large B cell and follicular lymphomas (1, 2). NHL involves the thorax in up to 45% of cases, occurring most often in the mediastinum, as disseminated extrathoracic lymphoma. Isolated chest wall masses are rare and are usually a manifestation of large B cell lymphoma (2).Lymphoma is a tissue biopsy-based diagnosis (4). Excisional biopsy remains the standard of care for initial diagnosis to determine cellular morphology and nodal architecture. For diffuse large B-cell lymphoma, determination of the gene expression pattern has been found to be predictive of cyclophosphamide, doxorubicin, vincristine and prednisone (CHOP) chemotherapy response (1).Both HL and NHL are staged using the Ann Arbor staging system which is based on the extent of nodal group involvement. Stage 1 is a single nodal group, stage II is multiple nodal groups ipsilateral to the diaphragm, stage III is involved nodal groups above and below the diaphragm, and stage IV includes noncontiguous extranodal involvement. Modifiers \u201cE\u201d and \u201cB\u201d refer to direct extension to extranodal site or an isolated involved single extranodal site, or systemic symptoms (fever, night sweats, or unexplained weight loss), respectively (1).Prior to treatment, both HL and NHL can be accurately staged with computed tomography (CT) and positron emission tomography (PET) (1, 4). PET/CT yields higher initial diagnostic accuracy, and is an excellent modality for assessing therapy response. Imagers should be aware that lymphomas differ in glucose metabolic activity. Diffuse large B-cell and high grade follicular lymphomas have higher FDG uptake compared to low grade follicular, mantle cell, and small cell lymphomas. However, low grade lymphomas can be accurately staged despite the low FDG uptake (4). Lymph nodes are well assessed by CT and magnetic resonance imaging (MRI). MRI shows greater sensitivity than CT when evaluating chest wall involvement (5).Our patient's diagnosis is diffuse large B-cell NHL. Unlike HL (which combines radiation with chemotherapy), NHL lymphomas are treated with chemotherapy regimens. Diffuse large B-cell lymphoma is treated with curative intent. The preferred chemotherapy regimen is CHOP with probable addition of rituximab.",
    "differential_diagnosis": "Non-Hodgkin's, Lymphoma, (diffuse, large, B-cell, subtype), Stage, IV, bronchogenic, carcinoma, Adenocarcinoma, metastasis, Chondrosarcoma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010219/000001.jpg?itok=vBMHrkhg",
            "caption": "Axial corrected PET-CT showing avid radiotracer uptake in the chest wall mass."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010219/000002.jpg?itok=vOuDszxM",
            "caption": "Coronal corrected PET-CT showing avid radiotracer uptake in the chest wall mass.\nAlso noted, in the superior right apical, and right paraspinal region is increase radiotracer avidity, suggesting adenopathy."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010219/000003.jpg?itok=JAtc1ZIy",
            "caption": "Prone axial CT localized needle biopsy.  Note is made of a tiny anterior right pleural effusion.  Also, right paravertebral soft tissue density, suggesting possible adenopathy."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010219/000004.jpg?itok=uatwtuqO",
            "caption": "Chest radiograph shows an opacity in the right mid lung with destruction of the right 8th rib."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010219/000005.jpg?itok=ns7yrECg",
            "caption": "Non-enhanced axial chest CT showing heterogeneous mass measuring 15 x 7.5 x 8 cm in the right posterior chest wall and destruction of ribs."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010219/000008.jpg?itok=ZNZr9VT8",
            "caption": "Contrast enhanced axial CT showing heterogeneous enhancing mass in the right posterior chest wall and destruction of ribs."
          },
          {
            "number": "Figure 4c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010219/000012.jpg?itok=zv8az861",
            "caption": "Axial CT in lung windows showing heterogeneous mass in the right posterior chest wall and destruction of ribs."
          },
          {
            "number": "Figure 4d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010219/000010.jpg?itok=lRBTc9z5",
            "caption": "Non-enhanced coronal chest CT showing heterogeneous mass  in the right posterior chest wall and destruction of ribs."
          },
          {
            "number": "Figure 4e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010219/000011.jpg?itok=Wgj5H-p9",
            "caption": "Contrast enhanced coronal CT showing heterogeneous enhancing mass in the right posterior chest wall and destruction of ribs.\nParaspinal soft density, may represent lymphadenopathy."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thoracic wall"
    ],
    "imaging_technique": [
      "CT",
      "PET-CT",
      "Conventional radiography"
    ],
    "link": "https://www.eurorad.org/case/10219",
    "time": "18.03.2013"
  },
  "10251": {
    "case_id": 10251,
    "title": "Intralobar pulmonary sequestration",
    "section": "Chest imaging",
    "age": "60",
    "gender": "male",
    "diagnosis": "Intralobar pulmonary sequestration",
    "history": "A 60-year-old man with cough and fever underwent chest radiograph.In the lateral projection a parenchymal opacity in the left lower lobe was noted. In the posteronterior projection the lesion did not silhouette the heart or the diaphragm (Fig. 1). A CT study was ordered for further investigation.",
    "image_finding": "As a congenital anomaly was suspected it was decided to perform a CT angiography according to standard protocols and arterial, venous and delayed phases were obtained in order to assess its vasculature. Maximum Intensity Projections (MIP) reconstructions in orthogonal views were also obtained.At the postero-basal segment of left lower lobe level, CT revealed an area of parenchymal consolidation with smooth borders, serpiginous morphology, without air bronchogram (Fig. 2). An abnormal arterial branch originating from the descending thoracic aorta was also seen (Fig. 3, 4 and 5).The aberrant pulmonary parenchyma was drained from the pulmonary veins (Fig. 6).A surrounding area of hypodensity mimicking \"emphysema\" (Fig. 7) was also disclosed.",
    "discussion": "Sequestration consists of an area of disorganised pulmonary parenchyma without normal pulmonary arterial vasculature or bronchial communications.Two types of sequestration are described: the intralobar (most common) and the extralobar one [1].Most of the cases of pulmonary sequestration diagnosed in the adult are intralobar, therefore they are contained in the lung parenchyma (in 65% of cases at the left lower lobe) and they are not covered by the visceral pleura. In most cases, these are an acquired disease, secondary to chronic infections which lead to the destruction of the normal pulmonary arterial supply and subsequent systemic arterial neovasculature. Usually the pulmonary drainage occurs through the pulmonary veins, more rarely through the azygos or hemiazygos system. Sequestration may appear as a homogeneous mass or as a well-defined cystic or multicystic lesion filled with air and fluid.The extralobar sequestration is a congenital form, almost always observed in neonates and infants, leading to an abnormal budding of the primitive cephalic portion of the intestine. This lesion is equipped with its own visceral pleural lining, is situated in 90% cases at the base of the medial left lower lobe, is almost always free of air and of connections with the pulmonary artery or normal bronchial afference. The arterial supply originates from the abdominal aorta or the lower portion of the thoracic aorta, while the venous drainage may be supported by the inferior vena cava, the azygous vein or the portal vein [2].The association with other congenital anomalies is common, particularly with anomalies of the diaphragm and hypoplasia of the ipsilateral lung [3].The therapy consists in surgical excision (segmental resection or lobectomy) and it may present difficulties depending on the characteristics of the abnormal vasculature.",
    "differential_diagnosis": "Intralobar, pulmonary, sequestration, Abscess, Lung, carcinoma, Other, tumours",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010251/000001.png?itok=wvDMpihd",
            "caption": "At the postero-basal segment of left lower lobe level, note the presence of an area of parenchymal consolidation with smooth borders, serpiginous morphology, without air bronchogram."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010251/000002.png?itok=6xE7-LJY",
            "caption": "An abnormal arterial vasculature extending from the descending thoracic aorta is well demonstrated."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010251/000003.png?itok=paBU-D6G",
            "caption": "MIP reconstruction on coronal planes."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010251/000004.png?itok=M3p4Pjbj",
            "caption": "Coronal reconstruction as in Fig.3 on more posterior planes."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010251/000005.png?itok=0uFK0fPf",
            "caption": "The aberrant pulmonary parenchyma is drained from the pulmonary veins."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010251/000006.png?itok=BcCCpAj5",
            "caption": "Around the lesion, a surrounding area of emphysema-like parenchymal changes were seen."
          }
        ]
      },
      {
        "number": "Figure 7",
        "subfigures": [
          {
            "number": "Figure 7a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010251/000007.png?itok=zLBmSmTr",
            "caption": "Posteroanterior view: smooth parenchymal opacity in the retrocardiac space that does not silhouette the heart or the diaphragm"
          },
          {
            "number": "Figure 7b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010251/000008.png?itok=9QJI3ZWb",
            "caption": "In the lateral projection note a parenchymal opacity at the level of postero-basal segment of the left lower lobe."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT",
      "CT-Angiography",
      "CT-High Resolution"
    ],
    "link": "https://www.eurorad.org/case/10251",
    "time": "19.09.2012"
  },
  "10260": {
    "case_id": 10260,
    "title": "Diffuse pulmonary ossification: the nodular type",
    "section": "Chest imaging",
    "age": "74",
    "gender": "male",
    "diagnosis": "Diffuse pulmonary ossification, nodular type",
    "history": "A 75-year-old male patient was referred to the pneumologist complaining of progressive dyspnoea and cough. There was a professional exposure to pesticides and a history of smoking.Clinical examination revealed normal vesicular breath sounds and malleolar oedema. Lung function test revealed a minor restrictive lung disease with low diffusion capacity.",
    "image_finding": "Chest radiograph showed a slightly enlarged heart and a peripheral reticulonodular pattern predominantly in the lower lobes and small nodules peripherally in the lateral and apical lung regions. An increased lung translucency in the upper regions was suggestive of emphysema.High Resolution Computed Tomography (HRCT) of the lung was performed and showed centrilobular and panlobular emphysema, predominantly on the right side and in the upper lobes. In the lower lobes there was peripheral honeycombing combined with traction bronchiectasis indicative of lung fibrosis. There were small calcified nodules (< 5mm) peripherally located with a lower lobe predominance, some of them aggregating to form a larger mass. Pulmonary artery hypertension was suggested by a slight increased diameter of the pulmonary artery (35 mm; normal <28 mm).",
    "discussion": "Diffuse pulmonary ossification originally was an anatomopathological diagnosis, now regaining interest since it is being diagnosed ante mortem due to the advent of High Resolution Computed Tomography of the lung (HRCT), lung tumour resection and open lung biopsy [1, 2].The two forms of pulmonary ossification, dendritiform type and nodular type, are defined as bone formation within the lung parenchyma [1]. The dendritiform type is found in patients with some form of pulmonary fibrosis and is a rare condition, firstly reported by Luschka in 1856 [3]. The nodular type is more common and is typically associated with passive congestion due to heart failure and mitral stenosis, although nodular ossifications are also described in idiopathic pulmonary fibrosis [4, 5]. In our case the pulmonary ossification is most likely caused by pulmonary congestion because nodular pulmonary ossification due to idiopathic fibrosis is rare, usually in a more severe stage and of the dendritic type [3, 5]. The differential diagnosis however should include both entities.On histological analysis the nodular form has no bone marrow and the bony spicules are located centrally in the alveoli in contrast to the dentritic type that can contain marrow in the bony trabeculated spicules in the alveolar septa [6, 7]. Although the nodular type may be found throughout the entire lung, both types have lower lobe predominance [7, 8]. Chest radiograph typically shows a fine reticulonodular pattern involving mainly the lower lobes [8]. HRCT imaging of the lung demonstrates the fine nodular pattern of ossified foci in the peripheral interstitium of the lungs, predominantly in the lower lobes [8]. Healed tuberculosis, silicosis and metastatic pulmonary calcification could be excluded because of their upper lobe predominance. Additionally our patient had no known history of previous infection, occupational exposure predisposing to lung disease or history of renal insufficiency. Alveolar microlithiasis is also unlikely because of its more diffuse distribution, the background of ground glass opacities and the typical age of diagnosis between 30 and 50 years. There were no nodular amyloid deposits indicative of amyloidosis [9]. A lung biopsy was not performed in our case because there was no therapeutic consequence involved in this benign entity. Therefore we should keep in mind the possibility of simple calcifications instead of true bone formation.Pulmonary ossification is a rare pathology but should be included in the differential diagnosis of bilateral lower lobe microcalcifications.",
    "differential_diagnosis": "Diffuse, pulmonary, ossification,, nodular, type, Healed, infection, (TB), Varicella, Metastatic, pulmonary, calcification, Occupational, or, inhalational, lung, diseases, Alveolar, microlithiasis, Sequals, of, amyloidosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010260/000001.jpg?itok=fFWprfvP",
            "caption": "The right upper lung field shows a higher translucency than the contralateral side due to emphysema.\nThere are multiple small opacities bilaterally peripheral located with lower lobe predominance additionally to the discrete reticulonodular lung pattern."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010260/000002.jpg?itok=rcZ_Wgvu",
            "caption": "Multiple calcified nodules are noted peripherally (&lt; 1cm) with lower lobe predominance, some clustering in larger nodules. \nDilated pulmonary veins are seen due to pulmonary congestion.\nCentrilobular emphysema in the upper lung regions of both lobes."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010260/000003.jpg?itok=mtmDYWcj",
            "caption": "Images on mediastinal window clearly demonstrate the calcifications in both lungs, predominantly distributed in the periphery of the lower lobes."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Thorax"
    ],
    "imaging_technique": [
      "CT-High Resolution",
      "Conventional radiography"
    ],
    "link": "https://www.eurorad.org/case/10260",
    "time": "13.10.2012"
  },
  "10261": {
    "case_id": 10261,
    "title": "Cough-induced intercostal lung and hepatic herni",
    "section": "Chest imaging",
    "age": "69",
    "gender": "male",
    "diagnosis": "Intercostal lung and hepatic hernia",
    "history": "The patient was referred because of a mass in the right lateral region at thoracic abdominal level, with a 2-month evolution after a bout of coughing. Physical examination revealed a soft, non-reducible and painful mass. The patient had a history of asthma treated with inhaled corticosteroids.",
    "image_finding": "Total bone scintigraphy with MDP-TC99m showed an increase in the compound radius capturing at the level of the right eighth costovertebral joint, ninth and tenth ribs compatible with recent fracture (Figure 1). CT confirmed a defect in the right lower thoracic wall with fracture of the eighth, ninth and tenth ribs, with diastasis of the intercostal space between the eighth and ninth ribs, and projection towards the subcutaneous soft tissue of the lateral basal segment of the right inferior pulmonary lobe and right hepatic lobe (Figure 2). The post-operative chest CT follow-up study showed projection of the right hepatic lobe outside the limits of the abdominal wall (Figure 3).",
    "discussion": "Intercostal hernias are a rare condition [1]. They may be congenital or acquired. The latter occur after a penetrating trauma or surgery, and less frequently spontaneously [2, 3]. However, spontaneous hernias occur in patients with predisposing factors such as chronic obstructive pulmonary disease, asthma treated with steroids and diabetes mellitus [4]. Also, patients with severe chronic cough may develop intercostal muscle tears and even costal fractures [1, 5]. Positive intrathoracic pressure during inspiration, coughing, vomiting and defecation can force the intrathoracic or intraabdominal content to exit through the weakened areas of the thoracic wall [1]. Anatomically, there are two weak sectors on the thoracic wall; an anterior sector, from the costochondral junction to the sternum, due to the absence of the external intercostal muscle; and a posterior sector, from the costal angle to the vertebra because of the absence of the internal intercostal muscle [1]. Spontaneous hernias are more common in the anterior region, since in the posterior region the paravertebral muscles are resistant to herniation. They generally appear as a soft, painful mass, which may increase in size after exertion, coughing, or Valsalva maneuver [4, 6, 7]. Intercostal hernias are at risk of incarceration and strangulation [1, 2]. Regarding imaging studies, both computed tomography and ultrasound may be applied, although the latter cannot exactly determine the hernial content. Computed tomography does not only reveal the hernia and its content, but it also assesses the exact location and size of the costal wall defect, relevant for surgical planning [1, 3]. The radiological presentation of pulmonary intercostal herniation consists of a subcutaneous hyperlucency containing pulmonary vessels, corresponding to a localized collection of air and contrasting with disseminated bubbles as seen in subcutaneous emphysema [3]. However, X-ray studies do not usually provide enough information about the hernia, even though they can provide data over associated injuries; besides, in the intercostal pulmonary hernias, they may fail to show the herniation of lung parenchyma unless it is tangential to the X-ray beam [8, 9]. The treatment is surgical. Regarding the techniques, it is preferable to use mesh after reducing the hernia, since applying sutures near the ribs has been associated to recurrence [1].",
    "differential_diagnosis": "Intercostal, lung, and, hepatic, hernia, post, raumatic, intercostal, lung, hernia, post, traumatic, intercostal, hepatic, hernia",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010261/000003.jpg?itok=Cd6GOKX8",
            "caption": "An increase in radius compound capturing is observed at the level of the eighth right costovertebral joint, and focal area in posterior arch of ninth and tenth right ribs."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010261/000004.jpg?itok=al2lGx8q",
            "caption": "Chest CT shows projection of the lung parenchyma of the right lower lobe towards the soft tissues of the chest wall."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010261/000005.jpg?itok=vphELmiD",
            "caption": "Abdomen CT shows projection towards the subcutaneous cell tissue of the right hepatic lobe."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010261/000011.jpg?itok=_2cVXu9y",
            "caption": "3D Reconstruction."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010261/000012.jpg?itok=YIPbAlJh",
            "caption": "3D Reconstruction."
          },
          {
            "number": "Figure 2e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010261/000013.jpg?itok=UILY0t2W",
            "caption": "3D Reconstruction."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010261/000009.jpg?itok=Q_RerwDe",
            "caption": "Protrusion of the right hepatic lobe is observed."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010261/000010.jpg?itok=wz-3Aq5I",
            "caption": "Protrusion of the right hepatic lobe is observed."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010261/000014.jpg?itok=kmKNaZj_",
            "caption": "3D Reconstruction."
          },
          {
            "number": "Figure 3d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010261/000015.jpg?itok=QZTOMfku",
            "caption": "3D Reconstruction."
          },
          {
            "number": "Figure 3e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010261/000016.jpg?itok=3Id-2Qv_",
            "caption": "3D Reconstruction."
          },
          {
            "number": "Figure 3f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010261/000017.jpg?itok=vW4kp9ax",
            "caption": "3D Reconstruction."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Nuclear medicine",
      "Liver",
      "Lung"
    ],
    "imaging_technique": [
      "Nuclear medicine conventional",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/10261",
    "time": "11.08.2012"
  },
  "10301": {
    "case_id": 10301,
    "title": "Solitary mediastinal pseudo-tumoral mass: an untypical presentation of tuberculosis",
    "section": "Chest imaging",
    "age": "64",
    "gender": "male",
    "diagnosis": "Primary active extra-pulmonary mediastinal tuberculosis.",
    "history": "The patient was referred to our hospital with a 2-week history of lack of appetite, low-grade evening fever, dyspnea and dysphagia for solid food. He reported a persistent cough not accompanied by other manifestations and there was no known contact with tuberculosis patients. The patient's medical history did not include tuberculosis.",
    "image_finding": "A chest radiograph revealed slight widening of mediastinum due to a subcarinal expansive lesion.CT examination demonstrated a solid 7-cm diameter mass in the posterior subcarinal mediastinal compartment, at the carina bifurcation level, with irregular contours and heterogeneous density. The lesion compressed and displaced the medial intrathoracic oesophagus without infiltration. Bilateral pleural effusion was also noted. The imaging findings were suggestive of a benign lesion. The patient underwent a chest MR imaging study that confirmed the existence of the posterior mediastinal mass, at the medial oesophageal level, which was compressing and relatively stenosing the oesophagus.US-endoscopic examination, with conventional linear probe, confirmed the presence of subcarinal mass, without further lesions or mediastinal lymphadenopathy and guided the transmural biopsy for histological characterization.",
    "discussion": "Though mediastinal involvement of tuberculosis is not a rare disease entity, solitary mediastinal pseudotumoral mass with no evidence of tuberculosis elsewhere is unusual. Interaction of the Mycobacterium Tuberculosis with the immune system manifests clinically in two forms, latent infection and active tuberculosis that manifests itself, except in pauci-bacillary forms, and is classified in pulmonary and extrapulmonary forms and primary and secondary forms.The most common extrapulmonary forms are the pleural and lymph nodes, followed by the genitourinary system, and can have variegated manifestations. However, presenting as an isolated mediastinal mass without parenchymal lesion is unusual [1, 2], yet not so unusual in immunocompromised patients [3]. The presence of mediastinal adenopathy causing necrosis and perforation of the adjacent structures can further cause tracheobronchial-esophageal fistulae. Most studies report variations in size and location, and the most common symptoms are chronic and paroxysmal cough, dysphagia, fever and pneumonia [4].In solitary tuberculous mediastinal masses there is loss of typical morphological features of lymphadenopathy and enlarged lymphnodes tend to look like pseudotumoral bodies; the last ones were not so easily diagnosed in the past, while nowadays, thanks to the new more refined imaging methods, these lesions can be more precisely identified [5], even if specific radiological patterns do not exist yet.Chest radiograph was suspicious for a subcarinal expansive lesion. The tuberculin test was non-reactive. Chest CT examination demonstrated a solid 7-cm mass in the posterior subcarinal mediastinal compartment. However, the negative epidemiological history and the absence of tuberculin reaction made diagnosis questionable.Chest MR study confirmed the existence of the mass.US-endoscopic examination, with conventional linear probe, showed the subcarinal mass without further lesions or mediastinal lymphadenopathy. However the definite diagnosis requires histological diagnosis [6]. Transmural biopsy through US endoscopy showed diffuse lymphoid tissue with giant cells necrotising and confluent granulomas, compatible with tuberculosis. Acid fast bacilli by Ziehl-Neelsen staining and cultures were positive for the presence of M. tuberculosis DNA by polymerase chain reaction. The patient responded to antituberculous treatment without complications, drug resistance or side effects with clinical and radiological improvement.In immunocompetent patients, the extrapulmonary forms only occasionally coexist with active pulmonary TB and though presentation as an isolated pseudo tumoral mediastinal mass is rare, even with a negative tuberculin test and without a history of exposure to adults infected with tuberculosis, it is important to suspect this condition in the appropriate clinical setting.",
    "differential_diagnosis": "Primary, active, extra-pulmonary, mediastinal, tuberculosis., Malignant, lymphoma, Metastatic, malignant, tumors, Teratomatous, neoplasms, Sarcoidosis, Thyroid, mass, Granulomatous, disease, Bronchogenic, cysts",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010301/000001.jpg?itok=RH-T5ETy",
            "caption": "These images show a solid inhomogeneous mass in the  posterior subcarinal mediastinal compartment with irregular contours and uneven density. The lesion displaced the medial intrathoracic oesophagus without infiltration."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010301/000002.png?itok=osqTkzy-",
            "caption": "Axial T1 (a); axial T2 GE (b); coronal T2 (c); sagittal T2 (d). These images show the mediastinum mass near to medial oesophageal portion, which was compressed and relatively stenosed and a bilateral pleural effusion."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010301/000003.png?itok=gy9zLTnd",
            "caption": "Axial (a) coronal (b) sagittal (c) T1 3D FAT-weighted images. These images show the existence of the posterior mediastinal mass with a bilateral pleural effusion."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010301/000005.png?itok=ecHWMJAi",
            "caption": "Histological examination: presence of diffuse lymphoid tissue with giant-cells necrotising and confluent granulomas, compatible with extra-pulmonary active tuberculosis."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010301/000006.jpg?itok=y7qf-5JS",
            "caption": "Ultrasound-endoscopic examination  with conventional linear probe (a) confirmed the presence of a subcarinal mass (white arrow) with bilateral pleural effusion (black arrow). Images b and c show the US-guided transmural biopsy."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Mediastinum",
      "Interventional non-vascular"
    ],
    "imaging_technique": [
      "Percutaneous",
      "MR",
      "Ultrasound",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/10301",
    "time": "13.11.2012"
  },
  "10304": {
    "case_id": 10304,
    "title": "Role of computed tomography and virtual tracheo-bronchoscopy in endobronchial tuberculosis",
    "section": "Chest imaging",
    "age": "45",
    "gender": "male",
    "diagnosis": "Endobronchial tuberculosis (EBTB).",
    "history": "A-45-year-old male patient was admitted to our hospital with low back pain and walking difficulties for several months. Clinical history was not suggestive of respiratory disease. Physical examination was unremarkable. Routine laboratory studies including haemoglobin, white blood cell count, erythrocyte sedimentation rate and C-reactive protein were within normal range.",
    "image_finding": "Chest radiograph showed an air-space consolidation in the left middle lung zone withoutassociated pleural effusion (figure 1). Chest computed tomography (CT) confirmed parenchymal consolidation with branching linear structures in the superior segment of the left lower lobe and segmental bronchus wall thickening (figure 2). Multiplanar reconstruction (MPR) integrated with virtual tracheo-bronchoscopy (VTB) (figure 3) demonstrated extended concentric stenosis in the superior branch of the left lower lobe (B6) without extrinsic bronchial compression or obstructive endoluminal mass.Flexible bronchoscopy confirmed narrowing of the lumen of the superior branch of the left lower lobe with swollen mucosa covered diffusely with a whitish cheese-like substance (figure 3).",
    "discussion": "Endobronchial tuberculosis represents the most common cause of inflammatory stricture of the bronchi. Airway involvement in tuberculosis has been reported in 10-20% of all patients with pulmonary tuberculosis [1].The airways can be secondarily involved by the spread of organisms within the airway lumen or along peribronchial lymphatic channels from an area of cavitations or localised tuberculous pneumonia. They can also be involved by extension from adjacent parenchymal infection, lymph node erosion or haematogenous spread [1]. In the presented case the radiographic findings were consistent with pulmonary consolidation. The CT integrated with virtual tracheo-bronchoscopy (VTB), showed bronchial stenosis with peribronchial cuff of soft tissue and concentric wall thickening with adenopathy, probably secondary to neoplastic stenosis, further indicating a fiberoptic bronchoscopy (FBS).In patients with chronic granulomatous disease, smooth narrowing of airways resistant to medical treatment with minimal wall thickening has been observed [1]. The lung parenchyma distal to the bronchial lesion may be involved with segmental atelectasis or consolidation, parenchymal cavities, or round area of low attenuation, suggesting mucoid impaction [1]. Peribronchial lymphnode calcification that either erodes into or causes major distortion of an adjacent bronchus is defined as broncholithiasis. \"Bronchiectasis\" most often consists of traction bronchiectasis together with peribronchial fibrosis. In case of active airways disease, circumferential and predominantly irregular luminal narrowing with wall thickening and contrast enhancement have been described.VTB offers three-dimensional, high-resolution endoluminal images, reveals inaccessible areas, evaluates bronchial stenosis and obstruction caused by both endoluminal pathology (tumour, mucus, foreign bodies) and extraluminal airways compression (anatomical structures, tumour, lymph nodes). VTB helps guiding biopsy and endobronchial treatment planning [2].VTB cannot clearly depict the mucosal surface and distinguish between infiltrating and vegetative lesions because mucus, bronchial secretion and flaked bronchial epithelium may mimic neoplastic lesions [2]. Recent studies have also demonstrated the role of the chest CT for detecting the abnormalities of small- and medium-sized bronchus in patients with active tuberculosis, including wall thickening, bronchial impaction, dilatation, amputated appearance of air column, peribronchial cuff of soft tissue and bronchocavitary fistula [3]. VTB plays an important role in detecting endobronchial tuberculous involvement.",
    "differential_diagnosis": "Endobronchial, tuberculosis, (EBTB)., Primary, endobronchial, lung, cancer, Secondary, endobronchial, metastases, Endobronchial, carcinoid, tumour, Endobronchial, benign, tumour",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010304/000001.png?itok=LxSXKOI8",
            "caption": "Chest radiograph showing air-space consolidation in left middle lung zone."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010304/000002.png?itok=2-QRlVT3",
            "caption": "CT examination showing segmental consolidation in the left lower lobe (a); with peri-bronchial cuff of soft tissue (b); atelectasis due to segmental bronchus obstruction (c)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010304/000003.png?itok=JWWJzLbM",
            "caption": "(a) Bronchoscopy shows  reduction of stenotic bronchus (superior branch of left lower lobe - B6), with its mucosa swollen and covered diffusely with whitish cheeselike substance (arrow) (b). Note correlation with virtual endoscopy images."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/10304",
    "time": "19.09.2012"
  },
  "10311": {
    "case_id": 10311,
    "title": "Ingested nails and stones and oesophageal perforation",
    "section": "Chest imaging",
    "age": "44",
    "gender": "male",
    "diagnosis": "Ingested foreign bodies with oesophagus perforation from impacted stone",
    "history": "The patient presented to emergency with severe pain and oedema of the neck and chest. His family reported that he was being treated for mental disorders for the past 5 years. During objective examination the surgeon found crepitations and pain in palpation. The patient did not report difficulty in breathing.",
    "image_finding": "A CT examination was required to evaluate the neck and the chest.A large number of nails and stones were found along the gastrointestinal tract extending from the stomach to the rectum (fig 1)  A big stone was detected within the pharynx (fig 2a, 2c). Subcutaneous emphysema and pneumomediastinum was also seen (fig 1, 2a, 2b, 2c, 3e). Patient was sent to the operating room immediately.",
    "discussion": "Oesophageal foreign body impaction usually occurs in children, who tend to ingest coins, toys, or other foreign materials. In adults, foreign body impaction in the oesophagus is usually caused by an inadequately chewed bolus of food or bones. Unchewed food tends to lodge in a lower oesophageal ring or stricture, whereas bones tend to lodge in the pharynx near the cricopharyngeus. Most patients with food impaction present with sudden onset of chest pain, odynophagia, or dysphagia. In contrast, young children usually exhibit respiratory distress, drooling, or regurgitation [1].Oesophageal perforation is rare, affecting less than 1% of all patients with foreign body impaction, but the risk of perforation increases significantly if the impaction persists longer than 24 hours. After that, the risk for retropharyngeal abscess highly increases as well. Oesophageal perforation is a catastrophic condition that may rapidly progress to fulminant mediastinitis and septic shock. The initial symptoms and signs include sudden onset of severe retrosternal chest pain, vomiting, and subcutaneous emphysema with crepitus in the soft tissues of the anterior chest wall (mediastinal crunch). In some cases, however, the initial signs and symptoms are nonspecific and may consist of hypotension, sepsis, or fever, falsely suggestive of myocardial infarction, acute aortic dissection, or intraabdominal abnormalities. The prognosis is directly related to the interval between perforation and initiation of therapy; within 24 hours, the mortality rate for thoracic esophageal perforation exceeds 80%.Plain radiography, especially lateral radiographs of the neck, may occasionally demonstrate bones or other radiopaque foreign bodies [1, 2].If we decide to administer oral CM we should always use hydrosoluble non ionic contrast agents to avoid the reaction of barium to the pleura or peritoneum.CT is also useful in evaluating oesophageal foreign body impaction. With its soft tissue and bone windowing, CT may replace the barium swallow because of its superior detection of thin, small, minimally calcified foreign bodies that are often obscured by overlying tissues. CT can also detect inflammatory changes in the adjacent structures. CT features of oesophageal perforation include oesophageal wall thickening, perioesophageal fluid, perioesophageal air, pleural effusion, and pericardial effusion, oesophageal wall laceration, and extravasation of oral contrast material. Pleural effusions are usually bilateral. CT is ideally suited for defining the extent of extraluminal air-fluid collection and for detecting small amounts of extravasated contrast material. In addition, CT may also be useful in monitoring the clinical course of patients treated conservatively [3, 4, 5].",
    "differential_diagnosis": "Ingested, foreign, bodies, with, oesophagus, perforation, from, impacted, stone, Inhaled, foreign, body, Mallory-Weiss, tear, Spontaneous, pneumothorax",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010311/000001.jpg?itok=G7dQEJQ0",
            "caption": "Note the ingested nails and stones and the free air in the soft tissues of the neck and the upper chest."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010311/000002.jpg?itok=KlDqNU4Z",
            "caption": "Note the impacted stone in the pharynx and the free air in neck soft tissues. Trachea appears normal."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010311/000003.jpg?itok=Z247jwpf",
            "caption": "Extensive subcutaneous emphysema is noted."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010311/000004.jpg?itok=1GE7jlv1",
            "caption": "Note the pneumomediastinum in all mediastinal compartments."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010311/000005.jpg?itok=15wbHDr6",
            "caption": "Note the ingested nails and stones"
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010311/000006.jpg?itok=qDM8vlUX",
            "caption": "Rotated volume rendered image."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010311/000007.jpg?itok=h-2zboJv",
            "caption": "MIP 3D"
          },
          {
            "number": "Figure 3d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010311/000008.jpg?itok=CYG07kBx",
            "caption": "Stones and nails in stomach and rectum are seen."
          },
          {
            "number": "Figure 3e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010311/000009.jpg?itok=wcgGpsMH",
            "caption": "Nail in small intestine and subcutaneous emphysema in the soft tissue of the neck and upper thoracic wall."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Emergency"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/10311",
    "time": "30.09.2012"
  },
  "10330": {
    "case_id": 10330,
    "title": "Pulmonary arteriovenous malformations in a patient with hereditary haemorrhagic telangiectasi",
    "section": "Chest imaging",
    "age": "64",
    "gender": "female",
    "diagnosis": "Pulmonary arteriovenous malformations",
    "history": "Patient with a diagnosis of hereditary haemorrhagic telangiectasia was sent to perform thoracic CT angiography for post-intervention control.The patient had previous history of epistaxis and gastrintestinal telangiectasias.",
    "image_finding": "CT angiography of the thorax revealed pulmonary arteriovenous malformation (PAVM) in the posterior segment of the right upper lobe, with the feeding vessels all arising from the upper lobe branch of the right pulmonary artery and draining to the right superior pulmonary vein (figure 1, 2). PAVM embolized with a coil in the right upper lobe is seen, with persistent permeable efferent vessel draining into the right superior pulmonary vein. A PAVM is also detected in the left upper lobe, with the feeding vessels arising from the upper lobe branch of left pulmonary artery and draining to the left superior pulmonary vein (figure 3).",
    "discussion": "PAVM consist of abnormal communications between pulmonary arteries and pulmonary veins via an aneurysmal sac which leads to a right-to-left shunt[1, 2].They occur rarely, are commonly congenital and strongly associated with hereditary haemorrhagic telangiectasia (HHT). HHT diagnosis is based on the Curacao criteria which include epistaxis, multiple telangiectasias, visceral lesions (pulmonary, hepatic, cerebral and spinal AVM, and gastrointestinal telangiectasias) and family history [2, 3].PAVM can be simple, in which single or multiple feeding arteries originate from a single segmental artery, or complex, in which feeding arteries originate from two or more segmental arteries. They can be single or multiple and tend to occur in the lower lobes [1, 2].The resulting right-to-left shunt may lead to hypoxaemia, paradoxical embolism with potential sequelae in the cerebral circulation, or rupture with consequent haemoptysis or haemothorax. Consequently, patients with large (>2 cm) or multiple PAVM present most commonly with dyspnoea, but may also complain of orthodeoxia, clubbing, haemoptysis and chest pain, whereas small malformations can be clinically silent. There is risk for central nervous system complications when feeding vessels are >3 mm [1, 2, 3].CT angiography is the preferred method for detecting PAVM and facilitates planning of transarterial embolisation by providing three-dimensional images. Diagnosis relies on the identification of an afferent artery, an efferent vein and the aneurysmal sac or nidus [2, 4].PAVM can also be identified on plain chest x-ray. Contrast-enhanced MR angiography has shown good results for PAVM more than 3 mm in diameter and is considered in young patients because of concern about radiation exposure [2, 3].Conventional angiography is the reference standard but is mostly used for endovascular treatment. Digital subtraction angiography is also required to assess morphologic features and flow characteristics prior to coil embolisation of larger communications [2, 4].Percutaneous transcatheter embolotherapy with the use of coils is the treatment of choice and is indicated when feeding vessels exceed 3 mm in diameter regardless of symptoms to avoid neurologic complications and pulmonary haemorrhage, or to improve hypoxemia in patients with diffuse malformations. Diffuse lesions may be difficult to treat with endovascular techniques and are referred for lung transplant [1, 3].Follow-up should be done 6-12 months after embolisation and then every 3 years if no new symptomatology arises. Coil recanalisation occurs in 12-15% of cases [3].",
    "differential_diagnosis": "Pulmonary, arteriovenous, malformations, Pulmonary, varices, Vascular, tumour",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010330/000001.jpg?itok=FmXJIbgP",
            "caption": "MIP axial image showing PAVM embolized with coil in the right upper lobe with persistent permeable efferent vessel draining into the right superior pulmonary vein."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010330/000002.jpg?itok=0sFYGS5Z",
            "caption": "MIP axial image showing PAVM with feeding vessels in the posterior segment of right upper lobe."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010330/000003.jpg?itok=bPZopaIG",
            "caption": "MIP coronal image showing PAVM in the posterior segment of right upper lobe.\nPAVM embolized with coil is also present in the right upper lobe with persistent permeable efferent vessel."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010330/000004.jpg?itok=4lkJPLvZ",
            "caption": "MIP sagittal image showing PAVM with feeding vessels in the posterior segment of right upper lobe."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010330/000009.jpg?itok=huqrW_S0",
            "caption": "MIP axial image showing PAVM in the left upper lobe, with the afferent vessels (arrow) arising from the upper lobe branch of left pulmonary artery."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010330/000010.jpg?itok=1MEeOUu3",
            "caption": "MIP coronal image showing PAVM in the left upper lobe, with the afferent vessels (arrow) arising from the upper lobe branch of left pulmonary artery."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010330/000007.jpg?itok=VN1ud6xM",
            "caption": "MIP axial image showing PAVM in the left upper lobe with efferent vessel (arrow) draining to the left superior pulmonary vein."
          },
          {
            "number": "Figure 3d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010330/000008.jpg?itok=gZRlFdLU",
            "caption": "MIP sagital image showing PAVM in the left upper lobe with efferent vessel (arrow) draining to the left superior pulmonary vein."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax",
      "Vascular"
    ],
    "imaging_technique": [
      "CT-Angiography"
    ],
    "link": "https://www.eurorad.org/case/10330",
    "time": "19.10.2012"
  },
  "10416": {
    "case_id": 10416,
    "title": "Addisonian crisis as a presentation of lung carcinom",
    "section": "Chest imaging",
    "age": "51",
    "gender": "male",
    "diagnosis": "Metastatic small cell lung carcinoma with resultant Addisonian crises",
    "history": "A 51-year-old gentleman presented with a two week history of pleuritic chest pain and lethargy, together with sustained weight loss for the last few months. He was found to be severely hypotensive. Biochemical analysis revealed hyperkalaemia and hyponatraemia.",
    "image_finding": "Chest radiograph showed two irregular opacities in the projection of the left hilum and in the right paratracheal location [Fig 1]. In view of the hilum overlay sign, it was deducted that the larger mass was either anterior or posterior to the left hilum \u2013 and therefore in the apical segment of left lower lobe or in the anterior segment of the left upper lobe. CT revealed a mass at the apical segment of left lower lobe, with satellite lesions in other segments of left lower lobe and also in right upper lobe [Fig 2]. Both ventricles were studded with hypovascular masses [Fig 3]. Low volume mediastinal and paraaortic lymphadenopathy was also evident [Fig 4], with a moderate pericardial effusion. Multiple deposits were seen within the adrenal glands [Fig 5], with no residual normal tissue, and also to a lesser extent within both kidneys and pancreas [Fig 6].",
    "discussion": "A) Background:The adrenal gland is a common site of metastasis from primary lung, breast, renal cell carcinomas, melanoma, and lymphoma. In this case the primary was lung carcinoma. Adrenal metastases are generally unilateral. However, bilateral adrenal metastases are seen in 10% of all lung cancer patients. 2\u20133% of adrenal metastases occur at the initial presentation of non-small cell lung cancer [1]. In most cases, adrenal metastases are asymptomatic lesions and incidentally discovered by CT-scan of the upper abdomen during a staging evaluation. Adrenal metastases may be complicated by primary adrenal insufficiency. This results from the destruction of adrenal gland architecture by tumour cells [2].B) Clinical Perspective:Adrenal insufficiency presents with nonspecific clinical features. Patients may complain of vague constitutional symptoms such as generalized weakness, fatigue and weight loss. Furthermore, gastrointestinal symptoms such as anorexia, nausea, vomiting and abdominal pain may be encountered. Many patients may present with hypotension, dehydration, postural hypotension and in case of adrenal crisis, syncope or shock. Laboratory tests often reveal hyponatremia, hyperkalaemia, mild metabolic acidosis, hypoglycemia, anaemia and lymphocytosis [3].This gentleman also had diffuse myocardial metastases at the time of presentation. The most common neoplasms associated with cardiac metastasis are lung cancer, oesophageal cancer, lymphoma, breast cancer, leukaemia, gastric cancer, and melanoma. In cardiac metastasis, the pericardium is the most frequent site of involvement, and patients typically present with clinical symptoms and signs of acute pericarditis. The patient may also present with cardiac tamponade, arrhythmias or myocardial infarction. The myocardium accounts for only approximately 12% of cardiac metastasis in autopsy lung cancer cases [4]. In this case cardiac markers and serial electrocardiograms were normal.C) Imaging Perspective:Adrenal metastases appear as focal masses or distortion of the contour of adrenal gland and may have central necrosis or haemorrhage. These lesions are heterogeneous with thick, enhancing rims and a slow absolute and relative washout of contrast upon further characterisation by delayed scanning on CT. Invasion of surrounding organs may occur [5, 6].D) Outcome:Treatment of adrenal insufficiency comprises daily administration of glucocorticoid and mineralocorticoid for life. In this case imaging helped make the diagnosis and stage extent of disease. Overall such extensive disease lends to a dismal prognosis.E) Take home message, teaching points:Hypotension associated with hyponatraemia and hyperkalaemia with a history of lung carcinoma should alert the physician to the possibility of adrenal metastases and hence the need for further imaging of the abdomen with a CT.",
    "differential_diagnosis": "Metastatic, small, cell, lung, carcinoma, with, resultant, Addisonian, crises, Metastatic, melanoma, Lymphoma, (Ann-Arbor, Stage, IV), Tuberculosis, Sarcoidosis, Amyloidosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010416/000002.jpg?itok=yPg7wX69",
            "caption": "Two irregular opacities are seen on plain radiography: one in the projection of the left hilum, another in a right para-tracheal location."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010416/000003.jpg?itok=vSr9_a-f",
            "caption": "Sagittal reconstructed CT image along a left para-median plane showing a cavitating spiculated lung lesion at the apical segment of the lower lobe of the left lung.  Pronounced cachexia is also evident."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010416/000004.jpg?itok=QvpnzcdL",
            "caption": "Cavitating lesion at the apical segment of the left lower lobe. This lesion is spiculated and extending to the left pulmonary hilum."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010416/000005.jpg?itok=RJtmagXl",
            "caption": "A lesion with similar characteristics is seen at the apical segment of the right lower lobe - this is much smaller."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_video/2018-08/0000010416/000006F.png?itok=-23G1iXM",
            "caption": "Sagittal reconstructed CT in lung window settings showing both lesions."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010416/000007.jpg?itok=QvYFJ1ny",
            "caption": "Diffuse myocardial metastatic deposits which are bulging and studding the contour of the left ventricle. \u00a0An associated small to moderate pericardial effusion measuring up to 1.5 cm thickness is seen."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010416/000008.jpg?itok=iDR3Bi7x",
            "caption": "Diffuse myocardial metastatic deposits which are bulging and studding the contour of the left ventricle.  An associated small to moderate pericardial effusion measuring up to 1.5 cm thickness is seen."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010416/000009.jpg?itok=rEmCrabN",
            "caption": "Diffuse myocardial metastatic deposits which are bulging and studding the contour of the left ventricle.  An associated small to moderate pericardial effusion measuring up to 1.5 cm thickness is seen."
          },
          {
            "number": "Figure 3d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_video/2018-08/0000010416/000017F.png?itok=eeip61Ce",
            "caption": "Diffuse myocardial metastatic deposits which are bulging and studding the contour of the left ventricle. The largest of these deposits measuring 3.2 cm in diameter."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010416/000010.jpg?itok=14AZuyvC",
            "caption": "Both adrenal glands are enlarged (especially the right) and replaced with hypovascular deposits. No residual normal adrenal enhancing tissue is seen."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010416/000011.jpg?itok=JmEgsKuz",
            "caption": "Both adrenal glands are enlarged (especially the right) and replaced with hypovascular deposits. No residual normal adrenal enhancing tissue is seen."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010416/000012.jpg?itok=g3F74fib",
            "caption": "Hypodense deposits were also seen in both kidneys and in the pancreas."
          },
          {
            "number": "Figure 5b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010416/000013.jpg?itok=W3AzXfMo",
            "caption": "Hypodense deposits were also seen in both kidneys and in the pancreas."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010416/000014.jpg?itok=FTCd_AXj",
            "caption": "Pre tracheal and subcarinal mediastinal lymphadenopathy with lymph nodes measuring up to 1.6 cm in short axis."
          },
          {
            "number": "Figure 6b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010416/000015.jpg?itok=eEd76SvV",
            "caption": "Pre tracheal and subcarinal mediastinal lymphadenopathy with lymph nodes measuring up to 1.6 cm in short axis."
          },
          {
            "number": "Figure 6c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010416/000016.jpg?itok=QZi11yBR",
            "caption": "Pre tracheal and subcarinal mediastinal lymphadenopathy with lymph nodes measuring up to 1.6 cm in short axis."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Cardiac",
      "Lymph nodes",
      "Adrenals",
      "Pancreas",
      "Kidney"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/10416",
    "time": "16.12.2012"
  },
  "10439": {
    "case_id": 10439,
    "title": "Pericardial cyst",
    "section": "Chest imaging",
    "age": "40",
    "gender": "male",
    "diagnosis": "Right-sided pleuropericardial cyst.",
    "history": "A 40-year-old male non-smoker came to the pulmonary outpatient department for check-up of lung functions due to occasional problems with breathing and suspicion of asthma. During diagnostic workup a routine chest radiograph showed a round-oval mass obscuring the right cardiophrenic angle.",
    "image_finding": "Chest Radiograph shows a round/ oval mass that obscured the right cardiophrenic angle measuring approximately 5.5 cm in diameter (Figure 1). Contrast enhanced CT of the thorax revealed a thin-walled, sharply defined, oval, homogeneous mass with attenuation near that of water measuring approx 7 x 7 cm in diameter in the right cardiophrenic angle, in the anterior mediastinum (Figure 2-5).",
    "discussion": "BACKGROUND:Pericardial cysts are benign lesions accounting for 5%\u201310% of mediastinal tumours. They are located more frequently in the right cardiophrenic space (77%) than the left (22%) [1, 2].Pericardial cysts generally have a congenital origin and are due to a defect in pericardial development. These cysts are almost always asymptomatic and are detected as an incidental finding on routine plain radiographs [3]. Histologically, these cysts are lined with a single layer of mesothelial cells in a stroma of connective tissue. They contain a clear, water-like fluid, giving rise to the term \u201cspring water cysts.\u201d They vary from 2-15 cm in dimension and are commonly located in the anterior mediastinum at the cardiophrenic angle [4].IMAGING PERSPECTIVE:Chest Radiographs: A mass with well-defined borders occupying the cardiophrenic space is suggestive of pericardial/pleuropericardial cyst [3]. CT Examination: The characteristic CT appearance is a fluid-filled lesion with well-defined borders and smooth walls. Because of its fluid content, the cyst has a characteristic attenuation coefficient of 0\u201320 HU, although in sporadic cases the attenuation can be greater (30 HU) [3]. MR: MRI findings are diagnostic, the fluid content being reflected in pronounced homogeneous high signal intensity on T2-weighted images and low signal intensity on T1-weighted images. The lesions do not show significant enhancement after intravenous contrast material administration [3].DIFFERENTIAL DIAGNOSIS:1. Bronchogenic cyst - Single, smooth, round/elliptic mass with imperceptible wall and uniform attenuation (dependening upon the contents of the cyst and can vary from water attenuation to soft-tissue attenuation. The value can be more than 100 HU owing to high protein level or calcium oxalate in mucoid cyst) [5].2. Hydatid cyst - Calcification of the cyst wall or internal septa is easily detected at CT.3. Thymic cyst - On CT simple congenital, uni-/multilocular, thymic cysts usually appear as well-de\ufb01ned water-attenuation masses with imperceptible walls. 4. Mature cystic teratoma - On CT these tumours are heterogeneous, well-de\ufb01ned masses with walls of variable thickness that may enhance. They may contain all four tissue types, including soft tissue, \ufb02uid, fat, and calcium, but \ufb02uid-containing cystic components are usually prominent [5].5. Lymphangioma - CT shows smooth, lobulated mass, which may mold to or envelop, rather than displace adjacent mediastinal structures. Unilateral/bilateral chylous pleural effusions may be present [5].6. Many tumours can undergo cystic degeneration and demonstrate mixed solid and cystic elements at CT or MR imaging. If degeneration is extensive, CT and gross appearances of the lesion are indistinguishable from congenital cyst [5].",
    "differential_diagnosis": "Right-sided, pleuropericardial, cyst., Bronchogenic, cyst, Hydatid, cyst, Thymic, cyst, Mature, cystic, teratoma/dermoid, cyst, Cystic, lymphangioma, Cystic, degenration, of, anterior, mediastinal, tumours, Peritoneal, fluid, in, a, retrocostoxyphoid, hernia",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010439/000001.jpg?itok=6-rXcVDM",
            "caption": "PA chest radiograph shows a round - oval mass that obscures the right cardiophrenic angle."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010439/000002.jpg?itok=gjyBRvnA",
            "caption": "Chest radiograph - lateral view"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010439/000003.jpg?itok=td53JJ3A",
            "caption": "Contrast enhanced CT on axial plane and in soft window shows a thin-walled, sharply defined, oval, homogeneous mass measuring approx. 7 x 7 cm in diameter in right costophrenic angle."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010439/000004.jpg?itok=8ndqYFVF",
            "caption": "Contrast enhanced CT axial plane in soft window shows a thin-walled, sharply defined, oval, homogeneous mass measuring approx. 7 x 7 cm in diameter in right costophrenic angle. Its attenuation is near that of water."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010439/000005.jpg?itok=f_PWa7iA",
            "caption": "Contrast enhanced CT coronal plane in soft window showing a thin-walled, sharply defined, oval, homogeneous mass at right cardiophrenic angle."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010439/000006.jpg?itok=RD8ev5A6",
            "caption": "Contrast enhanced CT coronal plane in soft window showing a thin-walled, sharply defined, oval, homogeneous mass at right cardiophrenic angle."
          },
          {
            "number": "Figure 4c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010439/000007.jpg?itok=RHnrG_uK",
            "caption": "Contrast enhanced CT coronal plane in soft window showing a thin-walled, sharply defined, oval, homogeneous mass at right cardiophrenic angle."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010439/000008.jpg?itok=LaIiYDAl",
            "caption": "Contrast enhanced CT on sagittal plane in soft window showing a thin-walled, sharply defined, oval, homogeneous mass at right cardiophrenic angle."
          },
          {
            "number": "Figure 5b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010439/000009.jpg?itok=arnTpSu-",
            "caption": "Contrast enhanced CT on sagittal plane in soft window showing a thin-walled, sharply defined, oval, homogeneous mass at right cardiophrenic angle."
          },
          {
            "number": "Figure 5c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010439/000010.jpg?itok=QFDTGtYM",
            "caption": "Contrast enhanced CT on sagittal plane in soft window showing a thin-walled, sharply defined, oval, homogeneous mass at right cardiophrenic angle."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Cardiac",
      "Mediastinum"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/10439",
    "time": "05.12.2012"
  },
  "10474": {
    "case_id": 10474,
    "title": "Accesory cardiac bronchus",
    "section": "Chest imaging",
    "age": "34",
    "gender": "male",
    "diagnosis": "Accesory cardiac bronchus",
    "history": "A 37-year-old man, referred to the hospital complaining for massive haemoptysis for the first time. He was a heavy smoker, in good general condition with no fever at presentation. Laboratory findings were normal.",
    "image_finding": "Plain chest radiograph was normal. Patient underwent chest CT in order to investigate possible underlying pathology. CT revealed minimal emphysematous changes. No mass, air-space consolidation changes or bronchiectasis were noted. There was no mediastinal lymphadenopathy. A short air-filled projection towards the heart was seen originating from the median wall of the right intermediate bronchus, looking just like a bronchus. It presented a blind end with some linear air filled pouches peripherally, that were possibly connected together.The radiological report was \"possible accessory cardiac bronchus\", as it had a characteristic location and morphology and moreover, it could be associated with the patient's symptoms. The patient declined to undergo bronchoscopy, suggested by the clinician for further investigation.",
    "discussion": "An ACB (accessory cardiac bronchus) is \"a supernumerary bronchus arising from the inner wall of the right main or intermediate bronchus, opposite to the origin of the right upper lobe bronchus\" [1]. It is a rare congenital abnormality (incidence ~0, 07% - 0, 5%), thought to occur between the 4th and 6th week of gestation, during the development of the bronchial tree [2].Most cases of ACB are asymptomatic. Occasionally an ACB can result in recurrent infections and/or haemoptysis, even massive. This is especially the case when the ACB is long (>1 cm) or associated with an accessory lobe. In these cases 3D-CT can be of importance in assessing its length. The symptoms can be attributed to anomalous drainage of secretions, inflammation, and hypermicrovascularization [3]. Possible shunt formation between the bronchial and pulmonary arteries has been suggested by Endo Shunshuke et al. A rare case of ACB resulting in middle lobe syndrome has been described by M.K.Daskalakis et al [4].An ACB is generally not visible on chest radiograph. It is almost always an incidental finding on a CT examination of the chest. It appears as a continuation of the lumen of the right main bronchus, projecting medially and directly inferiorly towards the posterior aspect of the heart. Most ACBs have a blind extremity, but anatomic and imaging studies have demonstrated that some develop into a series of small bronchioles, which may end in vestigual or rudimentary bronchiolar parenchymal tissue, cystic degeneration or a ventilated lobulus, demarcated from the right lower lobe by an anomalous fissure [5].The vast majority of ACBs are typical in appearance. Differential diagnosis of atypical cases includes:-Necrotic /cavitating mass, when ACB is associated with collapsed lung parenchyma.-Bronchial diverticula- acquired fistula: histologically ACB is lined by normal bronchial mucosal epithelium and has cartilage within its wall, which distinguishes it from a diverticulum-fistula [5].An ACB is different from the medial basilar segmental bronchus and does not correspond to the proximal migration of this structure, which arises from the right lower lobe bronchus [5].As ACBs are usually asymptomatic, no treatment is required. In rare instances, when recurrent infection can be attributed to a cardiac bronchus, surgical resection can be carried out [2].",
    "differential_diagnosis": "Accesory, cardiac, bronchus, Bronchial, diverticulum, Necrotic-cavitating, mass",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010474/000001.jpg?itok=8ykccPQW",
            "caption": "Orgin of the ACB at the medial wall of the intermediate bronchus."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010474/000002.jpg?itok=pE8-b3fF",
            "caption": "Orgin of the ACB at the medial wall of the intermediate bronchus."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010474/000004.jpg?itok=f9iUPqeu",
            "caption": "Orgin of the ACB at the medial wall of the intermediate bronchus."
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010474/000007.jpg?itok=VcLypH1S",
            "caption": "Orgin of the ACB at the medial wall of the intermediate bronchus."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010474/000008.jpg?itok=pMF0YtOp",
            "caption": "Origin of the ACB at the medial wall of the intermediate bronchus towards the heart."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010474/000009.jpg?itok=b6n-1ce0",
            "caption": "Origin of the ACB at the medial wall of the intermediate bronchus towards the heart."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010474/000010.jpg?itok=UrapyfhL",
            "caption": "Origin of the ACB at the medial wall of the intermediate bronchus towards the heart."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010474/000011.jpg?itok=pp6Wo8oO",
            "caption": "Origin of the ACB at the medial wall of the intermediate bronchus towards the heart."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/10474",
    "time": "04.12.2012"
  },
  "10483": {
    "case_id": 10483,
    "title": "Cryptogenic organising pneumoni",
    "section": "Chest imaging",
    "age": "64",
    "gender": "female",
    "diagnosis": "Cryptogenic organising pneumonia",
    "history": "Patient with one month history of fever, cough and dyspnoea, who had undergone several courses of different antibiotherapy agents without response. Physical examination showed hypoxaemia and focal sparse crackles in the base of the left lung. Laboratory showed leukocytosis, neutrophilia and elevated levels of C-reactive protein.",
    "image_finding": "Chest radiograph shows bilateral patchy consolidations (Figure 1a).High-resolution CT of the thorax showed several areas of peripheral and peribronchovascular consolidation, with air bronchograms, sparing the subpleural space, predominantly involving the middle and lower lobes bilaterally, but also the upper lobes (Figure b-e). There is also ectasia and thickening of the bronchial walls. There are areas of ground glass opacities around the areas of parenchymal consolidation (Figure b-e). Serial radiographic and clinical features were consistent with organizing pneumonia and corticosteroid treatment was initiated. Our patient showed rapid improvement after starting corticotherapy, with apirexia in the same day. She underwent 6 months of treatment without symptoms (Figure 2). When the dose of corticosteroids was progressively reduced, a relapse occurred (Figure 3) and a new course of treatment was performed (Figure 4). She had no cause known to induce secondary organizing pneumonia.",
    "discussion": "Cryptogenic organizing pneumonia (COP) is an idiopathic interstitial pneumonia with characteristic clinical and radiologic features. Some diseases (collagen vascular diseases, infections, malignancies) and drug reactions may induce similar findings (secondary organizing pneumonia (OP) [1-4]. OP is considered a non-specific response to lung injury. Histopathologically there is patchy distribution of intra-alveolar buds of granulation tissue, mild interstitial chronic inflammation, with preserved lung architecture [1-3, 5]. Mean age at onset is 55 years, there is no association with gender or cigarette smoking. Symptoms are nonspecific (cough, mild dyspnea, fever, flulike illness) with few weeks of evolution. Patients typically report a respiratory tract infection preceding their symptoms, and previous antibiotic treatments that fail [1-6]. High-resolution CT is indicated in virtually all patients suspected to have idiopathic interstitial pneumonias.Typical imaging features of COP consist of bilateral patchy areas of air-space consolidation, with or without ground-glass opacities, with a tendency to progress, change location over time or regress spontaneously. The distribution is predominantly peripheral and inferior. Air bronchograms and bronchial dilatation may be present in consolidated areas [7]. Less common imaging features need to be recognized so that the diagnosis will not be overlooked. These include focal organizing pneumonia that may resemble lung cancer, nodular patterns, bronchocentric distribution, linear and band-like opacities forming arcades, perilobular pattern, and a progressive, irreversible fibrotic form [7].The diagnosis should be confirmed with biopsy. However, when serial radiographic and clinical features are sufficiently characteristic, biopsy confirmation may be obviated [7] and corticosteroid treatment started. Rapid improvement reinforces the probability of COP. The final diagnosis is of exclusion of other causes of organizing pneumonia [1-5]. Patients show excellent response to corticosteroids with rapid clinical and imaging improvement. Patients recover without significant sequelae, however relapses are common within 3 months after stopping or reduction of corticosteroids, often leading to prolonged treatment [1, 3, 5]. The prognosis is good, as relapses do not appear to be associated with increased mortality or long-term morbidity. However, patients that show the progressive fibrotic pattern have a poorer prognosis [5, 7].",
    "differential_diagnosis": "Cryptogenic, organising, pneumonia, Bronchioloalveolar, carcinoma, Lymphoma, Vasculitis, Sarcoidosis, Infection, Chronic, eosinophilic, pneumonia, Pulmonary, haemorrhage",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010483/000001.jpg?itok=JLHUDz4V",
            "caption": "Chest radiograph at presentation shows bilateral patchy consolidations that resemble pneumonic infiltrates."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010483/000002.jpg?itok=tRzICPzo",
            "caption": "Area of consolidation with peripheral and peribronchovascular distribution, with air bronchograms, sparing the subpleural space."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010483/000003.jpg?itok=SxR0eZC_",
            "caption": "At a level below, another area of consolidation with peripheral and peribronchovascular distribution, with air bronchograms, sparing the subpleural space."
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010483/000004.jpg?itok=lmbzuhmb",
            "caption": "At the level of lung bases, another area of consolidation with peripheral and peribronchovascular distribution, with air bronchograms."
          },
          {
            "number": "Figure 1e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010483/000005.jpg?itok=Nad6P495",
            "caption": "Coronal view shows the bilateral distribution of the consolidations, predominantly involving the middle and lower lobes, but also the upper lobes. There are areas of ground glass opacities around the areas of parenchymal consolidation."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010483/000006.jpg?itok=97Bppt0D",
            "caption": "After first remission, there is marked improvement of the consolidations areas, as well as symptoms."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010483/000007.jpg?itok=bvTm-Xzn",
            "caption": "Two months later, the disease has recurred, with consolidations in a different distribution."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010483/000008.jpg?itok=7TwN0HWn",
            "caption": "After second course of corticosteroid therapy, there is marked improvement in the areas of consolidation and ground-glass opacities.\nA small focal opacity is seen."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010483/000009.jpg?itok=W3igkewr",
            "caption": "After second course of corticosteroid therapy, there is marked improvement. A band-like crescentic area of consolidation forming an arcade is seen associated with a discrete area of ground-glass opacity."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT-High Resolution",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/10483",
    "time": "23.02.2013"
  },
  "10494": {
    "case_id": 10494,
    "title": "Lung torsion after lobectomy",
    "section": "Chest imaging",
    "age": "67",
    "gender": "female",
    "diagnosis": "Left upper lobe torsion after left lower lobectomy",
    "history": "A 67-year-old female patient with left lower lobe lung cancer underwent lobectomy. The initial post-surgical chest radiograph was unremarkable. 12 hours post extubation she developed hypoxaemia and haemoptysis. Chest radiograph was initially performed, followed by MDCT to confirm the diagnosis.",
    "image_finding": "The initial routine AP chest radiograph showed post-surgical changes in the left lung.After 12 hours, the follow-up chest radiograph revealed unexpected near complete opacification of the left hemithorax and fluid collection (Figure 1). MDCT revealed extensive consolidation and peripheral interlobular smooth septal thickening, thus creating a crazy-paving pattern, with no parenchymal enhancement (Figures 2a, b). Enlargement of the left upper lobe (LUL) and clockwise rotation around its axis was noted (Figure 2c). There was cut-off of the left main pulmonary artery at the level of the hilum with intense enhancement of the bronchial artery (Figure 2d). Thick slab MIP demonstrated complete loss of pulmonary vasculature as opposed to the right lung (Figure 2d). Occlusion of the left mainstem bronchus was also present, better delineated in MinIP post-processing images (Figure 2e). Virtual bronchoscopy revealed the orifice mismatch between the left and right mainstem bronchus (fish-mouth bronchus) (Figure 2f).",
    "discussion": "Lung torsion is defined as the rotation of a lobe (or the complete lung) around its hilar axis. The rotational threshold for complete and incomplete torsion is 180o [1]. Predisposing conditions for torsion are a mobile lobe or lung, either due to iatrogenic causes (lobectomy, transplantation) (Figure 3) or spontaneously (anatomic variations, extrapulmonary pathology such as pleural effusion) and traumatic. Rare causes for torsion have been described (i.e. extralobar sequestration torsion) [12]. The torsive lung creates a trifold compromise in airways, arterial blood supply and the venous-lymphatic drainage [2] due to lumen kinking.The incidence of lung torsion is low (0.09-0.4%) [3], however, it is an important post-operative consideration not least because of its rather non-specific clinical presentation. A high index of clinical suspicion is required and imaging is the next step towards a definite diagnosis. Prompt treatment with thoracotomy and detorsion is essential for lobe salvage. Key radiographic findings consist of inappropriate hilar displacement, rapid opacification of ipsilateral lobe following trauma/surgery, marked change in position of opacified lobe on sequential radiographs, unusual position of a collapsed lobe, a reticular pattern from venous congestion and larger residual lung volume than expected from compensatory postoperative emphysema alone [4, 5].CT findings include consolidation, smooth interlobular septal thickening and ground glass opacity due to venous congestion, loss of parenchymal enhancement after CM administration, perihilar bronchial distortion or obstruction and alteration of normal relationship between vessels [2, 6, 7].Bronchoscopy and conventional angiography have been traditionally used for definitive diagnosis in ambiguous cases. However, MDCT with image postprocessing (MIP, minIP, Virtual Bronchscopy) produces excellent angiographic and bronchoscopic views respectively, thus streamlining the diagnostic algorithm [8].Once diagnosed, lung torsion is a medical emergency. The optimal therapeutic approach remains controversial [8]. The decision for detorsion or lobectomy usually depends on the viability of the torsive lung which is better appreciated after open thoracotomy. Detorsion offers lung salvage but if inappropriate, it may lead to rethoracotomy and lobectomy. Furthermore, detorsion is more often associated with vascular complications (arterial embolism) and grave outcome [9]. Apart from early diagnosis, imaging is useful in differentiating other early or late post lobectomy complications (pneumonia, vascular occlusion etc.) [3, 10, 11] which may have similar clinical presentation.Lung torsion, although a rare postoperative complication, should not be neglected in the diagnostic algorithm. Radiography may indicate torsion but CT with imaging postprocessing offers definitive diagnosis and prompt treatment, contributing to better overall prognosis.",
    "differential_diagnosis": "Left, upper, lobe, torsion, after, left, lower, lobectomy, Pneumonia, Pulmonary, oedema, ARDS",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010494/000001.png?itok=ZxU4l7v2",
            "caption": "Initial post-operative AP chest radiograph. The residual left upper lobe is well-aerated."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010494/000002.png?itok=nJhL8u0N",
            "caption": "Repeat post-operative AP chest radiograph after 12 hours.\nNear complete opacification of left hemithorax."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010494/000015.png?itok=sqVCcnnG",
            "caption": "Schematic representation of the post-lobectomy rotational mechanism (sagittal plane): (a) pre-lobectomy, (b) post-lobectomy and loss of LUL fixation (c) clockwise rotation, (d) enlargment due to venous congestion and final LUL reposition."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010494/000016.png?itok=IZVKkP7p",
            "caption": "Post-operative axial NECT(a), CECT(c-d) and lung windows images at the aortopulmonary window. \nThere is extensive consolidation, peripheral interlobular septal thickening and enlargment of LUL. There is also loss of parenchymal enhancement(c+d)."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010494/000017.png?itok=WNv8_qmY",
            "caption": "Axial CT images at the level of confluence of the lower  pulmonary veins, showing again parenchymal LUL changes and loss of parenchymal enhancement (c+d). Post operative findings include small pneumothorax and metallic staples."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010494/000018.png?itok=pP8ys0AU",
            "caption": "Sagittal reconstruction of the left hemithorax. LUL is enlarged, occupying almost the complete hemicavity and is rotated around its hilar axis in an anterio-posterior fashion. Parenchymal and post-operative changes are also present."
          },
          {
            "number": "Figure 3d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010494/000022.png?itok=G3d-rBhq",
            "caption": "Coronal midlung MIP reconstruction in arterial phase, demonstrating abrupt cut-off of the left main pulmonary artery (arrow) and loss of pulmonary vasculature in the LUL. The right lung has normal appearance."
          },
          {
            "number": "Figure 3e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010494/000019.png?itok=4TF1dRj9",
            "caption": "Coronal midlung MinIP reconstruction shows the left mainstem bronchus cut off and absence of ventilation due to LUL torsion and lumen kinking. A small pneumothorax is present."
          },
          {
            "number": "Figure 3f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010494/000021.png?itok=Pa5OjO9q",
            "caption": "3D reconstruction (Virtual Bronchoscopy) at the carina level. The orifice of the left mainstem bronchus is occluded and the lumen not visualised. Normal appearance of the right mainstem bronchus and bronchus intermedius."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Respiratory system"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/10494",
    "time": "16.03.2013"
  },
  "10496": {
    "case_id": 10496,
    "title": "lastofibroma dorsi (ECR 2012 Case of the Day)",
    "section": "Chest imaging",
    "age": "65",
    "gender": "male",
    "diagnosis": "Elastofibroma dorsi",
    "history": "A 65-year-old engineer with no significant medical history presented with a right subscapular mass of approximately 4 months duration. He denied debilitating pain, recent trauma, or weight loss. Clinical examination showed a firm swelling in the right infrascapular region which was fixed to the rib cage. Laboratory findings were unremarkable.",
    "image_finding": "Unenhanced axial transverse CT images of the lower thorax (Fig. 1 and 2). There is a semilunar-shaped mass of soft tissue density, with attenuation similar to that of surrounding skeletal muscle, abutting two right-sided ribs. The serratus anterior muscle is seen anterolateral to the mass and the tip of the scapula is posterolateral to it.T1-weighted (Fig. 3) and T2-weighted (Fig. 4) axial transverse MR images. There is a soft tissue mass located in the right subinfrascapular space, with signal intensity similar to skeletal muscle on both T1 and T2-weighted sequences.Gadolinium-enhanced T1- weighted axial transverse MR image with fat saturation technique (Fig. 5). There is mild enhancement of the most superficial part of the lesion following gadolinium injection.",
    "discussion": "Background: Elastofibroma dorsi (ED) is a benign lesion of the chest wall. It is regarded as a pseudotumour resulting from the chronic mechanical friction between the tip of the scapula and the chest wall, which accounts for its typical location. It is postulated that repetitive microtrauma caused by friction may cause reactive hyperproliferation of fibroelastic tissue. EDs are diagnosed almost exclusively in persons over the age of 40, with an overall mean age of 62 years at diagnosis. A familial predisposition with an underlying enzymatic defect may exist in 30% of the cases [1].Clinical Perspective: The majority of EDs are small and clinically silent; therefore they are often incidentally discovered on imaging. Swelling, discomfort, snapping of the scapula, and occasionally pain may be observed.Imaging Perspective: Key imaging findings include a semilunar-shape, an infrascapular location and attenuation, signal intensity or echogenicity similar to that of skeletal muscles [2].MRI is the most reliable non-invasive technique for diagnosis: the signal intensity is mostly low, comparable to that of muscle, and the margins are well defined. Interspersed adipose strands result in linear areas of higher signal intensity, disappearing with fat saturation techniques. EDs have been shown to have variable enhancement on MRI, which may reflect increased vascularity of the lesion [3]. The masses may also demonstrate low-grade diffuse F-18 FDG uptake on PET CT imaging, which can be misleading in oncologic patients [4].Outcome: In incidentally discovered asymptomatic cases, the pathognomonic imaging features may obviate the need for further intervention. In case of atypical MRI features, biopsy or surgical resection are indicated. Surgery is curative in symptomatic patients [5].Take Home Message/Teaching Points: Radiologists should be aware of this relatively common chest wall pseudotumour that may be seen on thoracic CT or PET CT performed for various reasons. The typical semilunar shape, well-defined margins, attenuation similar to skeletal muscle and infrascapular location are pathognomonic of ED.",
    "differential_diagnosis": "Elastofibroma, dorsi, Liposarcoma, Aggressive, fibromatosis, Lipoma, Chest, wall, metastasis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010496/000001.jpg?itok=qSmjrKso",
            "caption": "Semilunar-shaped mass of soft tissue density, with attenuation similar to that of surrounding skeletal muscle, abutting two right-sided ribs."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010496/000002.jpg?itok=uW4q3Yp-",
            "caption": "The serratus anterior muscle is seen anterolateral to the mass and the tip of the scapula is posterolateral to it."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010496/000003.jpg?itok=qwXVHwLM",
            "caption": "Soft tissue mass located in the right subinfrascapular space, with signal intensity similar to skeletal muscle on  T1-weighted sequence."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010496/000004.jpg?itok=jhyVNfsD",
            "caption": "Soft tissue mass located in the right subinfrascapular space, with signal intensity similar to skeletal muscle on  T2-weighted sequence."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010496/000005.jpg?itok=spac2t05",
            "caption": "Mild enhancement of the most superficial part of the lesion following gadolinium injection."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thoracic wall",
      "Thorax"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/10496",
    "time": "15.11.2012"
  },
  "10507": {
    "case_id": 10507,
    "title": "Pericardial lipom",
    "section": "Chest imaging",
    "age": "55",
    "gender": "male",
    "diagnosis": "Pericardial lipoma",
    "history": "An otherwise healthy patient presented with macroscopic haematuria. A renal tumour was suspected and the patient was referred to the urology department.",
    "image_finding": "Contrast-enhanced CT of thorax and abdomen was performed. A small tumour was seen in the cortex of the left kidney (Figure 1). The morphology of the tumour was suggestive of renal cell carcinoma. There was no involvement of the renal vein. No liver or lung metastases were detected. As an incidental finding a fat containing non-enhancing process (negative HU-values) was seen adjacent to the right and left atria (Figure 2a-c). The lesion was well-marginated without any solid components. There was no sign of tumour invasion into the atria. However, the lesion compressed the right atrium and was thought to represent a lipoma arising within the pericardial cavity.",
    "discussion": "Primary tumours of the heart and pericardium are rare. Lipomas account for 10% of primary cardiac tumours [1]. Pericardial lipomas usually remain asymptomatic. Most are detected incidentally during autopsies or imaging procedures [2]. Very large pericardial lipomas can cause cardiac symptoms, owing to the space-occupying effect of the tumour within the pericardium [3]. Symptomatic pericardial lipomas should be resected. Different imaging modalities such as CT, MRI and echocardiography can detect pericardial lipomas [1, 4]. On CT and MRI lipomas present as well-marginated lesions containing fat, as was seen in the present case. If solid areas are present inside the fatty lesion, malignant transformation should be ruled out.Pericardial tumours may complicate coronary bypass surgery [4]. It is therefore important to report these benign lesions.",
    "differential_diagnosis": "Pericardial, lipoma, Pericardial, effuison, Liposarcoma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010507/000001.jpg?itok=DAg7thk4",
            "caption": "Contrast-enhanced CT of the upper abdomen shows a small tumour in the left kidney."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010507/000002.jpg?itok=TKb4qyxy",
            "caption": "Axial contrast-enhanced CT showing a low density mass adjacent to the atria."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010507/000003.jpg?itok=Q9WN3Wgd",
            "caption": "Axial contrast-enhanced CT showing low density mass adjacent to the right and left atria. There is compression of the right atrium."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010507/000006.jpg?itok=uUm5DeG0",
            "caption": "Coronal contrast-enhanced CT showing the low density mass compressing the right atrium."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Kidney",
      "Thorax"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/10507",
    "time": "16.12.2012"
  },
  "10508": {
    "case_id": 10508,
    "title": "Behcet\u2019s disease (ECR 2012 Case of the Day)",
    "section": "Chest imaging",
    "age": "16",
    "gender": "male",
    "diagnosis": "Vasculitis - Behcet\u2019s disease",
    "history": "A 16-year-old Caucasian boy was admitted to hospital with haemoptysis. He had experienced several episodes of non-severe haemoptysis over a one month period. Physical examination revealed ulcers on the buccal mucosa; ulcerated lesions on the scrotum and arthritis in the left knee were also noted.",
    "image_finding": "Chest X-ray (Fig. 1) revealed bilateral hilar enlargement. Dilatation of the right and left pulmonary arteries was suspected.MDCT imaging of the thorax (Figs. 2, 3 and 4) with administration of iodinated contrast medium was performed.",
    "discussion": "Beh\u00e7et disease (BD) is a rare multisystemic, chronic inflammatory disorder with an unknown aetiology. It is suggested that there may be a genetic predisposition (human leukocyte antigen [HLA], HLA-B51) and that certain microorganisms may play a role. It is most frequently seen in the third decade of life and is more common in men. BD is most frequently seen in Mediterranean, Middle East, and Far East countries [1]. Recurrent oral and genital ulcers and uveitis are the clinical triad of the disease. BD can involve blood vessels of all sizes. Venous involvement is more frequent than arterial involvement, and accounts for over 85% of vascular involvement [2]. Arterial involvement is rare and accounts for less than 15% of vascular involvement. Arterial manifestations of the disease involve aneurysm formation (65%) and occlusions (35%) [1]. The most common cause of pulmonary artery aneurysm is BD [3]. Aneurysms can be seen in the main pulmonary arteries or their branches and are a characteristic CT finding. Patients with pulmonary aneurysms are known to have a poor prognosis [3].BD appears to target certain organs and tissues: the eyes, mouth, skin, lungs, joints, brain and gastrointestinal tract. Ulceration similar to recurrent aphthous stomatitis occurs in all patients diagnosed with BD. Oral ulceration is the initial clinical feature of up to 86.5% of patients with BD. Genital ulcers initially manifest as papules or pustules that later ulcerate. Ocular manifestations include uveitis, bilateral swelling of the optic nerve, retinal vasculitis, and bilateral lamellar macular hole. Ocular disease in 43% to 65% of patients [4]. Neurological complications involve the central nervous system (CNS). CNS disease is a serious complication of BD and may manifest as pseudotumour cerebri, brain-stem involvement, neuropsychiatric symptoms, and meningo-encephalitis [5]. In patients with BD, aneurysms of the thoracic aorta, pulmonary arteries or mediastinal veins can be seen as hilar or mediastinal enlargements on plain chest radiographs. Pulmonary parenchymal involvement may appear as nonspecific focal opacities on plain radiographs. MDCT with contrast enhancement is method of choice in workup of BD and can demonstrate vascular, mediastinal, pulmonary parenchymal and pleural findings suggestive of the disease very effectively.In our patient, on the basis of cutaneous manifestations, laboratory findings, positive pathergy test and the presence of aneurysms of the pulmonary artery, a diagnosis of BD was suspected. The patient was treated with immunosuppressive therapy. Five months later the patient underwent a follow-up contanst-enchanced MDCT of thorax which revealed normal pulmonary arteries.",
    "differential_diagnosis": "Vasculitis, -, Behcet\u2019s, disease, Vasculitis, -, Behcet\u2019s, disease, Primary, pulmonary, arterial, hypertension, Mycotic, pulmonary, aneurysms, and, pseudoaneurysms, Disseminated, malignancy, Tuberculosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010508/000001.jpg?itok=PMyFIK8n",
            "caption": "Plain Chest radiography shows bilateral parahilar opacification, dilatation of right and left pulmonary artery suspected."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010508/000002.jpg?itok=E9Kxg89l",
            "caption": "Axial CT image shows left pulmonary artery aneurism with thickened wall."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010508/000003.jpg?itok=uYHlVtmg",
            "caption": "Axial CT image demonstrates large pulmonary artery aneurysm with thrombus inside."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010508/000004.jpg?itok=SXRe_kHW",
            "caption": "MRP MIP reconstruction depicting right and left pulmonary artery aneurysms, right aneurism contains thrombus."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Vascular"
    ],
    "imaging_technique": [
      "CT-Angiography"
    ],
    "link": "https://www.eurorad.org/case/10508",
    "time": "14.11.2012"
  },
  "10514": {
    "case_id": 10514,
    "title": "Melanocytic schwannoma of the phrenic nerve",
    "section": "Chest imaging",
    "age": "49",
    "gender": "female",
    "diagnosis": "Melanocytic schwannoma of the phrenic nerve",
    "history": "A non-smoking 49-year-old woman with no relevant medical history presented with lower left chest pain for 6 months and dry cough. On clinical examination, left basal hypoventilation was noted. Laboratory findings were normal.",
    "image_finding": "Chest radiograph showed a left basal thoracic opacity with a broad pleural base suggesting a mass of pleural origin versus pleural effusion (Fig. 1). Computed tomography (CT) showed a heterogeneous soft tissue lesion measuring 20 cm in the axial plane, involving the left basal pleura and extending into the oblique fissure with central calcifications and multiple fluid-density loculated cavities (Fig. 2). Positron emission tomography-CT (PET-CT) showed a hypermetabolic mass adjacent to the left lower lobe (standardized uptake value max. 14) (Fig 3). No malignant cells were found on bronchoscopy.",
    "discussion": "Surgical excision with tumourectomy was performed in our patient. A voluminous mass adjacent to the left diaphragm was confirmed, with involvement of the phrenic nerve (sacrificed during surgery) and the diaphragm itself. The definitive histology showed a melanocytic schwannoma with positive S100 protein marker (Fig. 4).Intrathoracic neurogenic tumours are common but most often affect the intercostal nerves or the sympathetic chain. Their most common location is the posterior mediastinum. The phrenic nerve is not a frequent location with only 3 cases reported in the literature [1].Tumours arising from nerve sheaths (schwannomas, neurofibromas, and malignant peripheral nerve sheath tumours- MPNST) are differentiated from those arising from nerve cells - neuromas [1]. Schwannomas are benign nerve tumours composed of Schwann cells. Melanocytic schwannoma, however, is a rare and potentially malignant neoplasm. This tumour contains epithelioid cells with increased melanin content [2]. Apart from the presence of melanin, it has other unusual characteristics that distinguish it from schwannoma which include also psammoma bodies [3] or positive S100 protein marker as in our case. Pathologically, one important differential diagnosis of melanocytic schwannoma would be metastatic or primary melanoma. Melanocytic schwannoma shows considerably less cytologic pleomorphism and mitoses than one would expect in melanoma.The clinical presentation of melanocytic schwannoma is not specific and depends on its location. Patients with thoracic involvement, like in our case, may present with cough, hoarseness, weight loss, and less commonly with diaphragmatic paralysis or diaphragmatic eventration.On imaging studies, schwannomas appear usually as homogeneous and well-circumscribed lesions of soft-tissue density on non-enhanced CT [4, 5]. After contrast administration, the enhancement is variable and can be either homogeneous or heterogeneous, especially in larger lesions with zones of necrosis. Imaging modalities such as CT or MRI are inevitable to define the exact location of the lesion and to exclude a vascular origin [6]. Nevertheless, histology remains the gold standard for final diagnosis and allows exclusion of malignant lesions. The prognosis of melanocytic schwannoma implicates long-term follow-up, even after radical excision. The tumour can be aggressive with local recurrences occurring years after surgery. There is also a potential of malignant degeneration [7].The take home message is that despite neurogenic tumours being frequent paraspinal lesions, they may appear in unusual locations outside of the posterior mediastinum and mimic other lesions. The particular case of melanocytic schwannoma underlies the importance of histological analysis in the final diagnosis.",
    "differential_diagnosis": "Melanocytic, schwannoma, of, the, phrenic, nerve, Localized, fibrous, tumour, of, the, pleura, Metastasis, Lymphoma, MPNST, (malignant, peripheral, nerve, sheath, tumour), Neurofibroma, Schwannoma, Sarcoma, Melanoma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010514/000001.jpg?itok=-KrzkFeX",
            "caption": "Left basal thoracic opacity with a broad pleural base suggesting a mass of pleural origin or pleural effusion."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010514/000002.jpg?itok=rGiPvB1w",
            "caption": "Heterogeneous soft tissue density lesion at the left lung base involving the basal pleura with central calcifications and multiple fluid-density cavities."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010514/000003.jpg?itok=zwxmi5xD",
            "caption": "The lesion is extending into the oblique fissure."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010514/000004.jpg?itok=j2MCcQwl",
            "caption": "Hypermetabolic mass adjacent to the left lower lobe."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010514/000005.jpg?itok=FVoaxWIM",
            "caption": "Macroscopic aspect of one fragment of the lesion after fixation."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010514/000006.jpg?itok=RF07mbyq",
            "caption": "Tumour cells showing nuclei and lighter colored nucleoli."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "PET-CT",
      "Experimental",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/10514",
    "time": "03.12.2012"
  },
  "10515": {
    "case_id": 10515,
    "title": "Mucous plugging - findings on chest X-ray",
    "section": "Chest imaging",
    "age": "56",
    "gender": "female",
    "diagnosis": "Episodes of mucous plugging in advanced multiple sclerosis.",
    "history": "A 56-year-old lady with advanced multiple sclerosis was admitted with shortness of breath and pyrexia. Chest radiograph on admission showed left basal consolidation and she was commenced on treatment for aspiration pneumonia. The patient initially improved on antibiotics.",
    "image_finding": "Chest radiograph 1: Taken after an acute deterioration. On examination, there was reduced air entry to the entire right lung, oxygen saturation 66% on air, pO2 3.63. Chest radiograph shows dense right sided consolidation, right lower lobe and right middle lobe collapse.Chest radiograph 2: Taken only two days after chest radiograph 1. Shows complete resolution of previous right sided changes but now complete opacification of the left hemithorax. Nasogastric tube confirms correct labelling with left side marker.Chest radiograph 3: Taken seven days after chest radiograph 1. Shows marked resolution of previous changes. Lungs clear.",
    "discussion": "Background:Multiple sclerosis (MS) is a demyelinating disease of the central nervous system. It most commonly presents between the ages of 15 and 45 years and is more common in women [1]. It takes a highly variable relapsing-remitting course and there is currently no known cure. Treatment is aimed at modifying disease activity- to reduce the frequency and severity of attacks [2].Clinical Perspective: Respiratory complications are common in the advanced stages of MS and are one of the most common causes of mortality [3]. Weakness of the bulbar muscles results in difficulty swallowing, and respiratory muscle weakness leads to ineffective coughing and accumulation of airway secretions. The risk of aspiration pneumonia and airway obstruction by build-up of mucous is therefore greatly increased in these patients [4].Imaging Perspective:Mucous plugging can cause sudden blockage of the main bronchi leading to atelectasis and dramatic radiographic changes [5]. As illustrated by this case, these changes can also resolve rapidly once the blockage has been cleared.Outcome: Management of respiratory dysfunction in MS requires a multidisciplinary approach. Medication such as anticholinergics may help reduce the production of saliva and the risk of aspiration [6]. Speech and language therapists and dieticians may help with nutritional requirements but eventually nasogastric or PEG feeding may be needed to prevent aspiration. Chest physiotherapy is essential to prevent build-up of airway secretions and prevent mucous plugging [7]. Persistent mucous plugs may need removal with bronchoscopy [5].Teaching Points:The dramatic chest radiographic findings presented in this case are characteristic appearances of major airway obstruction resulting from mucous plugging.",
    "differential_diagnosis": "Episodes, of, mucous, plugging, in, advanced, multiple, sclerosis., Cystic, fibrosis, Asthma, COPD",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010515/000001.jpg?itok=o0a6sV0s",
            "caption": "Taken after a sudden deterioration. Patient was acutely breathless with oxygen saturations of 66% and reduced air entry to the entire right lung."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010515/000002.jpg?itok=p0FbjJDp",
            "caption": "Taken two days after chest radiograph 1. Complete opacification of left hemithorax is noted."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010515/000003.jpg?itok=0Q14CTEp",
            "caption": "Taken seven days after Chest radiograph 1. Marked resolution is seen."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/10515",
    "time": "09.01.2013"
  },
  "10520": {
    "case_id": 10520,
    "title": "The presentation of a possible effect induced by human contact with a source of  high voltage electrical current",
    "section": "Chest imaging",
    "age": "42",
    "gender": "male",
    "diagnosis": "Lesions by passage of electric current at high voltage.",
    "history": "The patient was admitted to the emergency unit of our hospital. He had touched, during his work activity, a wire of high voltage electricity. After initial loss of consciousness, the patient became alert and called rescue. At the first examination he had a Glasgow Coma Scale (GCS) score of 14.",
    "image_finding": "The patient was admitted at our emergency unit as \"red code\". The \"trauma team\" was immediately activated and an abdominal Ultrasound (US) and a chest radiograph were performed. US was negative while the radiographic examination showed an area of consolidation in the upper field of right lung. The parenchymal consolidation was more visible at the hilum and in the perihilar area (Figure 1). A consultation from the \"Burn Center\" was made: the entry points of the electrical current (15000V) were detected in the shoulder and in the right arm (Figure 2). In these locations III\u00b0 grade burns were highlighted. The lesions of output were multiple and were localised in the lower limb. A Computed Tomography (CT) was performed that confirmed the radiographic findings (Figure 3). One month later the patient underwent a follow-up CT that showed complete resolution of the ground-glass opacity in the right lung (Figure 4).",
    "discussion": "The true incidence and prevalence of injury from electrical current are difficult to ascertain.High-voltage injuries occur at 1000 Volts or greater [1]. These are most commonly work-related injuries and typically observed in men. Low-voltage injuries are usually observed in women and children as domestic injuries. Electrical current runs from an area of low resistance to high resistance [2]. The resistance of the body is concentrated primarily on the skin and changes in relation to its conditions (wet or clammy skin loses most of resistance).The current path through the body determines the nature of the damage. The passage from one arm to another, or from one arm to a contralateral foot, determines a pathway of current flowing through the heart involving it; so it is more dangerous than the passage between the leg and the ground.Lesions are the result of two basic mechanisms. The first consists in the phenomenon of electrolytic polarization, which causes, on one side, depolarization of the cells and then a nerve or muscle activation and, on the other, a protein denaturation for molecular stretching and rupture of covalent bonds. The Joule effect with its production of heat in the tissues crossed by the current is the second mechanism.The magnitude of voltage, the resistence of the body exposure to either direct or alternating current, the duration of exposure, and the pathway of the current inside body, all affect the potential mortality and morbidity.The current may result in serious alterations of physiological functions, such as involuntary muscle contractions, seizures, ventricular fibrillation or respiratory arrest, resulting in injuries to the central nervous system or muscle paralysis. There also may be thermal, electrochemical or other damage (such as haemolysis, protein coagulation, vascular thrombosis, dehydration) [3]. Often a combination of these effects occurs. In our case the current path involves only the right side as shown by cutaneous signs of entry and exit.The ground glass is suggestive of thermal damage: scientific data on the heat-induced damage to the lung are missing, except animal studies. Krzyzaniak et al demonstrated that burn-induced acute lung injury at histology showed thickening of the alveolar-capillary membrane, hyaline membrane formation, intraalveolar haemorrhage, and neutrophil infiltration [4]. These findings might justify our CT images.Initial fluid resuscitation, respiratory support and prevention of infection are the early treatments.Multidisciplinary management approaches involving the intensivist, neurologist, plastic surgeon, physical and occupational therapists, and nutritionist, is necessary to achieve the best possible outcomes.",
    "differential_diagnosis": "Lesions, by, passage, of, electric, current, at, high, voltage., Pulmonary, infection, Pneumonitis, Lung, cancer",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010520/000001.jpg?itok=GsPMmTtM",
            "caption": "This image shows a burn from electricity that has a special presentation at the entry point in the form of \\\"electric trade mark.\\\" The entry was at the proximal side of the right arm."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010520/000002.jpg?itok=R1ciNMV1",
            "caption": "The figure demonstrates localised opacification in the right perihilar region."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010520/000003.jpg?itok=xqEGR3Ha",
            "caption": "Sequential CT scans at the level of the upper lobes confirm the presence of a focal area of ground glass opacity in the anterior segment of the right upper lobe."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010520/000004.jpg?itok=m-9feRdC",
            "caption": "Sequential CT scans (the following four images craniocaudally) at the level of the upper lobes confirm the presence of a focal area of ground glass opacity in the anterior segment of the right upper lobe."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010520/000005.jpg?itok=RUDLNQBk",
            "caption": "Resolution of the area of \u200b\u200bparenchymal consolidation reported in previous examinations is noted."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010520/000007.jpg?itok=2bvtUOp6",
            "caption": "Ground glass opacity in the right upper lobe has resolved."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Soft tissues / Skin",
      "Lung"
    ],
    "imaging_technique": [
      "Image manipulation / Reconstruction",
      "Conventional radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/10520",
    "time": "18.12.2012"
  },
  "10535": {
    "case_id": 10535,
    "title": "Goodpasture\\&#039;s syndrome - A rare cause of diffuse alveolar haemorrhage in Asians",
    "section": "Chest imaging",
    "age": "24",
    "gender": "male",
    "diagnosis": "Goodpasture's syndrome",
    "history": "A 24-year-old man was admitted with a history of fever, cough and recurrent haemoptysis for 1 month and breathlessness for 5 days. His investigations revealed anaemia with normal bleeding parameters. Urine showed proteinuria and haematuria. Antibodies to glomerular basement membrane (Anti GBM- Abs) were positive.",
    "image_finding": "A series of chest radiographs taken over a period of 4 days showed bilateral areas of consolidation more pronounced on the right side (Figure 1). CT of the chest done at the time of admission showed extensive bilateral symmetrical areas of ground glass attenuation with smooth septal thickening resembling crazy paving pattern involving bilateral lungs (Figure 3, 4,  5). Possibility of pulmonary haemorrhage syndrome - Goodpasture\u2019s syndrome had to be ruled out.",
    "discussion": "DAH (diffuse alveolar haemorrhage) can be defined by the presence of haemoptysis, diffuse alveolar infiltrate, and a drop in haematocrit level. Pulmonary-renal syndrome is defined as the combination of DAH and glomerulonephritis. The differential diagnosis includes mainly the ANCA-associated vasculitides, Goodpasture\u2019s syndrome and systemic lupus erythematosus [1].Goodpasture\u2019s syndrome is a clinical triad of circulating antiglomerular basement membrane antibody, DAH, and glomerulonephritis [2, 3]. This condition is predominantly seen in young men and associated with pulmonary haemorrhage or pulmonary capillaritis. GPS is characterized by the presence of autoantibodies mainly in alveolar and glomerular basement membranes. Genetic and environmental factors are known to worsen the pulmonary lesions [4]. Circulating antibodies are predicative of the severity of the renal and pulmonary injury, as well as immediate and long term prognosis [5]. The pulmonary presentation consists of nonspecific signs and symptoms like cough and haemoptysis which overlap with those of infections, connective tissue diseases and malignancies [6].Chest radiographs typically show extensive patchy or diffuse bilateral air space opacities. The apex and cost-phrenic angles are usually spared. The consolidation usually resolves in 2-3 days and is replaced by reticulonodular pattern [1, 2, 6]. Bilateral ground glass opacities (GGO) and consolidation are the commonest CT features [6]. The presence of dense consolidation represents complete filling of alveoli with blood. Smooth interlobular septal thickening becomes superimposed on areas of GGO (a crazy paving appearance) within 2\u20133 days, as haemosiderin-laden macrophages accumulate in the interstitium. Occasionally ili-defined centrilobular nodules with no zonal predominance may be present reflecting intraalveolar accumulation of pulmonary macrophages [1, 2]. Complete clearing of airspace and interstitial opacities usually occurs within 10 days to 2 weeks if no further haemorrhage occurs. This is considerably slower than clearing of pulmonary oedema. Chronic cases show a persistent reticular pattern with areas of honeycombing and traction bronchiectasis [1].The diagnosis is confirmed by the presence of anti-basement membrane antibody in the serum or continuous linear deposits of IgG along the basement membranes in renal or lung tissue. In patients without clinical evidence of active renal disease, serum antibodies may be absent and the diagnosis can only be established by demonstrating linear immunofluorescence in lung or renal tissue [7].Radiologic signs of DAH may be nonspecific and variable but must be considered in patients with otherwise unexplained alveolar infiltrates, particularly when seen with new-onset renal insufficiency or a connective tissue disease to enable earlier diagnosis [1].",
    "differential_diagnosis": "Goodpasture's, syndrome, Pulmonary, haemorrhage, syndrome, Acute, interstitial, pneumonia",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010535/000001.jpg?itok=LkOFz8Cw",
            "caption": "Bilateral symmetrical air space opacities are noted in mid and lower zones"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010535/000002.jpg?itok=PO5KdDN9",
            "caption": "Bilateral air space opacities with no evidence of cardiomegaly"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010535/000003.jpg?itok=M7gdkZMw",
            "caption": "Diffuse bilateral air-space consolidations with air-bronchogram are noted. Few areas of ground glass opacities are also seen."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010535/000005.jpg?itok=es_NVkPT",
            "caption": "Coronal CT image shows extensive air space opacification with peripheral sparing."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010535/000006.jpg?itok=mNZiSafI",
            "caption": "Confirms the presence of air bronchogram"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Respiratory system"
    ],
    "imaging_technique": [
      "CT",
      "Conventional radiography"
    ],
    "link": "https://www.eurorad.org/case/10535",
    "time": "15.01.2013"
  },
  "10547": {
    "case_id": 10547,
    "title": "Mediastinal large B-cell lymphom",
    "section": "Chest imaging",
    "age": "16",
    "gender": "female",
    "diagnosis": "Mediastinal large B-cell lymphoma",
    "history": "Sixteen-year-old woman, presented to the Emergency Room with dyspnoea, asthaenia and dry cough for a week, without fever or expectoration. She reports the loss of 3 kg of weight in the last fifteen days and pain on the left arm, without loss of strength or sensibility.",
    "image_finding": "The chest radiograph showed bilateral pleural effusion and widening of the anterosuperior mediastinum (Figure 1, 2).Thoracic and abdominal computed tomography demonstrated a wide anterosuperior mediastinal mass with pleural and pericardial nodular implants, pericardial effusion and abundant pleural effusion, more evident on the right side. A left jugular vein thrombosed was identified. Some small retroperitoneal lymphnodes were also detected (Figures 3, 4, 5, 6 and 7).A CT-guided percutaneous biopsy of the mediastinal mass was performed. The diagnostic pathway was completed with brain CT, echocardiogram and sternal puncture.The final diagnosis was mediastinal large B-cell lymphoma.",
    "discussion": "Primary mediastinal large B-cell lymphoma is a sub-type of the category of large B-cell lymphoma, and constitutes approximately the 5% of all non-Hodgkin lymphomas (NHL). Typically it appears as an anterior mediastinal bulky mass, which frequently contains necrotic areas and has a locally aggressive behaviour [1, 2, 3].In our case the differential diagnosis should be established with two other entities that involve the anterior mediastinum: thymoma and germ cell tumour.Thymomas are solid neoplasms that occur sporadically or in association with myasthenia gravis, red cell aplasia, hypogammaglobulinaemia. Thymomas produce a distinct focal soft tissue density bulge along the normally smooth outer margin of the thymus or, when large, they totally replace the organ with a ovoid mass [4]. Approximately 15% are invasive. They may extend locally into adjacent mediastinal structures or implant along the pleural or pericardial surfaces. A widespread infiltration into the surrounding mediastinal fat or soft tissue masses along the pleural or pericardial surface are detected [4].Rarely this neoplasm may grow directly into the lung. Thymoma is usually a tumour of the adult and it is rarely seen in children.Extragonadal germ cell tumours usually appear between the second and fourth decade. Malignant tumours appear almost exclusively in men, they include seminoma and non-seminomatous germ cell tumours (embryonal carcinoma, tumours of the endodermic sinus, coriocarcinoma and mixed types). Seminoma is a slow growing tumour and it appears as a large and homogeneous tumour. Malignant non-seminomatous tumours are aggressive large, ill defined masses, which can be associated to Klinefelter syndrome; they grow very quickly and most patients have symptoms of mediastinal structures invasion and metastatic disease when diagnosed. Two subtypes of NHL are manifested as an anterior mediastinal mass: primary large B-cell lymphoma and lymphoblastic lymphoma. Large B-cell lymphoma involves patients among 10 and 45 years, mainly young women. It is an aggressive neoplasm, which rapidly reaches a large size (10 cm in 75% of patients) and usually involves other mediastinal organs as lung, pleura and pericardium, with associated superior vena cava syndrome in 50% of patients [1, 2, 3].In both subtypes the lesion appears as a prevascular, large mass, with invasion of adjacent vascular structures, lung and chest wall, tracheal and oesophageal compression and pleural-pericardial effusion.In our case the sex and age of the patient were very useful in order to establish the differential diagnosis among all these aggressive entities with a similar radiological appearance.",
    "differential_diagnosis": "Mediastinal, large, B-cell, lymphoma, Invasive, thymoma, Germ, cell, tumour, Lymphoma, Tuberculosis, Sarcomatous, tumour",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010547/000002.jpg?itok=8CNqPAqv",
            "caption": "Bilateral pleural effusions are noted."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010547/000003.jpg?itok=DqOPc8nI",
            "caption": "Chest radiograph shows widening of the antero-superior mediastinum and bilateral pleural effusions."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010547/000004.jpg?itok=2ntuZh0u",
            "caption": "Anterosuperior mediastinal mass with heterogeneous enhancement and some hypodense areas is noted. Chest wall infiltration, bilateral pleural effusions and right axillary adenopathy are also seen."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010547/000005.jpg?itok=EHtKUXV5",
            "caption": "Infiltration of the pericardium with pericardial effusion is seen."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010547/000006.jpg?itok=0pbURM1X",
            "caption": "Infiltration of the pericardium with pericardial effusion is seen."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010547/000007.jpg?itok=8UlbwwjF",
            "caption": "Nodular implants on the left anterior pleural base, with imaging characteristics similar to the pericardial nodularity after contrast administration."
          }
        ]
      },
      {
        "number": "Figure 7",
        "subfigures": [
          {
            "number": "Figure 7",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010547/000008.jpg?itok=cOqleL84",
            "caption": "Intraluminal hypodensity within the left jugular vein is seen consistent with thrombosis of this vessel."
          }
        ]
      },
      {
        "number": "Figure 8",
        "subfigures": [
          {
            "number": "Figure 8",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010547/000009.jpg?itok=EsXOEWts",
            "caption": "Proliferation of cells of medium-large size with severe cytological atypia, disposed forming nests and tracks with a marked sclerosing reaction of the stroma."
          }
        ]
      },
      {
        "number": "Figure 9",
        "subfigures": [
          {
            "number": "Figure 9",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010547/000010.jpg?itok=EtQ52sNF",
            "caption": "Neoplastic cells which show an intense positivity to the   lymphoid B-cell marker (Clone L26, DAKO)."
          }
        ]
      },
      {
        "number": "Figure 10",
        "subfigures": [
          {
            "number": "Figure 10",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010547/000011.jpg?itok=uEq9cVyu",
            "caption": "Complete resolution of the mediastinal mass is noted."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax",
      "Mediastinum"
    ],
    "imaging_technique": [
      "CT",
      "Experimental"
    ],
    "link": "https://www.eurorad.org/case/10547",
    "time": "21.02.2013"
  },
  "10565": {
    "case_id": 10565,
    "title": "Pulmonary hypertension as a primary manifestation of sarcoidosis",
    "section": "Chest imaging",
    "age": "29",
    "gender": "female",
    "diagnosis": "Pulmonary hypertension secondary to sarcoidosis",
    "history": "A 29-year-old female patient presented with progressive dyspnoea on exertion (NYHA class 3) and cough. She denied chest pain, orthopnoea, or paroxysmal nocturnal dyspnoea, or any history of deep vein thrombosis or other thromboembolic disease. She also denied exposure to toxic inhalants, cigarette smoking, or use of appetite suppressants.",
    "image_finding": "On admission to hospital, blood gas analysis was indicative of hypoxaemia. Chest radiograph demonstrated dilation of central pulmonary vasculature and enlarged heart with no parenchymal abnormalities (figure 1). Contrast-enhanced CT showed enlargement of central pulmonary arteries with no evidence of intraluminal thrombus, excluding pulmonary thromboembolic disease (confirmed by ventilation/perfusion scan) (figure 2). Chest CT on lung windows showed smooth thickening of interlobular septa, small ill-defined centrilobular nodules and some regions of ground-glass opacity - inhomogeneous attenuation of lung parenchyma, but no evidence of chronic obstructive pulmonary disease or pulmonary fibrosis (figure 3). Transthoracic echocardiordiogram demonstrated enlargement of the right chambers with normal left ventricular systolic function but diastolic dysfunction due to RV compression.Right heart catheterization demonstrated high mPAP (90mmHg) and PCWP (20mmHg), cardiac output (2, 3l/min) and elevated pulmonary vascular resistance.To exclude a secondary cause of pulmonary hypertension she underwent a lung biopsy that revealed granulomatous vasculitis compatible with sarcoidosis.",
    "discussion": "Pulmonary hypertension (PH) is defined haemodynamically by right heart catheter measurements of a mPAP \u2265 25 mm Hg at rest, with a PCWP \u2264 15 mm Hg and pulmonary vascular resistance \u2265 3 Wood units [1].PH is a well recognized complication of sarcoidosis occurring in 4-28% of patients and occurs commonly in patients with advanced pulmonary sarcoidosis [2, 3]. The pathophysiology of sarcoidosis-related PH (SAPH) is complex and includes multiple potential mechanisms: fibrous destruction of the pulmonary vascular bed, extrinsic compression of the central pulmonary vessels, hypoxic pulmonary vasoconstriction, pulmonary vascular remodelling, intrinsic pulmonary vasoreactivity, pulmonary veno-occlusive disease (PVOD), myocardial dysfunction, porto-pulmonary hypertension and an intrinsic sarcoid vasculopathy [2, 4]. Therefore PH is not always associated with overt parenchymal involvement, with 40\u201360% of patients with SAPH having no radiographic evidence of pulmonary fibrosis [2, 4].The classification of PH was revised at the World Symposium on Pulmonary Arterial Hypertension in Dana Point. As the pathogenesis of PH in sarcoidosis is complex and multifactorial, sarcoidosis is included in the fifth \u2018miscellaneous\u2019 group [1].Patients with SAPH have poorer functional status and greater supplemental oxygen requirements than sarcoid patients without PH, are more likely to be listed for lung transplantation and have a 10-fold increase in mortality over those with isolated pulmonary sarcoidosis. Moreover, SAPH in the absence of pulmonary fibrosis may be a more rapidly progressive disorder, with higher pulmonary vascular resistance levels.Current therapeutic recommendations include the reversal of resting hypoxaemia, treatment of comorbidities and treatment of underlying sarcoidosis. Specific PH therapy is not routinely recommended in SAPH but there are some studies that found that PAH-specific therapy may improve functional class, exercise capacity, and haemodynamics in PH associated with sarcoidosis [5].In this case a fortuitous association between sarcoidosis and idiopathic PH cannot be definitively ruled out but seems unlikely because of the low incidence of each disease.High-dose corticosteroid therapy was initiated, together with supplemental oxygen therapy and epoprostenol iv. The patient was referred to a lung transplant centre for evaluation.",
    "differential_diagnosis": "Pulmonary, hypertension, secondary, to, sarcoidosis, Idiopathic, pulmonary, arterial, hypertension, Pulmonary, veno-occlusive, disease, and/or, pulmonary, capillary, haemangiomatosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010565/000003.jpg?itok=91r4S3IH",
            "caption": "On mediastinal window settings the contrast-enhanced image clearly shows the greater calibre of the main pulmonary artery compared with the adjacent ascending aorta, suggesting raised pulmonary arterial pressure."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010565/000004.jpg?itok=Gg5Ja0iu",
            "caption": "Contrast enhanced computed tomography shows an enlarged main pulmonary artery (>29mm).\nDiameter right pulmonary artery > Aorta."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010565/000005.jpg?itok=s2FMTqii",
            "caption": "Cardiac signs:\n- Straightening of the interventricular septum\n(it could be deviated to the left) \n- Right ventricular hypertrophy (RV thickness >4mm)\n- Right ventricular dilatation (diameter RV-LV > 1:1)"
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010565/000006.jpg?itok=k8kKehAa",
            "caption": "Coronal image - contrast enhanced computed tomography"
          },
          {
            "number": "Figure 1e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010565/000007.jpg?itok=S7gCA_P4",
            "caption": "Retrograde opacification of inferior vena cava and hepatic veins - associated with right-sided heart disease."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010565/000008.jpg?itok=Iun8S1B1",
            "caption": "CT image reveals an elevated artery-bronchus ratio (the size of the adjacent bronchus was inferior to that of the artery)."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010565/000009.jpg?itok=Q60P401q",
            "caption": "HRCT showed smooth thickening of interlobular septa, small ill-defined centrilobular nodules, and focal regions of lobular or centrilobular ground-glass opacity. Lung parenchyma shows a inhomogeneous attenuation, likely due to mosaic perfusion."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010565/000010.jpg?itok=5opYi6Kw",
            "caption": "HRCT (coronal image) showed smooth thickening of interlobular septa, small ill-defined centrilobular nodules, and focal regions of lobular or centrilobular ground-glass opacity. Lung parenchyma shows a inhomogeneous attenuation, likely due to mosaic perfusion."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010565/000011.jpg?itok=iHtCrRGX",
            "caption": "Frontal radiograph of the chest shows an enlarged main pulmonary artery\nand a markedly enlarged right and left pulmonary arteries. The peripheral vasculature is\nnormal and there are no infiltrates or interstitial findings."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010565/000012.jpg?itok=SyiOujA-",
            "caption": "The lateral view also reveals enlarged pulmonary arteries and cardiomegaly with decreased retrosternal air space that suggest right ventricular dilation or hypertrophy."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "CT-High Resolution",
      "CT-Angiography",
      "Conventional radiography"
    ],
    "link": "https://www.eurorad.org/case/10565",
    "time": "06.01.2013"
  },
  "10569": {
    "case_id": 10569,
    "title": "Miliary pulmonary metastases from mesothelioma (miliary mesothelioma)",
    "section": "Chest imaging",
    "age": "60",
    "gender": "male",
    "diagnosis": "Miliary metastases from mesothelioma",
    "history": "A 60-year-old patient on palliative chemotherapy for known pleural mesothelioma presented with a 3-week history of progressive shortness of breath and generalized deterioration. There were no signs of any concurrent second malignancy or any infection.",
    "image_finding": "The initial chest radiograph (figure 1a) and CT examination (figure 2a) performed 6 months prior to the current admission demonstrate circumferential pleural thickening with volume loss affecting the left hemithorax with imaging features typical for pleural mesothelioma. At this stage there was no evidence of chest wall or diaphragmatic invasion or contralateral lung involvement. During the admission, the chest radiograph (figure 1b) showed deterioration of pleural thickening and accompanying volume loss of the left hemithorax. In addition there was a suggestion of numerous miliary type nodules throughout the contralateral (right) lung. These findings were further confirmed by a CT scan (figure 2b). The patient continued to deteriorate clinically and a subsequent CT scan 2 weeks later (figure 2c) demonstrated even worse pleural thickening, volume loss and interlobular septal thickening of the left hemithorax with many more conspicuous miliary type nodules within the right lung.",
    "discussion": "Mesothelioma is a neoplasm that generally carries a very poor prognosis. It typically arises from serosal membranes of the pleura and rarely from the pericardium and/or peritoneum [1]. Its typical pattern of growth is by aggressive local spread [1-2], with tumour frequently invading the chest wall, mediastinum, and / or diaphragm. Tumoural encasement with retraction of the lung (as was shown even on the initial images of the presented case) is a typical imaging feature [1]. In autopsy studies, 40-45 % of cases may have metastatic hilar or mediastinal nodal involvement. A much rarer metastatic pattern of mesothelioma is the one characterized by distant ipsilateral or contralateral lung metastases. This tends to occur particularly in the late phase of disease [3]. Contralateral pulmonary metastases can manifest in various forms which include: 1. Large masses [1]2. Smaller nodular lesions [1] 3. Alveolar opacities [4] 4. Small miliary lesions [5-6] It is thought that the incidence of distant ipsilateral or contralateral lung metastases have become more common over the recent years in the advent of more modern treatment strategies (i.e. induction chemotherapy followed by extra-pleural pneumonectomy and adjuvant high-dose hemithoracic radiation therapy) especially as patients live longer with the disease giving more opportunity for the disease to manifest in more atypical forms [2]. A miliary metastatic pattern to the lungs is still an uncommon phenomenon overall [1, 3-7]. This can involve both the ipsilateral as well as contralateral lung [8]. Important differential diagnoses to consider on imaging include miliary type nodules secondary to a concurrent infective source (haematogenous infection or miliary tuberculosis) or miliary metastases from a concurrent second malignancy. This case highlights the imaging features of an uncommon but recognised mode of disease spread of mesothelioma as miliary lung metastases.",
    "differential_diagnosis": "Miliary, metastases, from, mesothelioma, Miliary, tuberculosis, with, background, mesothelioma, Haematogenous, infection, with, numerous, nodules, with, background, mesothelioma, Miliary, metastases, from, a, different, lung, primary, on, a, background, of, mesothelioma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010569/000001.jpg?itok=F1OvNoyf",
            "caption": "Initial chest radiograph (6 months prior to admission) demonstrates circumferential pleural thickening involving the left hemithorax associated with lung retraction."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010569/000002.jpg?itok=3ZWyWO2Y",
            "caption": "Chest radiograph during current admission (6 months later) demonstrates significantly greater volume loss and pleural thickening of the left hemithorax. Numerous miliary micronodules throughout the lungs are noted bilaterally."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010569/000003.jpg?itok=LsTU3bm7",
            "caption": "Initial chest CT examination (6 months prior to admission) shows circumferential pleural thickening with retraction of the left hemithorax in keeping with the known mesothelioma. There is no evidence of chest wall or contralateral lung involvement"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010569/000004.jpg?itok=NzPWo2WX",
            "caption": "CT examination during current admission (6 months later) demonstrates significantly greater circumferential pleural thickening of the left hemithorax with interlobular septal thickening. Numerous small miliary micronodules within the contralateral (right) lung are also noted."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010569/000005.jpg?itok=lMGEAUnf",
            "caption": "CT examination two weeks later during admission demonstrates even greater circumferential pleural thickening of the left hemithorax and increase in number of  the miliary type nodules within the contralateral (right) lung."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "Digital radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/10569",
    "time": "13.03.2013"
  },
  "10572": {
    "case_id": 10572,
    "title": "Diffuse idiopathic pulmonary neuroendocrine cell hyperplasi",
    "section": "Chest imaging",
    "age": "55",
    "gender": "female",
    "diagnosis": "Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia",
    "history": "A 55-year-old non smoker presented with a 4-month history of mild dyspnoea and wheezing. There was no clinical or serological evidence of infection. She had been previously well and had no relevant past medical history.",
    "image_finding": "Posteroanterior and lateral radiograph (figures 1a-b) demonstrates numerous small bilateral nodular type densities. Subsequent HRCT scans (figures 2a-g) confirm the presence of multiple nodular densities (arrows on figures 2d-f) and in addition show occasional areas of mucus plugging (arrows on figure 2g). The coronal HRCT images also suggest a very mild mosaic attenuation pattern (figures 3a-c). The patient later underwent a lung biopsy which showed diffuse proliferation of pulmonary neuroendocrine cells.",
    "discussion": "Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia (DIPNECH) is an extremely rare pulmonary disorder characterised by a proliferation of neuroendocrine cells within the lungs. It is recognised with increasing frequency [2, 6]. The condition typically presents around the 5th to 7th decade [3, 8]. There is a recognised strong female predilection with women accounting for approximately 90% of cases. Most patients tend to be non-smokers [6]. Many patients are asymptomatic at diagnosis and discovery is made often incidentally on thoracic imaging for an unrelated reason [7]. Some may have symptoms such as an insidious cough, wheezing and/or a slowly progressive dyspnoea [7, 8]. Onset of symptoms may widely range from days to years before diagnosis. DIPNECH is characterised by a generalised proliferation of scattered single cells, small nodules or linear proliferations of pulmonary neuroendocrine cells. It is sometimes considered a precursor for pulmonary carcinoid tumours and a diagnosis of DIPNECH requires the presence of hyperplasia of airway neuroendocrine cells without invasion beyond the basement membrane [4].HRCT imaging of the chest can be useful but not definitive in determining the diagnosis.Various HRCT features have been described, each of which are non specific on their own and not all of them are present in the same case. These include 1. Small lung nodules [2-3, 6] - considered generally a frequent feature2. Mosaic perfusion pattern [1-3, 8]3. Mucus plugging [8]4. Bronchial wall thickening [1, 8] 5. Bronchiectasis [2, 8] 6. Ground-glass changes [2] The first three of the above mentioned imaging findings were present in this case. Pulmonary function tests can often show an obstructive ventilatory disease [2, 6], which was also present in this case.The rarity of the condition poses some clinical challenge on establishing treatment and assessing prognosis. Limited studies suggest that the condition can have a variable prognosis ranging from clinical improvement to being stable to progressive clinical deterioration. Various treatment strategies have been described, including systemic and inhaled corticosteroids, bronchodilators, and occasionally lung resection. Some advocate excision of the dominant lesion [5]. However, the main mode of management in the majority of patients tend to be surveillance [4].This case highlights some of the reported imaging features of DIPNECH, although it is important to remember that findings are not specific and differential diagnosis should be considered. Moreover in some cases - i.e. lung nodules that may mimic malignancy - a tissue diagnosis is almost always required.",
    "differential_diagnosis": "Diffuse, idiopathic, pulmonary, neuroendocrine, cell, hyperplasia, Multiple, nodular, metastases, from, an, occult, malignancy, Atypical, pulmonary, infection",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010572/000001.jpg?itok=gMADS9l0",
            "caption": "Initial posteroanterior chest radiograph demonstrates numerous ill defined micronodular densities without any accompaying volume loss."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010572/000002.jpg?itok=Vy6curSu",
            "caption": "Initial lateral chest radiograph demonstrates numerous ill defined micronodular densities without any accompaying volume loss."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010572/000003.jpg?itok=SiHEMDqg",
            "caption": "Axial HRCT images confirms multiple small nodular densities bilaterally throughout the lungs (arrows)."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010572/000005.jpg?itok=wlOGADvA",
            "caption": "Axial HRCT images confirms multiple small nodular densities bilaterally throughout the lungs (arrows)."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010572/000006.jpg?itok=khD56UWA",
            "caption": "Axial HRCT images confirms multiple small nodular densities bilaterally throughout the lungs (arrows)."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010572/000012.jpg?itok=uyfc2nsc",
            "caption": "Axial HRCT images confirms multiple small nodular densities bilaterally throughout the lungs (arrows)."
          },
          {
            "number": "Figure 2e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010572/000014.jpg?itok=JJi0qnmT",
            "caption": "Axial HRCT images confirms multiple small nodular densities bilaterally throughout the lungs (arrows)."
          },
          {
            "number": "Figure 2f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010572/000013.jpg?itok=EcJUd2J7",
            "caption": "Axial HRCT images confirms multiple small nodular densities bilaterally throughout the lungs (arrows)."
          },
          {
            "number": "Figure 2g",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010572/000007.jpg?itok=_0AMgJk9",
            "caption": "Axial HRCT images confirms multiple small nodular densities bilaterally throughout the lungs (arrows)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010572/000008.jpg?itok=osbpnEM8",
            "caption": "Coronal HRCT images showing multiple small lung nodules throughout the lungs bilaterally. A very subtle mosaic attenuation pattern is also seen."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010572/000009.jpg?itok=JHjWShjN",
            "caption": "Coronal HRCT images showing multiple small lung nodules throughout the lungs bilaterally. A very subtle mosaic attenuation pattern is also seen."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010572/000011.jpg?itok=x36TNaG6",
            "caption": "Coronal HRCT images showing multiple small lung nodules throughout the lungs bilaterally. A very subtle mosaic attenuation pattern is also seen."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax",
      "Respiratory system"
    ],
    "imaging_technique": [
      "CT-High Resolution",
      "Digital radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/10572",
    "time": "15.01.2013"
  },
  "10591": {
    "case_id": 10591,
    "title": "The atoll sign",
    "section": "Chest imaging",
    "age": "74",
    "gender": "male",
    "diagnosis": "Cryptogenic organizing pneumonia",
    "history": "An elderly man with non-productive cough and slight fever for three months was sent to our institute to undergo a thoracic CT. No drug consumption was reported nor were there any blood count changes.",
    "image_finding": "The CT study was performed without contrast medium injection and it showed some irregular areas of parenchymal consolidation (Fig. 1, 2, 3); subpleural and peribronchovascular ground glass opacities, were also associated (Fig. 1, 2, 4). Besides, there were also some millimetric ill-defined centrilobular nodules (Fig. 4) and the atoll sign, described as a circular area of parenchymal opacity surrounding normal parenchyma (Fig. 1, 3). There was no evidence of nodular walls or nodules inside the atoll sign. Based on these imaging findings a diagnosis of cryptogenic organizing pneumonia was made.",
    "discussion": "In 1996, Voloudaki et al. [1] described two cases of OP with areas of central ground-glass-like opacity surrounded by a ring of increased density. The central area corresponds to a histological finding of inflammation of the alveolar septa with cellular debris, and the peripheral ring of consolidation corresponds to OP in the alveolar ducts. This presentation is exactly the opposite to that of nodules with a halo sign and has therefore been called \u201creversed halo sign\u201d [2], or atoll sign [3]. A wide spectrum of diseases can manifest with the reversed halo sign on chest HRCT. This pattern is most often an indication of cryptogenic organizing pneumonia, but it may also be associated with other conditions such as inflammatory, neoplastic, or infectious diseases. Although the reversed halo sign is relatively nonspecific, correlation of clinical findings and other HRCT patterns with this finding can sometimes help the physician to narrow the differential diagnosis. Because cryptogenic organizing pneumonia may be idiopathic or may be secondary to infections, collagen vascular diseases, eosinophilic lung diseases, Wegener granulomatosis, and neoplasms, knowing whether the reversed halo sign is a manifestation of primary disease or secondary organizing pneumonia is difficult. Morphologic aspects of the halo, particularly the presence of small nodules in the wall or inside the lesion, usually indicate an active granulomatous disease (infection or sarcoidosis) rather than a primary cryptogenic organizing pneumonia [4]. Although COP is considered the most frequent cause of the reversed halo sign, the presence of nodular walls or nodules inside the reversed halo strongly favours a diagnosis of active pulmonary tuberculosis rather than COP [5]. The presence of reticulation inside the \"reversed halo sign\", outer rim thickness > 1 cm, and associated pleural effusion strongly suggest the diagnosis of invasive fungal infection rather than OP [6]. The cryptogenic organizing pneumonia in the majority of cases is an idiopathic disease, while less frequently it can be associated with infectious pneumonias, airway obstruction, aspiration, drug reaction, or collagen vascular disease associated with an intake of toxic substances. The prognosis is favourable because there is a good response to steroid therapy [3].",
    "differential_diagnosis": "Cryptogenic, organizing, pneumonia, Cryptogenic, organizing, pneumonia, (COP)., Secondary, organizing, penumonia, (OP, reaction, pattern):, bacterial, or, viral, infections",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010591/000001.jpg?itok=t1xynnuV",
            "caption": "Axial chest CT shows bilateral circular areas of parenchymal opacity surrounding normal parenchyma (atoll sign/reversed halo sign)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010591/000002.jpg?itok=meM5olNR",
            "caption": "Irregular areas of parenchymal consolidation with air bronchogram and some ground glass opacities, localized in the peribronchial space."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010591/000003.jpg?itok=KRHuQkp_",
            "caption": "Irregular areas of parenchymal consolidation with air bronchogram; on the left a circular area of parenchymal opacity surrounding normal parenchyma (atoll sign/reversed halo sign)."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010591/000004.jpg?itok=op4Sm-jR",
            "caption": "Small ill-defined centrilobular nodules are seen in the upper lobes bilaterally."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/10591",
    "time": "22.01.2013"
  },
  "10608": {
    "case_id": 10608,
    "title": "All that grows is not a tum",
    "section": "Chest imaging",
    "age": "33",
    "gender": "female",
    "diagnosis": "Pseudo-tumoural pulmonary tuberculosis",
    "history": "A 33-year-old female patient with no past medical history presented with chest pain, cough and dyspnoea. The chest radiograph showed a right dense upper lobe opacity and further investigation with CT of the chest was warranted.",
    "image_finding": "Chest radiograph showed an apical opacity of the right hemithorax (figure 1). Chest CT showed a \"tumour-like\" lesion of the right upper lobe. The lesion was dense with spiculated borders and nodular satellite lesions demonstrating intimate contact with the mediastinum and the vertebra (figure 2, 3). There were enlarged lymph nodes in the mediastinum and the hilum (figure 4). CT scan raised suspicion of a pulmonary tumour. Investigations for tuberculosis remained negative: sputum acid-fast bacilli test, tuberculin skin test. Bronchoscopy found inflammation of bronchial mucosa and transbronchial biopsy was unremarkable. A transthoracic biopsy revealed a nonspecific inflammatory reaction. Surgery was indicated for both diagnostic and therapeutic purpose. The procedure consisted on an upper right lobectomy by a posterior thoracotomy. Pathologic analysis of the surgical specimen revealed presence of granulomas with epithelioid and giant cells and caseous necrosis. Six month follow-up CT post antituberculosis treatment showed no residual tumour (figure 5).",
    "discussion": "Pulmonary tuberculosis is the most common form of tuberculosis, the diagnosis is usually straightforward but a pseudotumoural presentation may need to be differentiated from lung cancer [1]. This case shows that a delay in the diagnosis might delay the treatment. It also stresses the rarity of this form of tuberculosis among immunocompetent patients, while it is observed more in immunocompromised patients [2] and its incidence is estimated at 4.3% [3].The clinical presentation does not have any specificity: chest pain, cough, haemoptysis, dyspnoea and weight loss are all symptoms found in both tuberculosis and lung cancer. The clinicoradiologic and laboratory examinations that are supposed to establish the diagnosis tend to lead to lung cancer especially when the patient is male and or a smoker. The sputum acid-fast bacilli test is negative in the direct examination as well as the culture because the pseudotumoural form of tuberculosis is solid and poorly oxygenated [3, 4].The chest CT scan usually shows a tumour-like mass that is suggestive of malignancy. Bronchial biopsy under bronchoscopy and CT-guided transthoracic needle biopsy can give a positive diagnosis in some cases [1], However the transbronchial biopsy did not find any signs of tuberculosis in this case. The PET-scan could help but it is not available in our hospital. Chaouch and al found 12 cases of tuberculosis pseudotumour among 314 cases of pulmonary tuberculosis over a period of 11 years [1], radiological investigation found consolidation in 5 cases and mass lesion in five cases, bronchoscopy visualized a tumour in 4 cases and a stenosing infiltration in one case. The positive diagnosis was made by: bronchial biopsy (4 cases), transbronchial biopsy (2 cases) and surgical specimen (4 cases). Bouayad and al reported 13 cases of tuberculosis pseudotumour [5]; among them 8 were smokers, the chest CT scan showed a tumour with mediastinal nodes with invasion of soft tissue in one case, the diagnosis was confirmed by: bronchial biopsy in 3 cases, ultra-sound guided biopsy in 6 cases and surgery in 3 cases. Bahlaoui and al reported two cases of pseudotumour tuberculosis, both male and smokers, the CT scan showed a tumour of the Culmen, the diagnosis was confirmed by the bronchial biopsy and the transparietal biopsy [6]. Pseudotumoural tuberculosis is a rare form of pulmonary tuberculosis. The clinicoradiologic presentation is similar to lung cancer. Samples for bacteriological study are usually negative which reinforces the neoplastic aetiology.",
    "differential_diagnosis": "Pseudo-tumoural, pulmonary, tuberculosis, Bronchogenic, cancer, Other, types, of, lung, neoplasms",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010608/000001.jpg?itok=heD-41UY",
            "caption": "CT of the chest shows  a right upper lobe spiculated mass with nodular satellite lesions."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010608/000002.jpg?itok=_-ewRp89",
            "caption": "CT scan on mediastinal windows shows a right upper lobe mass in broad contact with the mediastinum and the vertebral body."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010608/000003.jpg?itok=Sk1-G0YG",
            "caption": "Six-month postoperative CT scan after antituberculous treatment shows no tumour."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010608/000004.jpg?itok=sA9MeoFx",
            "caption": "Chest radiograph shows an apical opacity of the left hemithorax"
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010608/000005.jpg?itok=ivSDltF7",
            "caption": "CT scan showing enlaged lymph nodes of the anterior mediastinum"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Mediastinum"
    ],
    "imaging_technique": [
      "CT",
      "Conventional radiography"
    ],
    "link": "https://www.eurorad.org/case/10608",
    "time": "02.02.2013"
  },
  "10610": {
    "case_id": 10610,
    "title": "An incidental finding: a benign schwannom",
    "section": "Chest imaging",
    "age": "58",
    "gender": "female",
    "diagnosis": "A benign schwannoma",
    "history": "A 58-year-old woman came to our hospital to undergo a presurgical evaluation for possible kidney donation to her son. She did not have relevant medical history and her physical exploration and laboratory tests were normal.",
    "image_finding": "Posteroanterior (PA) and lateral (L) chest radiographs were performed. A lesion projected over the left hilium was observed in the PA view. The lesion did not obscure hiliar vessels (Fig 1). Lateral view revealed that the mass was located in the posterior aspect of the left hemithorax. Smooth margins conforming obtuse angles delineated the mass in both views, suggesting an extrapulmonary lesion (Fig 2). Computed tomography (CT) without and after intravenous contrast medium revealed a six centimetre left extrapulmonary mass which did not show enhancement after contrast medium administration. It was still quite hypodense in the latter ten minute acquisition. There was no evidence of adjacent rib erosion. No relationship with the vertebral foramen was established (Fig 3, 4, 5) . An ultrasound-guided biopsy was performed to confirm the suspected diagnosis. The histological study revealed a tumour constituting of spindle-cells expressing S-100 protein suggestive of a typical benign schwannoma.",
    "discussion": "Neurogenic tumours (NT) are the most frequent cause of posterior mediastinum masses, accounting for more than 90% of them [1]. They can be subdivided in three groups according to the neurological structures where they originate. They can derive from nerve root (schwannomas and neurofibromas), sympathetic ganglion (neuroblastomas, ganglioneuroblastomas, ganglioneuromas) and paragangliomas (chemodectomas and pheochromocytomas) [2]. NT are usually diagnosed in middle-aged patients, without no sex predominance [2], the most common location being the thorax and the posterior mediastinum.The most frequent type of neurogenic tumours are benign schwannomas. Schwannoma or neurinoma derive from the peripheral nerve and they are formed by Schwann cells [3]. Histological studies of schwannomas are composed of spindle cells arranged in fascicles. Inmunohistochemical tests help us to confirm the diagnosis because S100 protein is strongly expressed by most of these tumours [4].Schwanommas are often asymptomatic, and they are usually diagnosed when an imaging procedure is performed for other reasons. The presence of symptoms raises the suspicion of malignancy [2]. These tumours may occasionally be associated with bone and central nervous system lesions; when it infiltrates the whole nerve trunk we have to consider the Von Recklinghausen\u2019s disease as a possible diagnosis [3].The first imaging technique in a patient with a lesion in the posterior mediastinum must be posteroanterior chest radiography, [5] where deformation of mediastinal contours and line displacement of normal structures can be observed.Computed tomography (CT) and magnetic resonance (MR) are good techniques that provide important information of mediastinal masses, concerning the extent of neoplasm and its relationship to vascular and mediastinal structures [6]. On CT, schwannomas are well-defined, homogeneous or heterogeneous masses. Schwannomas usually have similar density to muscle. They may be seen as areas of low attenuation on non-contrast CT when they have high concentration of lipid-rich Schwann cells [7]. Schwannomas can show a homogeneous, heterogeneous or peripheral enhancement after contrast administration [4]. The relationship with vertebraes, ribs, and spinal canal are essential for planning therapy.MRI is also indicated in patients suspected for a neurogenic tumour, because it allows investigation of the intraspinal extension of the tumour.In all of these cases, imaging techniques (CT and MRI) play an essential role. Ultrasound may also be useful for performing biopsy. The principal treatment of choice of schwannomas is surgery by thoracoscopy or thoracotomy because the tumour will continue to increase in size if left untreated [2]. Patients with benign neurogenic tumours have an excellent prognosis [3].",
    "differential_diagnosis": "A, benign, schwannoma, Cysts, (bronchogenic, and, enteric), Descendent, aortic, aneurysm, Haematomas, Abscess, Lymph, nodes, Oesophageal, lesions, Extramedullary, haematopoesis, Mesenchymal, tumours",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010610/000001.jpg?itok=FYJ7puwr",
            "caption": "Posteroanterior radiograph shows a mass projecting to the left hilium."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010610/000002.jpg?itok=jgxsthDy",
            "caption": "A mass with smooth margins conforming obtuse angles was noted suggestive of an extrapulmonary lesion."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010610/000003.jpg?itok=OhmJ28dL",
            "caption": "CT revealed a well-defined six centemetre, soft tissue mass, in the left posterior mediastinum."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010610/000004.jpg?itok=fx3IthNl",
            "caption": "Coronal CT suggesting an extrapulmonary lesion."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010610/000005.jpg?itok=22DK09CQ",
            "caption": "Axial CT after contrast administration.\nThere is no evidence of adjacent rib erosion."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/10610",
    "time": "15.01.2013"
  },
  "10628": {
    "case_id": 10628,
    "title": "Posterior mediastinal leiomyosarcoma with spinal canal extension",
    "section": "Chest imaging",
    "age": "81",
    "gender": "male",
    "diagnosis": "Mediastinal leiomyosarcoma",
    "history": "An 81-year-old man presented with a 3-month history of progressive right posterior chest pain, with anterior irradiation. In the past two weeks there was significant worsening of pain. The patient referred anorexia, asthenia and irritative cough. No fever, dysphagia or other gastrointestinal/respiratory complaints were present. A CT scan was performed.",
    "image_finding": "A large thoracic heterogeneous lobulated mass (with 7.5 cm maximum diameter) is visualized in the posterior mediastinum, extending to the right prevertebral region from the level of T3 to T6 thoracic vertebrae. The mass contacts and deviates the oesophagus and also contacts the trachea and its bifurcation. The mass is vascularized, with some areas of low attenuation. A small component of the mass is extending through the right T4-T5 intervertebral foramen into the spinal canal (with dumbbell shape) resulting in compression of the spinal cord to the left. No bone erosion of the vertebrae or ribs is identified.",
    "discussion": "Mediastinal sarcomas are rare tumours that constitute approximately 2% of the mediastinal tumours. Mediastinal leiomyosarcomas account for about 11% of primary mediastinal sarcomas [1]. Most cases of leiomyosarcoma of the mediastinum arise from the wall of the oesophagus or great vessels and their clinical manifestation is usually related to oesophageal or vascular obstruction, respectively [2]. Leiomyosarcomas arising within the mediastinal soft tissue, without relation to the surrounding structures, are extremely rare. It is possible that such tumours arise from small vessels within the mediastinal soft tissue. Moran et al. [2] reported the largest series of this type of tumour, with 10 cases of leiomyosarcoma of the mediastinal soft tissues (3 in the anterior mediastinum; 7 in the posterior mediastinum). The mean age was 56 years and a female:male ratio of 3:7 was found. In our case, the upper digestive endoscopy examination showed only external compression at the middle third of the oesophagus, with normal oesophageal mucosa. A histological CT guided core biopsy was performed, revealing the diagnosis of leiomyosarcoma. Surgery was not performed and the patient was referred for radiotherapy. In our case, the oesophagus is deviated by the mass, being difficult to evaluate the origin of the tumour as primary mediastinal or from the oesophageal wall with extrinsic growth. In oesophageal leiomyosarcomas, progressive dysphagia is almost always present as the main complaint (in 91.7% of the cases in a case series of 12 from Zhang et al. [3]). Our patient denied dysphagia, however, as the tumour was not removed we cannot exclude oesophageal wall origin.A small component of the tumour was extending through the T4-T5 intervertebral foramen into the spinal canal with compression of the spinal cord. This is an extremely unusual feature for leiomyosarcoma tumours [4]. The tumour extension into the spinal canal leads to the differential diagnosis of the \"dumbbell-shaped tumours\". Dumbbell tumours are located in the paravertebral areas with an extension through the neural foramina into the spinal canal. Neurogenic neoplasms are usually associated with the dumbbell appearance and can be divided into the following groups: tumours of peripheral nerve origin, more common in adults (Schwannoma and Neurofibroma); tumours of the sympathetic ganglia origin, more common in childhood (Ganglioneuroma, Glanglioneuroblastoma and Neuroblastoma); tumours of the paraganglia origin (Paraganglioma). Nonneurogenic tumours, such as meningiomas and sarcomas and haematopoietic neoplams, like lymphoma and solid leukaemic infiltrates, are also included in the dumbbell tumours group [5].",
    "differential_diagnosis": "Mediastinal, leiomyosarcoma, Neurogenic, tumours, Lymphoma, (NHD, more, common, in, the, posterior, mediastinum)",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010628/000001.jpg?itok=Mvw_WC-Q",
            "caption": "Axial CT image: Large heterogenous mass (*) in the posterior mediastinum and prevertebreal area, with enhancing vessels (arrowheads), with a small component into the spinal canal (arrow), resulting in spinal cord compression to the left."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010628/000002.jpg?itok=cvrcN00T",
            "caption": "Axial CT image bone window (a): no bone involvement was detected (arrow). Sagittal CT image (b): The tumour extends through the T4-T5 intervertebral foramen into the spinal canal with a dumbbell shape configuration (*)"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010628/000003.jpg?itok=tUdyZ9tQ",
            "caption": "Axial CT image (a) and Oblique Coronal CT reformatted image (b): The mass contacts and deviates the oesophagus (arrow) and also contacts the trachea (*)."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Mediastinum"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/10628",
    "time": "10.04.2013"
  },
  "10647": {
    "case_id": 10647,
    "title": "Pleural and mediastinal collections secondary to pancreatitis",
    "section": "Chest imaging",
    "age": "41",
    "gender": "male",
    "diagnosis": "Pleural and pericardial collection secondary to acute pancreatitis.",
    "history": "A patient with previous high alcohol intake presented with a 4-week history of abdominal pain and vomiting and subsequent drenching sweats, cough and right-sided chest pain. On presentation he was pyrexial, in septic shock with high inflammatory markers and renal failure.",
    "image_finding": "The contrast-enhanced computed tomography (CECT) scan demonstrates several peripherally enhancing intrathoracic and upper abdominal collections. These are most notable in the mediastinum tracking along the oesophagus and inferior to the pericardium (figure 1, 2, 3). A fluid track is demonstrated connecting the posterior mediastinal collections to collections in the upper abdomen, via the oesophageal hiatus of the diaphragm (figure 4). The abdominal collection distorts the fundus and body of the stomach. Additionally, there are bilateral pleural effusions with smooth enhancement of the right pleural surface and some gas within the pleural cavity, the latter being attributed to recent pleural aspiration (figure 2). Right lower lobe consolidation is present. There is a small pericardial effusion with no CT features to suggest tamponade. Of note, the pancreas appears relatively normal on CT which is attributed to the subacute presentation.",
    "discussion": "Background: Acute pancreatitis is an inflammatory process characterised by release of proteolytic enzymes within pancreatic tissues. This results in autolysis, oedema, vascular damage and necrosis which can extend to peripancreatic tissues [1]. The major aetiological factors in acute pancreatitis are biliary disease and alcohol abuse (as in our patient) but it can also occur following trauma including ERCP, aetiologies which obstruct pancreatic exocrine drainage (including tumours), infection (mumps and cocksackie B) and in relation to drugs such as azathioprine and corticosteroids.Clinical Perspective: It most commonly presents with abdominal pain, nausea and vomiting but can result in systemic inflammatory response syndrome (SIRS). Local complications of acute pancreatitis include ascites, peripancreatic fluid collections (including pseudocysts and abscesses), pancreatic necrosis, haemorrhage, venous thrombosis, and pseudoaneurysm formation. Multiorgan involvement including intrathoracic fluid accumulation, renal dysfunction and paralytic ileus are associated with worse prognosis (up to 50% mortality) [2].Pleural effusions are common, occurring in 4-17% of cases. Whilst usually small, they are a marker for severity, being present in up to 50% of the most serious cases [3]. Patients with acute pancreatitis and large pleural effusion(s) tend to have more severe disease and are more likely to develop pseudocysts than those without effusions [4].Clinically relevant pericardial effusions and mediastinal fat necrosis are rare, having been described in only a handful of case reports [5]. Diagnosis is through clinical suspicion of pancreatitis and sampling of pleural or pericardial fluid (fluid amylase greater than the upper limit of normal for serum or a pleural fluid/serum ratio >1.0) [4]. In our case pleural amylase was 256U/L, with normal serum amylase, attributed to the delayed presentation.Imaging Perspective: CECT is the main imaging modality for diagnosing complications of acute pancreatitis including significant pancreatic necrosis, collections and vascular complications (thrombosis / pseudoaneurysm). It can also identify aetiologies although has lower sensitivity than ultrasound or MRCP for gallstones [6]. Ultrasound or CT can also be used to guide drainage of collections and as a route to subsequent necrosectomy, although our patient was managed conservatively.Take home messages/teaching points: CT is invaluable in the detection and characterisation of pancreatitis complications.Anatomical communications between the thoracic and abdominal cavities allow channels for thoracic involvement in acute pancreatitis.In subacute presentations, serum amylase may not be elevated and imaging changes in the pancreas to suggest pancreatitis can be minimal.",
    "differential_diagnosis": "Pleural, and, pericardial, collection, secondary, to, acute, pancreatitis., Boerhaave\\'s, syndrome, (oesophageal, rupture, with, pleural, effusion)., This, is, often, associated, with, considerable, free, gas, in, the, mediastinum, possibly, the, pleural, space, and, subcutaneous, tissues., Patients, are, generally, very, unwell., Empyema/infected, mediastinal, collection, secondary, to, community, acquired, pneumonia, would, not, result, in, elevated, pleural, amylase.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010647/000001.jpg?itok=FvS0AAAn",
            "caption": "Axial contrast-enhanced CT slice demonstrating mediastinal collections"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010647/000002.jpg?itok=vZ0kTlKp",
            "caption": "Axial contrast-enhanced CT demonstrating pleural effusion with pockets of gas, mediastinal collections and pericardial effusion."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010647/000003.jpg?itok=qu8kMlIR",
            "caption": "Coronal contrast-enhanced CT scan demonstrating pleural and pericardial effusions along with mediastinal and perigastric fluid collections."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010647/000004.jpg?itok=waRLVwR6",
            "caption": "Coronal contrast-enhaced CT scan demonstrating the tract of communication between the retroperitoneum and the mediastinum. Pleural effusion and perigastric fluid collection is also shown."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Mediastinum",
      "Thorax",
      "Cardiac",
      "Abdomen"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/10647",
    "time": "22.01.2013"
  },
  "10650": {
    "case_id": 10650,
    "title": "Peribronchovascular nodular infiltrates as a presentation of granulomatosis with polyangitis (GPA, formerly Wegener\\&#039;s granulomatosis)",
    "section": "Chest imaging",
    "age": "48",
    "gender": "male",
    "diagnosis": "Granulomatosis with polyangitis (formerly Wegener's granulomatosis)",
    "history": "A patient presented with a one month history of nasal congestion and dry cough. He developed night sweats and weight loss (>5 kg). Blood tests revealed high inflammatory markers. Urine dipstick and renal function were initially normal but deteriorated. ANCA titres were positive, but bronchoscopic biopsy was non-specific.",
    "image_finding": "Contrast enhanced CT demonstrates extensive predominantly central ill-defined irregular peribronchial thickening (figures 1-4). There were associated enlarged hilar nodes and small enhancing mediastinal nodes (figures 5-7). The lungs, mediastinum and pleura otherwise appeared normal, as did the trachea. Of particular note, there were no pulmonary nodules or cavities. There were no abdominopelvic abnormalities.",
    "discussion": "Background:Granulomatosis with polyangitis (GPA, formerly Wegener's granulomatosis) is a rare multisystem, granulomatous vasculitis involving small to medium-sized blood vessels. Clinical Perspective:Respiratory tract symptoms (sinusitis, epistaxis, cough or haemoptysis) and renal impairment may be present to a variable degree at onset. Nonspecific constitutional symptoms (fever, night sweats, lethargy and weight loss) are also common. Renal involvement is usually asymptomatic until advanced and therefore should be screened for early. Other involved systems include ophthalmic, rheumatologic, cutaneous, cardiac and neurological [1].The nonspecific broad ranging symptoms, in a rare condition, generally necessitate early imaging, and careful correlation with clinical, serological and histological evaluation to attain the diagnosis. Serum ANCAs (Anti-Neutrophil Cytoplasmic Autoantibody) should be measured, with cANCA the most specific. However, approximately 10% of GPA is ANCA-negative [1].Imaging Perspective:Chest radiograph is abnormal in two-thirds of patients at presentation, however CT better assesses abnormalities.Pulmonary nodules and masses are the most common finding (< 70% of patients). These can be single or multiple (usually <10) measuring a few millimetres to several centimetres. They may be transient. Central cavitation occurs in up to 50% of nodules particularly those larger than 2 cm. Radiating linear scarring, spiculation, and tags to adjacent pleural surfaces are prominent features of nodules and masses secondary to GPA.Tracheobronchial abnormalities are the second most common thoracic manifestation. Smooth or nodular thickening of central airways, usually circumferential and may be associated with stenosis. Involvement of the posterior tracheal wall may help distinguish from other pathologies including amyloid and relapsing polychondritis. Absence of calcification may also distinguish GPA from the latter 2 diagnoses. Other imaging manifestations include consolidation and ground glass opacification, generally dense and in a perihilar and peribronchovascular distribution. Interstitial thickening and pleural effusions are present in 12-20% of patients either due to direct involvement or secondary to renal failure. Mediastinal and hilar node enlargement is not usually a dominant feature [2, 3, 4].Outcome:Without treatment GPA had a high mortality (>90% within 2 years) but with immunosuppression this has improved. Relapse is common and patients die of renal or respiratory failure, overwhelming infection or malignancy.Take Home Message, Teaching Points:Imaging is often the earliest investigation demonstrating features suggestive of vasculitis and therefore radiologists play a key role.However, GPA appearances are non-specific and enter the differential diagnosis of airway thickening, ground-glass opacification, consolidation, nodules/masses and cavities. The overlapping appearances of vasculitis with infection can cause difficulties in patients on immunosuppressants.",
    "differential_diagnosis": "Granulomatosis, with, polyangitis, (formerly, Wegener's, granulomatosis), Amyloid, Relapsing, polychondritis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010650/000001.jpg?itok=HbYBUsLe",
            "caption": "Left-sided peribronchial thickening is demonstrated on mediastinal windows"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010650/000002.jpg?itok=MI5EI4V0",
            "caption": "The process was bilateral and the right sided peribronchial thickening is demonstrated on mediastinal windows"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010650/000003.jpg?itok=6hZDoEsm",
            "caption": "On lung windows, the peribronchial thickening is again demonstrated bilaterally and appears less smooth than on mediastinal windows"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010650/000004.jpg?itok=iO-CvDam",
            "caption": "Bilateral peribronchial thickening -  more affected on the left side - is noted."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010650/000005.jpg?itok=NqhbJ5QT",
            "caption": "Enlarged left hilar node demonstrated"
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010650/000006.jpg?itok=-HPUwdhV",
            "caption": "Enlarged right hilar node"
          }
        ]
      },
      {
        "number": "Figure 7",
        "subfigures": [
          {
            "number": "Figure 7",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010650/000007.jpg?itok=FTRcNiFA",
            "caption": "Small enhancing subcarinal node"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Respiratory system",
      "Lymph nodes"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/10650",
    "time": "10.02.2013"
  },
  "10665": {
    "case_id": 10665,
    "title": "Legionella pneumophila pneumoni",
    "section": "Chest imaging",
    "age": "80",
    "gender": "male",
    "diagnosis": "Legionella pneumophila pneumonia",
    "history": "The patient presented to the emergency room after 7 days of hyperpyrexia (maximum 39\u00b0 C), productive cough, headache and right scapular pain. He had been under penicillin and cephalosporin treatment for 3 days, without any benefits.Laboratory examinations showed high values of CRP (42.2 mg/dl) and WBC (14.000 mm3).",
    "image_finding": "Chest radiograph showed a consolidation with air bronchogram in the right upper, middle and lower lobes and a right pleural effusion (Fig.1). Sputum test results were negative for common germs and Koch's bacillus. A therapy based on rifampicin and ciprofloxacin was prescribed. After three days from the beginning of this therapy a contrast-enhanced CT was performed. CT scan revealed right unilateral involvement constituted by consolidation with air-bronchogram, mainly in the upper lobe (Fig.2), but also in the middle lobe, ground-glass opacities in the lower lobe (Fig.3), unilateral pleural effusion and some mediastinal lymphnodes (Fig.4).Urinary test was positive for Legionella Pneumophila infection.",
    "discussion": "Legionella microorganisms are responsible for sporadic and epidemic pneumonia, both community acquired and nosocomial. Since its first identification, in 1976, many species of Legionella have been discovered. Among them, mainly the group of Legionella Pneumophila can be related to human disease, and serogroup 1 causes more than 80% of human infections [1, 5]. This microorganism finds a natural habitat in water; human disease occurs when bacteria are inhaled. Legionella enters the cytoplasm of alveolar macrophages, inhibits its elimination and starts replication. Pneumonia is the most common clinical and often severe manifestation. However, Legionella can also cause Legionnaires\u2019 disease, a pneumonia associated with gastro-intestinal, renal or central nervous system symptoms, or Pontiac fever, a self limiting flu-like illness [1, 2]. Diagnosis of Legionella Pneumophila infection is made with serological tests on sputum, blood and urine. Urinary antigen is cheap, easy to perform, and specific, though it identifies only serogroup 1. Legionella is successfully treated with macrolides or quinolones [1, 2]. There is not a specific radiological pattern; chest radiograph cannot distinguish Legionnaires' disease from other pneumonias [5]. Furthermore, imaging findings may vary on the basis of disease progression. At the beginning there is an opacification that gradually increases until it fills an entire lobe. If the infection persists, opacification will extend to other lobes including the contralateral lung [3]. Pleural effusion is quite common, and is seen in one third of cases [5]. Many studies have concluded that there is not a specific imaging pattern. However, imaging is crucial in establishing the presence of pneumonia and to evaluate its evolution [4].",
    "differential_diagnosis": "Legionella, pneumophila, pneumonia, Bacterial, pneumonia, Viral, pneumonia",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010665/000001.jpg?itok=4BNP6nS8",
            "caption": "Chest radiograph shows an extended area of opacification in the right upper, middle and lower  lobes. A small right pleural effusion is also seen."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010665/000002.jpg?itok=zYolPd4z",
            "caption": "Lateral projection."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010665/000003.jpg?itok=e4xgMK9-",
            "caption": "Contrast enhanced CT on lung windows shows the consolidation with air bronchogram in the right upper lobe and right pleural effusion."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010665/000004.jpg?itok=bdH6Cchf",
            "caption": "CT of the chest at the level of the lower lobes shows ground glass opacities in the middle and right lower lobes and pleural effusion."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010665/000005.jpg?itok=NaDT5SqR",
            "caption": "Contrast-enhanced CT of the chest shows mediastinal lymphadenopathy."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/10665",
    "time": "25.04.2013"
  },
  "10693": {
    "case_id": 10693,
    "title": "Sarcoidosis-lymphoma syndrome",
    "section": "Chest imaging",
    "age": "63",
    "gender": "female",
    "diagnosis": "Sarcoidosis \u2013 lymphoma syndrome",
    "history": "A 63-year-old lady presented as an emergency with out of hospital cardiac arrest responding to cardioversion. Investigations revealed elevated serum troponin and normal coronary arteries. In view of history of pulmonary and skin sarcoidosis that was in remission, cardiac sarcoidosis was considered as the cause for cardiac arrhythmia.",
    "image_finding": "18F-FDG PET/CT examination was performed to corroborate cardiac MRI findings (suggestive of cardiac and pulmonary sarcoidosis) and to assess the overall burden of active sarcoidosis for immunosuppressive treatment. Increased metabolism was identified within mediastinal and hilar nodes (SUV max 5.8g/ml), lung parenchyma and heart. A 4.2cm left para-aortic retroperitoneal node exhibiting very intense metabolic activity (SUV max 18.0 g/ml) well above that of thoracic nodes was also identified. There was no other abnormal uptake below the diaphragm.Clinicians were alerted to the possibility of a co-existing separate (probably malignant) pathology at this site. Contrast enhanced CT confirmed a complex left para-aortic soft tissue mass and revealed other lymphadenopathy raising the possibility of a lymphoproliferative disorder. The spleen was not enlarged. A CT guided biopsy of left para aortic nodal mass yielded a diagnosis of high grade B cell lymphoma with follicular cell phenotype. The patient was promptly started on chemotherapy.",
    "discussion": "Sarcoidosis is an autoimmune, inflammatory systemic disorder. The sarcoidosis-lymphoma syndrome is an uncommon but known association, first described in 1986 [1]. A 5.5-11 times higher incidence of lymphoma has been described in sarcoidosis patients. These two conditions can coexist or precede one another. In a review of 112 cases, sarcoidosis preceded lymphoma in the majority (69.6%) and Non Hodgkin Lymphoma was more common than Hodgkin Lymphoma [2].Several mechanisms have been proposed to explain the development of lymphoma after sarcoidosis, including underlying T cell related immunological abnormalities, abnormal cytokine production, cutaneous anergy to particular antigens and hypergammaglobulinaemia [3]. Sarcoidosis has also been reported after lymphoma and chemotherapy treatment [4].Coexisting sarcoidosis and lymphoma pose diagnostic challenge for clinicians as they share similar clinical features. In a sarcoidosis patient, new onset of lymphoma can be suggested by splenic and new lymph node involvement or by an atypical distribution of nodal enlargement. In this case, the unusual distribution of nodal disease and the difference in SUV max between the known sarcoidosis and retroperitoneal node suggested coexisting pathology. Conversely, the development of new respiratory symptoms, elevated Angiotensin Converting Enzyme levels, bilateral hilar lymphadenopathy, pulmonary and possibly skin disease can suggest a diagnosis of sarcoidosis in lymphoma patients [2].18F-FDG PET may be useful for assessment of organ involvement in sarcoidosis [5]. It has become an important imaging modality in diagnosis and follow-up of lymphoid and other malignancies. Although semi quantitative metabolism (SUV max) is less in benign disease (mean 5.02) than in malignant (mean 10.8), this is not definitive [6]. A SUV max value on PET may be misconstrued as indicative of malignancy or benign inflammatory condition and only a tissue diagnosis is definitive. Without pathological analysis it is not possible to distinguish, based on FDG-PET, between malignancy and inflammatory diseases [7]. It has been suggested that combination of 18F-FDG and 18F-FMT (fluorine-18-alpha-methyltyrosine) may be an effective method to distinguish sarcoidosis from malignancy [8]. In a group of 24 sarcoidosis patients with suspected malignancy, all showed increased 18F-FDG uptake, no one demonstrated increased uptake of 18F-FMT in the lymphadenopathy. None had malignancy confirmed later. Our case demonstrates the powerful synergy of interpreting FDG SUV max values within the context of a full clinical history, reporter knowledge of the typical pattern and distribution of sarcoidosis on CT imaging, and being alert to the possibility of a second diagnosis in the presence of atypical structural and functional findings.",
    "differential_diagnosis": "Sarcoidosis, \u2013, lymphoma, syndrome, Malignancy, Lymphoproliferative, disorder",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010693/000001.jpg?itok=iYw2c9Rn",
            "caption": "Axial CT showing sarcoidosis with bilateral calcified hilar and mediastinal lymphadenopathy and lung parenchymal nodularity along bronchovascular bundles"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010693/000002.jpg?itok=iF9RWYbC",
            "caption": "Axial PET-CT image showing increased metabolic activity in the bilateral enlarged hilar lymph nodes with a SUV max value of 5.8g/ml."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010693/000003.jpg?itok=zFcWSoWA",
            "caption": "Contrast enhanced axial CT abdomen showing a 4.2 cm para-aortic retroperitoneal soft tissue nodal mass"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010693/000004.jpg?itok=zZnMATea",
            "caption": "Axial PET-CT image showing very intense metabolic activity in the para-aortic nodal mass with SUV max value of 18 g/ml well above that of the hilar nodes ( SUV max 5.8 g/ml)"
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010693/000005.jpg?itok=qF1F1UUh",
            "caption": "PET-CT coronal MIP image showing comparitively much more intense metabolic activity in the left para-aortic nodal mass than the low intense metabolic activity in the lungs, mediastinum and heart."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Lymph nodes",
      "Abdomen",
      "Nuclear medicine"
    ],
    "imaging_technique": [
      "CT",
      "PET-CT"
    ],
    "link": "https://www.eurorad.org/case/10693",
    "time": "13.03.2013"
  },
  "10697": {
    "case_id": 10697,
    "title": "Rounded atelectasis in an asbestos-exposed worke",
    "section": "Chest imaging",
    "age": "76",
    "gender": "male",
    "diagnosis": "Rounded atelectasis in an asbestos-exposed worker",
    "history": "A 76-year-old man with history of asbestos exposure presented to the emergency department for chest pain, cough and dyspnoea.",
    "image_finding": "The chest radiograph showed a well-defined oval mass in the right lower lobe, which was most possibly pleurally based with associated volume loss and presence of bilateral pleural effusions (Fig. 1). CT of the chest demonstrated a pleurally based well-defined round mass in the right lower lobe, with air bronchogram centrally, associated with distortion, displacement and convergence of adjacent broncovascular structures and volume loss (Fig. 2). Small calcified pleural plaques, pleural thickening and pleural effusion were also observed (Fig. 3, 4). The mass enhanced homogeneously after contrast administration (Fig. 3, 4). No filling defects were detected in the main lobar or segmental branches of the pulmonary arteries (Fig. 3b).",
    "discussion": "Rounded atelectasis is a benign condition in which a peripheral lung area collapses and is surrounded by pleural invagination. This form of atelectasis has also been termed \u2018folded lung\u2019, \u2018pseudotumour\u2019, \u2018pleuroma\u2019, \u2018Blesovsky syndrome\u2019, \u2018pleural asbestotic pseudotumour\u2019 and \u2018twisted lingula\u2019 [1, 2].Rounded atelectasis can result from any type of pleural inflammatory reaction, with asbestos being the most common cause [1]. The pathogenesis is not clear, but it probably represents an inflammatory reaction of the pleural surface with development of fibrosis tissue [2, 3, 4]. As this fibrous tissue matures, it contracts with the lung causing pleural invagination and parenchymal collapse [2-4].Rounded atelectasis is usually asymptomatic [1], with chest pain and cough generally being the most common symptoms either due to the pleuritis or due to the underlying disease [3].Chest radiography shows a round or oval well-defined mass, demonstrating the \"incomplete border sign\" representing a pleurally-based mass. There is associated volume loss and obliteration of the costophrenic angle due to pleural thickening [1].CT shows a round or oval well-defined mass that has a broad contact with the pleura and is associated with distortion, displacement and convergence of adjacent bronchovascular structures (\u201cvacuum cleaner effect\u201d or \u201ccomet tail\u201d sign) [1-5]. Volume loss of the affected lobe is frequent, but not constant. Rounded atelectasis is often associated with other asbestos exposure findings such as pleural plaques, pleural thickening or pleural effusion [1-5]. However, the absence of these findings does not exclude asbestos exposure as the cause of this entity [2]. After contrast administration rounded atelectasis enhances homogeneously, although this finding is not useful to differentiate it from bronchogenic carcinoma [3].MRI often shows a mass with low signal intensity on T1 weighted-sequences with distortion and convergence of adjacent bronchovascular structures that manifest as curved low-signal-intensity lines due to visceral pleura thickening.Rounded atelectasis often remains stable on long-term follow-up, although it may decrease or disappear completely. Enlargement has been reported in very few cases [3].Radiologic follow-up is recommended. Fine needle aspiration is reserved just for atypical cases and excisional biopsy is rarely performed [3-5].",
    "differential_diagnosis": "Rounded, atelectasis, in, an, asbestos-exposed, worker, Bronchogenic, carcinoma, Pulmonary, embolus, with, infarction, Mesothelioma, Pleural, fibrous, tumour",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010697/000001.jpg?itok=kHKhip28",
            "caption": "A well-defined oval mass in the right lower lobe, is seen demonstrating the incomplete border sign and probably reresenting  a pleurally based mass. Lobar volume loss and obliteration of the costophrenic angles were also seen."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010697/000002.jpg?itok=G3NXxH4Y",
            "caption": "A well-defined oval mass in the right lower lobe, is seen demonstrating the incomplete border sign and probably reresenting  a pleurally based mass. Lobar volume loss and obliteration of the costophrenic angles were also seen."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010697/000007.jpg?itok=ZYPijabJ",
            "caption": "The mass enhanced homogeneously after intravenous contrast administration."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010697/000008.jpg?itok=OnZk7j89",
            "caption": "Small calcified pleural plaques, bilateral pleural thickening and pleural effusions were also observed."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010697/000009.jpg?itok=LiW-jNw8",
            "caption": "Small calcified pleural plaques, bilateral pleural thickening and pleural effusions were also observed."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010697/000010.jpg?itok=L1h5CQgs",
            "caption": "Small calcified pleural plaques, bilateral pleural thickening and pleural effusions were also observed."
          },
          {
            "number": "Figure 2e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010697/000011.jpg?itok=t_8e9zLz",
            "caption": "No filling defects were detected in the main lobar or segmental branches of the pulmonary arteries."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010697/000012.jpg?itok=Oxao4f4d",
            "caption": "Well-defined round mass that has broad contact with the pleura and shows distortion, displacement and convergence of adjacent broncovascular structures (\u201cvacuum cleaner effect\u201d or \u201ccomet tail\u201d sign)."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010697/000013.jpg?itok=Y6q3lv11",
            "caption": "Well-defined round mass that has broad contact with the pleura and shows distortion, displacement and convergence of adjacent broncovascular structures (\u201cvacuum cleaner effect\u201d or \u201ccomet tail\u201d sign)."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010697/000014.jpg?itok=88DTbnMK",
            "caption": "Air bronchogram within the mass and volume loss of right lower lobe were also observed."
          },
          {
            "number": "Figure 3d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010697/000015.jpg?itok=N5H8T4B3",
            "caption": "Air bronchogram within the mass and volume loss of right lower lobe were also observed."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010697/000016.jpg?itok=QpThqeCS",
            "caption": "Lung window: Well-defined round mass with broad contact with the pleura associated with volume loss."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010697/000017.jpg?itok=oDTvQ9fA",
            "caption": "Lung window: Well-defined round mass with broad contact with the pleura associated with volume loss."
          },
          {
            "number": "Figure 4c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010697/000018.jpg?itok=hqnY3yGo",
            "caption": "Mediastinal window: The mass enhanced homogeneously after intravenous contrast administraci\u00f3n. Small calcified pleural plaques, pleural thickening and pleural effusions were also noted."
          },
          {
            "number": "Figure 4d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010697/000019.jpg?itok=nrSAC2tl",
            "caption": "Mediastinal window: Well-defined round mass with broad contact with the pleura associated with volume loss."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "Digital radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/10697",
    "time": "24.02.2013"
  },
  "10698": {
    "case_id": 10698,
    "title": "Giant fibrous tumor of the ple",
    "section": "Chest imaging",
    "age": "40",
    "gender": "male",
    "diagnosis": "Fibrous tumour of the pleura",
    "history": "An asymptomatic 40-year-old man with no previous asbestos exposure presented for routine CXR. His medical history and laboratory tests were unremarkable.",
    "image_finding": "Chest X-ray of this asymptomatic patient revealed a large mass, with slightly lobulated, smooth contours, occupying the left hemithorax. Mediastinum was displaced to the right (Fig. 1).CT examination demonstrated a well-defined soft tissue mass (Fig. 2, 3) with central low attenuation areas (Fig. 3b), calcifications (Fig. 3c) and inhomogenous enhancement, after intravenous contrast administration (Fig. 4), creating an obtuse angle to the lower thoracic wall (Fig. 3d). The adjacent thoracic wall, muscles and bones were intact. There was no mediastinal lymphadenopathy or pleural effusion (Fig. 2-4).The diagnosis was established after surgical excision of the mass, which proved to be a fibrous tumour of the pleura on pathology examination. One and a half years later his follow up examinations were stable and normal (Fig. 5).",
    "discussion": "Fibrous tumour of the pleura is a primary tumour of the pleura, [1, 2, 5] with a mainly benign but occasionally unpredictable biological behaviour. [10] Pathologically it is composed of spindle-shaped fibroblast-like cells with collagen separation. [2] It typically affects equally men and women over the age of 40 years. [5] It is less common than malignant mesothelioma (< 5% of all pleural tumours). [4] There appears to be no recognised association with asbestos exposure. [6] Patients with FTPs may present with respiratory complaints (cough, dyspnoea, chest wall pain etc), non-specific symptoms or para-neoplastic syndromes (hypoglycaemia ~2-4% and hypertrophic pulmonary osteoarthropathy ~20%). Up to 50% of patients may be entirely asymptomatic. Both on CXR and CT studies, FTPs present as solitary, well circumscribed, often lobulated soft tissue masses, located on a pleural surface, including the fissures. [1, 2] They may originate both from the visceral (80%) and parietal (20%) pleura. [6] At least one angle with the chest wall is more often acute, which is different from the rest of pleural masses.[1] Tumours originating from the mediastinal pleura extend into the mediastinum. [3] Pleural effusions coexist in approximately 10% of the cases. [2] On CT examination, the majority of FTPs show uniform soft tissue density. Intraregional geographic, focal or linear areas of low attenuation due to necrosis, haemorrhage, cystic or myxoid degeneration may be evident. [1, 2, 8] Calcification is rare. [4] There is no associated mediastinal lymphadenopathy. [2] CT documentation of mobility within the thorax may be seen with pendunculated tumours. Visualization of the pendicle itself is rather unusual. After IV contrast administration FTPs, especially larger ones, enhance avidly and inhomogenously. [1] MR may show necrotic, haemorrhagic or cystic components in better detail. [3] Tumours with a diameter greater than 15-18 cm are characterised as \"giant\". [8, 9] Most FTPs follow a benign clinical course, but up to 20-36% of resected tumours - especially larger, symptomatic FTPs with necrosis - may contain malignant components. [7, 8] Surgical resection is the treatment of choice, with a long term, disease free survival in 90% of cases. [2, 9] Excisional biopsy remains the gold standard for the diagnosis of FTP. Percutaneous biopsy may fail to diagnose malignant FTPs due to insufficient tissue sampling. Because of their potential recurrence or malignant transformation follow up is necessary.  Our patient underwent surgical excision, without previous MRI or biopsy. The mass pathologically proved to be a fibrous tumour of the pleura. One and a half years later his follow up examinations were stable and normal.",
    "differential_diagnosis": "Fibrous, tumour, of, the, pleura, Pleural, lipoma, Pleural, fibrosarcoma, Intercostal, schwannoma, Askin, tumour",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010698/000001.jpg?itok=7u8rthnx",
            "caption": "A huge  mass, with an obtuse angle to the lower thoracic wall, is seen in the left hemithorax. There is some degree of mediastinal deviation to the right."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010698/000002.jpg?itok=MCJ_45is",
            "caption": "A giant (approximately 18.8 x 14.5 x 11 cm), well defined soft tissue mass  in the left hemithorax is shown on coronal reformat."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010698/000003.jpg?itok=BIhN9Nyp",
            "caption": "Figures 2a -2d show an almost uniform soft tissue mass in the left hemithorax."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010698/000004.jpg?itok=zFBdDxQ5",
            "caption": "Central low attenuation areas (probably due to necrosis-degeneration) (fig 2b), as well as central areas of calcification (fig 2c) are present."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010698/000005.jpg?itok=VUlQ1ohh",
            "caption": "Central low attenuation areas (probably due to necrosis-degeneration) (fig 2b), as well as central areas of calcification (fig 2c) are present."
          },
          {
            "number": "Figure 3d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010698/000006.jpg?itok=4mcCnb4b",
            "caption": "An obtuse angle is created between the lower part of the mass and the thoracic wall."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010698/000007.jpg?itok=F492DqHA",
            "caption": "The mass demonstrates inhomogeneous enhancment  after IV contrast administration."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010698/000009.jpg?itok=IBGY7RM7",
            "caption": "The mass demonstrates inhomogeneous enhancment  after IV contrast administration."
          },
          {
            "number": "Figure 4c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010698/000010.jpg?itok=5ED0Evxt",
            "caption": "The mass demonstrates inhomogeneous enhancment  after IV contrast administration."
          },
          {
            "number": "Figure 4d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010698/000011.jpg?itok=bYK24xM-",
            "caption": "The mass demonstrates inhomogeneous enhancment  after IV contrast administration."
          },
          {
            "number": "Figure 4e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010698/000012.jpg?itok=Qp2XM-5s",
            "caption": "The mass demonstrates inhomogeneous enhancment  after IV contrast administration."
          },
          {
            "number": "Figure 4f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010698/000013.jpg?itok=6MrugbMo",
            "caption": "The mass demonstrates inhomogeneous enhancment  after IV contrast administration."
          },
          {
            "number": "Figure 4g",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010698/000014.jpg?itok=Ngqi0dfJ",
            "caption": "The mass demonstrates inhomogeneous enhancment  after IV contrast administration."
          },
          {
            "number": "Figure 4h",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010698/000008.jpg?itok=SvzstXAd",
            "caption": "The mass demonstrates inhomogeneous enhancment  after IV contrast administration."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010698/000016.jpg?itok=JKw9gqbR",
            "caption": "Post-operative scout image - 3 months after surgical excision.\nThere is no evidence of recurrence."
          },
          {
            "number": "Figure 5b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010698/000015.jpg?itok=V2HYeMe6",
            "caption": "Coronal post-operative image - 3 months after surgical excision. \nThere is no evidence of recurrence. Linear post-operative fibrous bands are seen in the lung parenchyma, adjacent to the area of surgical excision."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thoracic wall",
      "Thorax"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/10698",
    "time": "22.11.2013"
  },
  "10798": {
    "case_id": 10798,
    "title": "Mucocoele formation secondary to a central bronchial carcinoi",
    "section": "Chest imaging",
    "age": "27",
    "gender": "female",
    "diagnosis": "Mucocoele in right lower lobe secondary to central bronchial carcinoid.",
    "history": "A 27-year-old female patient presented with history of cough and right sided chest pain for the past 6 months. No significant history of fever, haemoptysis or weight loss could be elicited. She was referred for CT to evaluate a lobulated opacity in right perihilar region detected on chest radiograph.",
    "image_finding": "Well-defined lobulated opacities were seen in right perihilar region on CT topogram (Fig. 1). Lung window images revealed prominence of right perihilar region with cut-off of the superior segmental bronchus of the right lower lobe. A convex impression was seen within this segmental bronchus at the level of cut-off. A lobulated opacity with well-defined borders was seen in the superior segment of the right lower lobe (Fig. 2).Post contrast images in mediastinal window settings revealed a relatively well-defined significantly enhancing soft tissue density mass with a tiny focus of calcification in the right perihilar region cutting-off and partly extending into the superior segmental bronchus of right lower lobe (Fig. 3 a, b). A lobulated non enhancing fluid attenuation lesion was seen radiating from this enhancing mass lesion suggesting dilated fluid/mucus filled distal bronchi in the superior segment of the right lower lobe secondary to proximal obstruction (Fig. 3 a, b).",
    "discussion": "The respiratory system is the second most common site for carcinoids after the gastrointestinal system. Bronchial carcinoids (BC) arise from the neuroendocrine cells of the bronchial epithelium. BC have been classified as central and peripheral types based on location, with central lesions located in the medial third of the chest. They have also been classified as typical and atypical types based on histology, with the atypical type exhibiting increased mitotic activity, nuclear pleomorphism and cellularity [1, 2]. Common presenting complaints include cough, dyspnoea, haemoptysis and chest pain [1, 2].On imaging central BC usually appear as well defined hilar or perihilar masses and show rapid contrast enhancement due to high vascularity. About 30% of central carcinoids show foci of calcification. Most central carcinoids also show an endobronchial component. The tumour may be entirely endobronchial or may have a predominant extrabronchial component with minimal endobronchial extension described as an iceberg lesion. The other imaging findings described are secondary to bronchial obstruction and include distal consolidation, atelectasis or bronchiectasis [2].Rarely retention of mucus occurs within the bronchi distal to the site of obstruction, a finding described as a mucocoele or bronchocoele [2]. On conventional radiographs, such mucus impacted bronchi appear as sharply marginated V or Y shaped opacities radiating from the hilum and may show a \u201cgloved finger\u201d appearance. CT allows easy visualization of mucus filled bronchi which appear as well defined non-enhancing V or Y shaped structures when oriented transversely and rounded structures when oriented craniocaudally. Contrast enhanced CT also allows definite separation of the enhancing central carcinoid from the non enhancing bronchocoele, findings clearly visualized in our case. T2 weighted MRI is another excellent tool to differentiate the homogeneously hyperintense bronchocoele from the slightly heterogeneous signal of the carcinoid [1, 2]. Congenital bronchial atresia is another condition associated with segmental mucocoele formation. In this condition however there are no enhancing lesions proximal to the mucocoele. Associated features of distal air trapping are also usually seen in congenital bronchial atresia. Allergic bronchopulmonary aspergillosis (ABPA) may also be associated with mucocoeles. The lung changes in ABPA are however diffuse and not limited to one segment. Rarely central bronchogenic carcinoma may be associated with distal mucocoele formation.Bronchoscopic biopsy in our case confirmed the endobronchial lesion to be a typical carcinoid. Complete excision of the tumour with varying degrees of pneumonectomy, lobectomy or segmentectomy is considered to be the only effective treatment option [1].",
    "differential_diagnosis": "Mucocoele, in, right, lower, lobe, secondary, to, central, bronchial, carcinoid., Consolidation, in, right, lower, lobe, Segmental, collapse, in, right, lower, lobe, Lung, abscess, Bronchogenic, carcinoma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010798/000001.jpg?itok=i8gKNHqP",
            "caption": "At least two well-defined lobulated opacities are noted in the right perihilar region overlying the right heart border. No definite cavitation or surrounding scarring is seen."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010798/000002.jpg?itok=b0tBjVK5",
            "caption": "Prominence of the right perihilar region is seen with cut-off of the superior segmental bronchus of the right lower lobe. A convex impression (arrow) is seen within the bronchus at the level of cut-off."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010798/000003.jpg?itok=ItQmtI_1",
            "caption": "A lobulated lesion with well-defined margins is seen in the right perihilar region and in the region of superior segment of right lower lobe. The basal segmental bronchi (arrow) appear indented and displaced anteriorly."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010798/000004.jpg?itok=qOjzAWSo",
            "caption": "Well-defined oval/rounded lesions are seen in the region of the superior segment of right lower lobe with no significant surrounding scarring or spiculation. The basal segmental brochi are seen anterior to these lesions."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010798/000005.jpg?itok=z932uq_R",
            "caption": "A lobulated non enhancing fluid attenuation lesion is seen radiating from the hilum in the region of the superior segment of the right lower lobe. No definite septations or calcifications are noted within this lesion."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010798/000006.jpg?itok=FAib3vUS",
            "caption": "A well-defined significantly enhancing lesion (horizontal arrow) is seen in the right perihilar region causing cut-off of the superior segmental bronchus of right lower lobe, separate from the non enhancing fluid attenuation lesion (vertical arrow)."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010798/000007.jpg?itok=Lo3ofA6T",
            "caption": "Delayed post contrast image showing the enhancing right perihilar mass lesion with a focus of calcification (arrow) and the adjacent non enhancing fluid attenuation lesion radiating from it."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/10798",
    "time": "25.04.2013"
  },
  "10801": {
    "case_id": 10801,
    "title": "Subpleural Lipom",
    "section": "Chest imaging",
    "age": "52",
    "gender": "male",
    "diagnosis": "Subpleural lipoma",
    "history": "Case 1: a 52-year-old man with cough and fever.Case 2: a 72-year-old woman with precordial chest pain.",
    "image_finding": "Case 1: Chest radiograph (April 2004) shows an oval mass projecting on the upper left lung (Fig. 1a). The mass measures 5x2.5 cm in diameter and exhibits a sharp inner border, tapered margins, whereas the outer border is ill defined. The mass abuts the posterior chest wall on the lateral view (Fig. 1b). Non-enhanced CT shows a subpleural fatty mass with thin septa extending into the underlying intercostal space; no rib erosion is evident (Fig. 2). On a chest radiograph undertaken on December 2012 the mass is unchanged in size (Fig. 3a, b).Case 2: Chest radiograph shows round opacity with obtuse angles measuring 2.5 cm in diameter abutting the anterior right chest wall (Fig. 4a, b). Contrast-enhanced CT shows a subpleural, transmural (\u201chourglass\u201d) fatty lesion of the right chest wall containing thin septa and displacing the parietal pleura and the pectoralis minor muscle. Ribs are not eroded (Fig. 5).",
    "discussion": "Pleural lipomas are rare, benign, encapsulated fatty tumours mainly found in adult people [1-4]. They originate from the submesothelial connective tissue and may extend into the subpleural, pleural, or extrapleural space [2]; transmural lipomas typically exhibit a \u201chourglass\u201d or \u201cdumbbell\u201d shape [5-7].Pleural lipomas are slow-growing tumours usually asymptomatic and incidentally detected on a chest radiograph, which typically shows as a peripheral mass with a sharp border and tapering margins [1, 2, 5]. Masses generally measure 2 to 4 cm in size, but large lipomas have also been reported [1, 5]; a large transmural lipoma can cause rib erosion [5, 6].A pleural lipoma can be easily characterised with CT or MRI, which depict an encapsulated homogeneous adipose mass, often containing thin septa (<2 mm) [2, 3, 8, 9]. After contrast administration the capsule and septa can faintly enhance on CT and MRI [3, 4, 10]. Sagittal and coronal reformations are helpful in distinguishing lipomas of diaphragmatic pleura from diaphragmatic hernias or focal eventrations [2].Lipomas should be differentiated from other fat-containing masses. A well-differentiated liposarcoma is suggested by a large lesion size, thick septa, presence of intralesional nodular tissue and an amount of adipose component <75% of the mass; lesion enhancement alone is not a reliable differential finding as septa and tissue components can or cannot enhance on MR images after gadolinium administration [4, 9, 10]. High signal intensity of these findings in T2FS/STIR MR images can help to identify a well-differentiated liposarcoma [11]. However, it should be kept in mind that also a lipoma can show non fatty areas due to fat necrosis and associated calcification, fibrosis, inflammation, and myxoid change [10]. MRI features of lipomas and well-differentiated liposarcomas overlap in 4%\u20139% of cases [4].Hibernoma is a benign tumour of brown fat appearing heterogeneous hyperintense on T1, T2 and STIR sequences. Besides lipoma-like hibernoma, lesions show intratumoural prominent vessels as internal void signal structures enhancing after contrast material injection. Moreover an intense activity is appreciable on FDG-PET [9, 12, 13].Parosteal rib lipoma is a very rare fatty tumour adherent to the underlying periosteum but without continuity with the adjacent bone. CT well depicts osseous excrescence within the lipomatous mass whereas MRI better delineates fibrovascular septa and cartilaginous components as structures with intermediate signal on T1 sequence and hyperintense on T2-MRI [9].",
    "differential_diagnosis": "Subpleural, lipoma, Well-differentiated, liposarcoma, Hibernoma, Parosteal, rib, lipoma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010801/000001.png?itok=9woy_nD9",
            "caption": "Posteroanterior view. An oval mass projects on the upper left lung; the mass exhibits inner sharp border and tapered margins."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010801/000002.png?itok=g0IZD_Ew",
            "caption": "Lateral view. The mass abuts the posterior chest wall (arrow)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010801/000003.png?itok=aaMm4KfA",
            "caption": "The mass is located in the subpleural space and shows a fatty density (-115 HU) with thin septa. The lesion involves the underlying intercostal space."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010801/000004.png?itok=3Nb3kOKJ",
            "caption": "Posteroanterior view. The mass is unchanged in size."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010801/000005.png?itok=AWj-mCgu",
            "caption": "Lateral view."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010801/000006.png?itok=P4dwuwC2",
            "caption": "Posteroanterior view. A round opacity projects on the upper right lung."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010801/000007.png?itok=cwwJthzC",
            "caption": "The mass shows obtuse angles on the lateral view."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010801/000008.png?itok=V1zPCTdK",
            "caption": "CT depicts a hourglass fatty mass of the right thoracic wall; thin septa are present within the lesion."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thoracic wall"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/10801",
    "time": "22.04.2013"
  },
  "10822": {
    "case_id": 10822,
    "title": "Ganglioneuroblastoma in a 6-year-ol",
    "section": "Chest imaging",
    "age": "6",
    "gender": "male",
    "diagnosis": "Primary ganglioneuroblastoma in the right subclavicular fossa",
    "history": "A 6-year-old boy came to our department after the sudden development of a hard and slightly mobile swollen area below the right clavicle. The child was asymptomatic.",
    "image_finding": "An ultrasound demonstrated the presence of a solid, inhomogeneous swollen area with increased vascularisation, localised in the right subclavicular fossa (fig. 1).CT scan showed (fig. 2):-a right apical, paravertebral rounded mass with well-defined margins, parenchymal density with calcifications inside, with neither infiltration of nearby structures nor bone erosion;-a connection between the tumour and the intervertebral foramina (IF), that was confirmed in a subsequent MRI (fig. 3): tumour pedicle was extending through C7-T1 IF, with no evidence of bone marrow oedema.The tumour at MRI displaced the parietal pleura, extending between it and the chest wall, had a cerebroid aspect and showed inhomogeneous contrast enhancement.Patient underwent surgery to remove the tumour and histological analysis of the surgical specimen revealed the presence of a ganglioneuroblastoma (areas of ganglioneuroma mixed with undifferentiated neuroblastoma areas).After surgery the patient began chemotherapy with cyclophosphamide-adriamycin.I123 scintigraphy (fig. 4) showed no metastasis.Two-month follow-up chest radiograph demonstrated no evidence of recurrence (fig. 5).",
    "discussion": "Neuroblastic tumours (NTs) are the second most common extracranial malignant tumours of childhood and the most common solid tumours of infancy [1]. NTs (ganglioneuroma, ganglioneuroblastoma and neuroblastoma) represent 80% of the tumours under 5 years of age. They are rare above 10 years old, median age at diagnosis is 22 months, affecting mostly Caucasian boys, most NT are sporadic; few are autosomal dominant and in this case, NT may affect both adrenal glands and have mulitple locations [2]. NTs originate from embryonic cells involved in the development of the sympathetic nervous system due to a block in their differentiation process.NT mainly affect adrenal glands (40%), but may develop anywhere there is sympathetic tissue (abdomen, mediastinum, neck).NTs differ from each other depending on the cellular maturation and the stroma amount [3]. Neuroblastoma (NB) is the most serious but also the most common type of NTs.Ganglioneuroma is mainly asymptomatic and the only symptoms are those related to compression. NB creates a mass, symptoms are absent or non-specific (fever, fatigue, weight loss). Diagnosis is difficult until metastatic manifestations appear, such as pain, respiratory symptoms or gastrointestinal disorders.NB metastasises through both lymphatic and blood vessels, may metastasise everywhere, especially to the liver. In the newborn multiple locations to the skin may give a bluish coloration \"blueberry muffin baby\".Imaging findings may help diagnosis, especially concerning the location of the mass, describing the magnitude and relationships, identifying metastases: US is a first level examination, MRI is better to determine spinal tumours, CT for staging, nuclear medicine for recurrences. The 90% of NB produces catecholamines and their presence in the urine may direct the diagnosis, which becomes certain after histological examination. NB consists of poorly defined small cells with dark nuclei, less cytoplasm and solid growth; immunohistochemical examination is positive for NSE, CD56, synaptophysin. Ganglioneuroblastoma consists of ganglion cells with abundant eosinophilic cytoplasm, nucleoli and \"vesicular\" nuclei, mixed with undifferentiated neuroblasts. To establish the diagnosis of a ganglioneuroblastoma the presence of schwannian stroma, consisting of Schwann cells, fibroblasts, neurites is required [4, 5].NB course is variable, depending on clinical, histopathological, molecular factors. Age and stage are the most important factors, the younger the child the better the prognosis. N-MYC gene amplification and deletion of 1p are other factors of an aggressive disease [6]. NB represents 15% of all deaths from cancer in children, treatment of choice is surgery and chemotherapy (cisplatin, etoposide, doxorubicin); new treatment with stem cell transplant is being studied [7].",
    "differential_diagnosis": "Primary, ganglioneuroblastoma, in, the, right, subclavicular, fossa, Ganglioneuroma, Neuroblastoma, Extracranial, meningioma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010822/000002.jpg?itok=kW1g9Ql9",
            "caption": "Ultrasound image: presence of a tumefaction in the right subclavicular fossa."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010822/000001.jpg?itok=BjMFl1hm",
            "caption": "Ultrasound image that shows presence of vascularisation inside the tumefaction."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010822/000003.jpg?itok=FRif6ozM",
            "caption": "Axial CT image (same level, two different window): Cranial extension of the tumour."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010822/000004.jpg?itok=2pVmkGxd",
            "caption": "Axial CT image (same level, two different window): maximum medio-lateral extension of the tumour."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010822/000005.jpg?itok=dVCQcaxC",
            "caption": "Axial CT image (same level, two different window): Caudal extension of the tumour."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010822/000006.jpg?itok=8xypc5JV",
            "caption": "MPR coronal CT images: tumour is next to the trachea and toracic spine."
          },
          {
            "number": "Figure 2e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010822/000007.jpg?itok=jLWdcs4f",
            "caption": "MPR coronal CT image: maximum craniocaudal e mediolateral extension of the tumour."
          },
          {
            "number": "Figure 2f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010822/000008.jpg?itok=tHTpuiJS",
            "caption": "MPR oblique image: the tumour has connection with the vertebral foramina, note the calcification within the tumour."
          },
          {
            "number": "Figure 2g",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010822/000009.jpg?itok=5zgFeB2y",
            "caption": "MPR oblique image: the tumour does not invade vertebra or rib."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010822/000010.jpg?itok=-bl_X2ZG",
            "caption": "T2-wt image: Tumour with connection to the intervertebral foramina."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010822/000011.jpg?itok=OfRZuwk1",
            "caption": "Axial T2-wt image: calcification within the tumour, hyperintense in T2-wt scan."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010822/000012.jpg?itok=p5DqcaMS",
            "caption": "Coronal T1-wt and T2-wt images: presence of a tumour at the apical part of the right lung."
          },
          {
            "number": "Figure 3d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010822/000013.jpg?itok=XVEYBYSl",
            "caption": "Coronal STIR-wt image: the tumour is hyperintense due to hypercellularity."
          },
          {
            "number": "Figure 3e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010822/000014.jpg?itok=Yd66YRHj",
            "caption": "T1-wt dynamic images, first image taken after contrast administration: inhomogeneous contrast enhancement of the lesion."
          },
          {
            "number": "Figure 3f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010822/000015.jpg?itok=gvf2p3bv",
            "caption": "T1-wt dynamic images, second image taken after contrast administration: inhomogeneous contrast enhancement of the lesion."
          },
          {
            "number": "Figure 3g",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010822/000016.jpg?itok=sN7JAOmK",
            "caption": "T1-wt dynamic image, third image taken after contrast administration: inhomogeneous contrast enhancement of the lesion."
          },
          {
            "number": "Figure 3h",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010822/000017.jpg?itok=ZScoWiim",
            "caption": "T1-wt dynamic image, fourth image taken after contrast administration: inhomogeneous contrast enhancement of the lesion."
          },
          {
            "number": "Figure 3i",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010822/000018.jpg?itok=I3pVIhYQ",
            "caption": "Axial T1 image, the lesion is still hyperintense after administration of contrast stopped."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010822/000020.jpg?itok=DUPzvgiq",
            "caption": "I123 Scintigraphy shows no metastasis"
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010822/000021.jpg?itok=OfwsMn_P",
            "caption": "I123 Scintigraphy shows no metastasis"
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010822/000022.jpg?itok=YY3myrJT",
            "caption": "Chest X-ray image is negative for recurrence of disease. there There are results of costal excision and liquid at the right clavicle."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Nuclear medicine",
      "Lung",
      "Spine",
      "Thoracic wall",
      "Head and neck",
      "Musculoskeletal spine",
      "Mediastinum",
      "Oncology",
      "Paediatric"
    ],
    "imaging_technique": [
      "SPECT",
      "Ultrasound",
      "Ultrasound-Colour Doppler",
      "CT",
      "MR",
      "MR-Diffusion/Perfusion",
      "Conventional radiography"
    ],
    "link": "https://www.eurorad.org/case/10822",
    "time": "10.04.2013"
  },
  "10850": {
    "case_id": 10850,
    "title": "Acute tamponade from ecchinoccoccus cyst",
    "section": "Chest imaging",
    "age": "45",
    "gender": "male",
    "diagnosis": "Pericardial tamponade due to ruptured pericardial hydatid cysts",
    "history": "A 45-year-old shepherd was admitted for thoracic pain and acute dyspnoea.Transthoracic echocardiography and CT were performed revealing pericardial effusion and two cystic masses.",
    "image_finding": "CT examination showed a thin-walled unilocular cyst adjacent to the right ventricle and another calcified ruptured cyst next to the left ventricle, accompanied by a pericardial effusion. The morphologic features and the history of contact with dogs led to the diagnosis of pericardial hydatid cysts. Emergency thoracic surgery was performed.",
    "discussion": "Hydatidosis is a parasitic infection caused by Echinococcus granulosus. The incidence of cardiac envolvement is <2%, even in countries where it is endemic with the interventricular septum and left ventricular free wall being more affected.Patients may remain asymptomatic or present nonspecific symptoms during many years. Prior history of hydatid disease associated to hypereosinophilia can lead to the diagnosis of hydatid cysts. Diagnosis is confirmed by imaging techniques [1].Echocardiography is a reliable technique for the diagnosis of intracardiac masses, but in some cases the echoluscent and multiseptate nature of echinococcal cysts may be absent.Therefore hydatid cysts, in endemic areas, should be included in the list of differential diagnosis of cardiac tumours [1].  Cardiac motion artefacts limit the CT evaluation of small cystic lesions localised in the myocardium. However, the increasing use of multidetector CT scanners have overcome this problem. Indeed, a round, thin-walled, multiloculated mass is characteristic of a hydatid cyst. Septa and calcifications may occasionally coexist. However, identification of cardiac and pericardial hydatid cysts may be very difficult, particularly the small ones [2].In the presented case, although there was no prior history of hydatid cyst, the imaging findings and the history of contact with dogs led to the diagnosis.Although medical treatment (albendazole) has shown interesting results, surgery is still the treatment of choice [1, 2]. Pericardial hydatid cyst is a rare pathology, but in endemic areas a very high suspicion is justified in any cystic disease of pericardium. Once diagnosed, early surgical excision is required to prevent complications.",
    "differential_diagnosis": "Pericardial, tamponade, due, to, ruptured, pericardial, hydatid, cysts, Cardiac, tumours, Pericardial, tumours",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010850/000001.jpg?itok=x0N_ze2J",
            "caption": "Contrast-enhanced chest CT shows an anterior simple unilocular thin-walled pericardial cyst and a posterior pericardial cyst with calcified wall. A large anterior pericardial effusion is also noted."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010850/000002.jpg?itok=BMRBNOUF",
            "caption": "Reformatted sagittal enhanced chest CT shows a simple anterior pericardial cyst with a significanltly large pericardial effusion."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Cardiac"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/10850",
    "time": "27.03.2013"
  },
  "10857": {
    "case_id": 10857,
    "title": "Iatrogenic venous air embolism",
    "section": "Chest imaging",
    "age": "73",
    "gender": "male",
    "diagnosis": "Iatrogenic venous air embolism",
    "history": "A 73-year-old man underwent a contrast-enhanced CT scan for colorectal cancer follow-up.",
    "image_finding": "Two gas bubbles of 15 mm in size, with air-fluid levels, were detected in the main pulmonary artery, during the preliminary evaluation of the thoracic images (Fig. 1 a). Other smaller gas bubbles were observed in right subclavian vein and in the brachiocephalic vein a triradiated image was present, due to a motion artefact from pulsation of intravascular gas bubbles (dynamic mercedes-benz sign) (Fig. 1 b, c, d). These findings were characteristic of iatrogenic venous air embolism. The patient was asymptomatic but was kept prudently in observation for 24 hours; since there were no complications during this period he returned home the day after the incident.",
    "discussion": "Venous air embolism (VAE) is a condition resulting from the presence of gas bubbles inside the venous bloodstream.Generally this is an iatrogenic complication that can occur during venous access procedures, caused by the incidental introduction of atmospheric gas into the venous blood flow [1-2].During contrast media injection for computed tomography (CECT) small amounts of air can be discovered in about 23% of patients [3].This gas can arise from the inadequate removal of the air from the syringe, from the pressure tubing or from microbubbles present within the contrast medium.Generally the patients are asymptomatic; however, a bigger amount of air can be a potentially lethal process, because a large bubble of gas is able to stop blood flow to the lungs.The risk of morbidity or mortality not only is affected by the amount of air but also by the speed of introduction; for this reason the most serious accidents are linked by to use of injectors pump [4-5].The more common symptoms are: sudden dyspnoea, chest pain, cough, tachyarrhythmias or bradycardias, hypotension, circulatory shock or cardiovascular collapse, feeling of impending doom. VAE appears on CT as gas bubbles, within the veins enhanced by contrast medium, variable in size by less than 1 cm to 1-3 cm in diameter; generally located in the main pulmonary artery, superior vena cava, right side of heart, subclavian or brachiocephalic vein. Several patients can have multiple emboli in different sites [1].In some cases, for the preexistence of anatomical anomalies such as patent foramen ovale or pulmonary shunts, the gas from venous system can go in the arterial system with the possibility of arterial air embolism.Typically gas bubbles can have a triradiate aspect (dynamic mercedes-benz sign) due to motion artefact.For preventing or minimizing the risk of VAE, before initiating the injection, it is essential to remove the air from the syringe and from pressure tubing and orientate the syringe downward.At the onset of the slightest symptoms, because of this potentially life-threatening condition, it is suggested to put the patient immediately in the left lateral decubitus position with the head down (Durant's maneuver), then give oxygen with high flow rates in order to reverse ischaemia and reduce the air bubble size. In severe cases haemodynamic support and hyperbaric oxygen therapy is required.",
    "differential_diagnosis": "Iatrogenic, venous, air, embolism, Pulmonary, embolism, Arterial, embolism",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010857/000002.jpg?itok=_ffi2iVO",
            "caption": "CECT (axial view) shows, in the main pulmonary artery, two gas bubbles of 15 mm of size with air-fluid levels. (arrowheads)"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010857/000001.jpg?itok=A0PA_R2-",
            "caption": "CECT (Axial view) shows:  triradiate image due to pulsation artefact (circle) caused by intravascular air bubble (dynamic Mercedes Benz sign) in the brachiocephalic vein."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010857/000003.jpg?itok=jYpFDvpH",
            "caption": "CECT (axial view) shows gas bubbles in right subclavian vein (red arrow)."
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010857/000004.jpg?itok=iM-eViqs",
            "caption": "CECT (MPR coronal view) shows gas bubbles  in right subclavian vein (red arrow)."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Cardiovascular system"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/10857",
    "time": "11.06.2013"
  },
  "10901": {
    "case_id": 10901,
    "title": "Recurrent respiratory papillomatosis",
    "section": "Chest imaging",
    "age": "69",
    "gender": "male",
    "diagnosis": "Recurrent respiratory papillomatosis",
    "history": "A 69-year-old male patient presented with dysphonia. He denied dysphagia or shortness of breath. Physical examination revealed hoarseness of voice; lungs were clear in auscultation bilaterally.",
    "image_finding": "Axial CT images through the lungs show bilateral solid and cystic nodules consistent with papillomatosis (Fig. 1). Axial CT and virtual bronchoscopy images through the trachea demonstrate tracheal papillomatosis causing intrinsic airway stenosis (Fig. 2, 3).",
    "discussion": "Recurrent Respiratory Papillomatosis (RRP) is an uncommon condition affecting the respiratory tract. It is associated with Human Papilloma Virus (HPV), specifically types 6 and 11 [1]. RRP can affect both children and adults. The cause of RRP in adults is thought to be sexually-transmitted. In children transmission is thought to be vertical from an HPV infected mother during childbirth. Risk factors include mother <20 years of age, being the first-born child, and vaginal delivery (though cesarean section does not always prevent transmission) [1]. The incidence of RRP is estimated at 4.3 cases per 100,000 in children, and 1.8 cases per 100,000 in adults. RRP is characterised by multiple lobulated, warty intraluminal lesions throughout the airways. The vast majority of patients have laryngeal involvement [1]. Lesions can arise anywhere throughout the respiratory tract by gravitational seeding from lesions in the upper airways. Less than 1% of patients develop pulmonary papillomatosis [2].Patients commonly present clinically with dyspnoea, hoarseness, haemoptysis, dysphagia, and obstructive pneumonia, but symptoms vary depending on the location and number of lesions [3]. Papillomas in the airways cause mechanical obstruction, necessitating many patients to undergo laryngoscopy and excision. Unfortunately surgical procedures to relieve airway obstruction are associated with a higher incidence of pulmonary involvement, which is thought to be the result of spread of viral particles through the airways [3].Characteristic CT findings include soft tissue lobulated nodules spread throughout the large airways [2]. Lung nodules begin as small solitary lesions that progressively enlarge and cavitate as the tumour outgrows its vascular supply. RRP lesions can undergo malignant degeneration into squamous cell carcinoma in 2% of patients with pulmonary involvement [2]. Patients undergo surveillance with serial chest CT scans. Three dimensional reconstructions from CT images can generate virtual bronchoscopic images which evaluate the airway distal to luminal obstruction which is an advantage over conventional bronchoscopy.Treatment is aimed at palliation of symptoms (primarily maintaining the airway) once the disease has disseminated. Pulsed dye lasers and oscillating microdebriders are commonly employed for resecting lesions in many institutions [3]. Injection of the surgical bed with antiviral agents such as cidofovir has also been shown to slow lesion recurrence [3]. Photodynamic therapy and systemic chemotherapeutic agents have not cured RRP, and the side effect burden is high [1]. The lesions of RRP are notoriously difficult to control and prognosis is poor [2]. Patients often die from respiratory failure as airway papilloma burden increases.",
    "differential_diagnosis": "Recurrent, respiratory, papillomatosis, Wegener\u2019s, Granulomatosis, Septic, emboli, Metastases",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010901/000001.jpg?itok=BktS8ryJ",
            "caption": "Chest CT on lung windows demonstrates right lower lobe solid and cavitary nodules consistent with papillomas."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010901/000002.jpg?itok=V26sS_-v",
            "caption": "Axial CT image at a slightly more superior level demonstrates bilateral cavitary lesions and two right-sided solid papillomas."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010901/000003.jpg?itok=axk2KynY",
            "caption": "Axial chest CT image demonstrates significant intrinsic airway stenosis secondary to tracheal papillomatosis."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010901/000004.jpg?itok=JeOE8w0M",
            "caption": "Virtual bronchoscopic image and MPR images demonstrate intraluminal papillomatosis."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Mediastinum",
      "Lung"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/10901",
    "time": "25.04.2013"
  },
  "10906": {
    "case_id": 10906,
    "title": "Cardiac volvulus (ECR 2012 Case of the Day)",
    "section": "Chest imaging",
    "age": "57",
    "gender": "male",
    "diagnosis": "Cardiac volvulus - following intrapericardial pneumonectomy and partial pericardiectomy for mesothelioma",
    "history": "This 57-year-old man developed acute haemodynamic compromise one day following major cardiothoracic surgery for a right-sided pleural based mesothelioma.",
    "image_finding": "Fig. 1a: AP chest radiograph in the immediate post-operative period. This demonstrates the air-filled right pleural cavity with central venous catheter in situ.Fig 1b: AP chest radiograph on post-operative day 1 immediately following the patient's clinical deterioration.",
    "discussion": "Cardiac herniation and volvulus are rare complications following pneumonectomy and are even less common following lobectomy. The majority of cases result from a pericardial defect created at the time of surgery, most frequently following intrapericardial pneumonectomy, resulting in a large dead space with negative pressure that predisposes to cardiac herniation and volvulus. Cardiac herniation can occur irrespective of the size of the surgically created pericardial defect and shows no side predilection [1].Clinical perspective: Cardiac herniation typically presents in the early post-operative period and is a catastrophic complication requiring immediate treatment. The clinical presentation relates to the location of the pericardial defect. On the right side kinking or torsion of both the SVC and the IVC may impair cardiac venous return resulting in haemodynamic shock due to impaired filling. SVC obstruction syndrome may also occur in this setting. On the left side cardiac herniation produces dysrhythmias and acute myocardial ischaemia due to strangulation of the ventricular wall by the pericardial edges [2].Important clinical signs include loss of the normal cardiac apex beat and bizarre ECG patterns. Imaging perspective: The plain chest radiograph in the setting of partial or impending herniation may show a slight bulge at the site of the pericardial defect (snow cone sign) with the heart shifting toward the operative side [3]. Right sided cardiac herniation is usually unmistakable; the shadow of the herniated heart can easily be seen in the vacant right pleural cavity at chest radiography and is easily recognisable and pathognomonic. The residual pericardial sac is then empty and may be outlined by air. Left-sided herniation is less easily recognised; there may be mediastinal shift to the left and abnormal cardiac contour with bulging of the left heart border [4]. Bedside echocardiography may be helpful in cases of diagnostic uncertainty. The acuity of the clinical scenario typically precludes CT evaluation where findings are similar to those seen on the plain radiograph [5].Outcome: The diagnosis of cardiac volvulus in our patient was made on the chest radiograph findings. The patient returned immediately to the operating theatre for repeat thoracotomy with repositioning of the heart and patch repair of the pericardial defect. The patient recovered well with no further complications.Take home message: Clinical awareness and a high index of suspicion are essential for the prompt diagnosis and treatment of this rare but well recognised and potentially catastrophic post-pneumonectomy complication.",
    "differential_diagnosis": "Cardiac, volvulus, -, following, intrapericardial, pneumonectomy, and, partial, pericardiectomy, for, mesothelioma, Pericardial, mass, Intrathoracic, haemorrhage, Bronchial, stump, dehiscence, Cardiac, tamponade",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010906/000001.jpg?itok=c83P-aiC",
            "caption": "AP chest radiograph in the immediate post-operative period. This demonstrates the air-filled right pleural cavity with central venous catheter in situ."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010906/000003.png?itok=WuAO1_oB",
            "caption": "AP chest radiograph on post-operative day 1 immediately following the patient\\'s clinical deterioration."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Cardiac"
    ],
    "imaging_technique": [
      "Conventional radiography"
    ],
    "link": "https://www.eurorad.org/case/10906",
    "time": "04.04.2013"
  },
  "10939": {
    "case_id": 10939,
    "title": "Pulmonary polymethyl methacrylate (PMMA) - cement embolism",
    "section": "Chest imaging",
    "age": "80",
    "gender": "female",
    "diagnosis": "Pulmonary polymethyl methacrylate (PMMA) - cement embolism",
    "history": "An 85-year-old female patient, with a background history of vertebroplasty for compression fractures, presented with a subacute history of shortness of breath. She was investigated with a CT scan of the chest.",
    "image_finding": "Axial post contrast bone windowed CT image at the level of the right pulmonary artery (Fig. 1 - arrow) demonstrates peripheralised radiodense intravascular material representing an embolised polymethyl methacrylate (PMMA) cement fragment. Note that this is as dense as the undiluted contrast jet within the superior vena cava. An axial CT image further below at the level of right ventricle (Fig. 2 - arrow) demonstrates a similarly dense intracardiac embolic fragment within the right ventricle abutting the interventricular septum. This image and an image more inferiorly at the level of T12 (Fig. 3 - arrow) show radiodense migrated PMMA material within the paravertebral veins. A cast of paravertebral migrated PMMA cement material within the paravertebral veins extends from vertebroplasty material within T10 to L2 and is confirmed on sagittal images (Fig. 4a-d).",
    "discussion": "BackgroundVertebroplasty is a commonly performed procedure for symptomatic relief and strengthening of diseased bone resulting from various pathological processes such as compression fractures. It is usually performed by administration of a hard setting acrylic cement (poly-methyl methacrylate or PMMA). A complication that can uncommonly occur is extravertebral extrusion and venous migration, which can in turn result in distal embolisation. The incidence of PMMA pulmonary embolism is estimated at around 5-23% [1-3]. Clinical perspectiveWhile most patients with PMMA-cement emboli are asymptomatic, a small proportion can have symptoms [2, 4]. In many instances, leakage is related to injection of poly-methyl-methacrylate (PMMA) which is at an extremely liquid state or by applying excessive pressure during injection [5]. Other predisposing factors include close needle positioning with respect to basivertebral veins and overfilling of vertebral bodies [6]. PMMA-cement hardens through time and can be typically seen as a cast of radiodense material extending into paravertebral veins from a vertebral body. Reported management options vary greatly ranging from conservative strategies (i.e. observation) to anticoagulation to embolectomy. Imaging perspectiveDue to extreme hyperattenuation of PMMA, the diagnosis of PMMA emboli can be made on a non contrast CT scan. Post (IV) contrast scans may give more detailed information, although reviewing on bony window settings is essential as PMMA can be easily masked by intravenous contrast on soft tissue window settings. The administration of contrast helps assessment of the rest of the vascular system. In an event of PMMA emboli to the lungs, CT scans typically show extremely dense intraluminal material within the pulmonary arterial system. Recognition and reporting of intracardiac embolic fragments is important. There are published reports of cardiac perforation from intracardiac PMMA fragments [7-8] although this fortunately did not occur in our case. Sagittal and coronal review of vertebral levels aid direct visualisation of a typical cast of extravertebral extension of migrated PMMA. OutcomeThe peripheral location of embolic pulmonary arterial PMMA-cement as well as the duration of symptoms in our case suggested that the embolic event may not have been acute. Due to minimal and resolving symptoms, other comorbidities and a relatively low embolic burden, a conservative strategy was adopted in our case with no further adverse outcome.Teaching pointsThis case highlights the importance of recognising intracardiac and pulmonary PMMA-cement emboli as potential complications associated with vertebroplasty. The case also emphasises the value of reviewing intrathoracic images in bony window settings in this clinical context.",
    "differential_diagnosis": "Pulmonary, polymethyl, methacrylate, (PMMA), -, cement, embolism, Contrast, within, the, pulmonary, artery, Calcification, associated, with, the, pulmonary, artery",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010939/000001.jpg?itok=6ShRjZf6",
            "caption": "Axial post contrast CT image windowed on bone settings demonstrate a radio-opaque peripheralised density within the right lower pulmonary artery (arrow) representing an embolised PMMA cement fragment"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010939/000002.jpg?itok=wbpNtpXO",
            "caption": "Axial post contrast CT image on bone window settings demonstrates a similarly radiodense linear density within the right ventricle abutting the interventricular septum (arrow) representing a further embolic intracardiac PMMA fragment"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010939/000003.jpg?itok=kBwPwVK-",
            "caption": "Axial bone windowed post contrast CT image at the level of the T12 vertebra demonstrates migrated radiodense PMMA-cement within the right paravertebral vein (arrowed)"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010939/000007.jpg?itok=jyRH7PpY",
            "caption": "Sagittal post contrast CT images demonstrate vertebroplasty material from T10 to L2 levels with evidence of migration of similarly dense vertebroplasty cement - PMMA material into the paravertebral veins."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010939/000004.jpg?itok=XgZkEWHP",
            "caption": "Sagittal post contrast CT images demonstrate vertebroplasty material from T10 to L2 levels with evidence of migration of similarly dense vertebroplasty cement - PMMA material into the paravertebral veins."
          },
          {
            "number": "Figure 4c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010939/000005.jpg?itok=rKKIMiSi",
            "caption": "Sagittal post contrast CT images demonstrate vertebroplasty material from T10 to L2 levels with evidence of migration of similarly dense vertebroplasty cement - PMMA material into the paravertebral veins."
          },
          {
            "number": "Figure 4d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010939/000006.jpg?itok=n_Q_TbJz",
            "caption": "Sagittal post contrast CT images demonstrate vertebroplasty material from T10 to L2 levels with evidence of migration of similarly dense vertebroplasty cement - PMMA material into the paravertebral veins."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax",
      "Thoracic wall"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/10939",
    "time": "25.06.2013"
  },
  "10966": {
    "case_id": 10966,
    "title": "Swyer-James syndrome",
    "section": "Chest imaging",
    "age": "40",
    "gender": "male",
    "diagnosis": "Swyer-James-MacLeod Syndrome",
    "history": "A 40-year-old male patient came to the emergency department with a one-week history of fever, cough and haemoptysis.",
    "image_finding": "Posteroanterior chest radiograph shows the right pulmonary hilum decreased in size and an asymmetry of the lung vasculature, lower on the right side. The left pulmonary artery shows slight compensatory enlargement and the right lung volume seems slightly decreased (Fig. 1). CT angiography study confirms the findings described in radiography and displays a heterogeneity in the right lung parenchymal density consistent with a mosaic attenuation pattern (Fig. 2, 3). Cylindrical bronchiectasis, and some cystic, are observed in the right lung, although they are more numerous in the right lower lobe (Fig. 2). Furthermore, there is bronchial wall thickening. No obstruction in the right main bronchus is noted (Fig. 2c).",
    "discussion": "Swyer-James-Mc Leod Syndrome (SJMS) is also known as unilateral hyperlucent lung syndrome. SJMS is generally believed to be a post-infectious complication of viral bronchiolitis or pneumonitis acquired during early childhood. SJMS can result from various lower respiratory tract infections, including adenovirus, measles, pertussis, tuberculosis, or mycoplasma. The infection leads to obliterans bronchiolitis causing inflammation and fibrosis of the respiratory bronchiolar walls and the interalveolar septa which causes reduction of ventilation and distal airways trapping. Secondarily, these changes lead to decrease blood flow to the major pulmonary artery segments which in turn results in the hypoplastic arterial development resulting in pulmonary parenchyma hypoperfusion. [1, 2]Clinically, most patients are asymptomatic and the disease is often an incidental finding on chest X-ray. However, affected patients may have a history of recurrent pulmonary infection and present with nonspecific respiratory symptoms, such as dyspnoea on exertion, productive cough, and shortness of breath. [3] The hyperlucency results from air trapping and decreased pulmonary vascular marking in the involved area. The characteristic radiographic findings of SJMS consist of asymmetric hyperlucency of the lung or lobe, small hilar shadow with decreased vascularity, bronchial wall thickening, mediastinal shift toward the hyperlucent thorax, sometimes it can see signs of bronchiectasis. Characteristic CT appearances include lobar hyperlucency due to underlying air trapping, with decreased size of the pulmonary artery and reduction in the number of its branches, bronchiectasis, mosaic attenuation pattern. Expiratory ct images are more reliably in demonstrating air trapping, which is the key finding to differentiate this entity from other conditions. [2, 4, 5]Among the conditions that may mimic unilateral lung hyperlucency, are the following: Technical problems, chest wall abnormalities (absence or wasting of pectoral muscle, absence of breast, soft tissue surgery, scoliosis, hypolucency of the contralateral lung), parenchymal abnormalities (compensatory overinflation, emphysema, central obstruction of a bronchus, partial bronchial obstruction -foreign body or endobronchial tumour-),  vascular abnormalities (pulmonary embolism, pulmonary artery stenosis or agenesis). [5]The prognosis is generally good. Most patients have an asymptotic course unless the opposite lung becomes diseased. The treatment is generally symptomatic. However, surgery should be considered if secondary infection or bronchiectasis become severe. [1, 2]Radiologists have a key role in this entity, if the typical findings are present (as in our case, although an expiratrory image would have been desirable) then the diagnosis can be reached without performing other examinations.",
    "differential_diagnosis": "Swyer-James-MacLeod, Syndrome, Technical, problems, Chest, wall, abnormalities, Parenchymal, abnormalities, Vascular, abnormalities",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010966/000001.png?itok=RYKojGI2",
            "caption": "Posteroanterior chest radiograph shows the right pulmonary hilum decreased in size and an asymmetry of the lung vasculature, lower on the right side. The left pulmonary artery shows slight compensatory enlargement."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010966/000003.png?itok=fZilNwae",
            "caption": "CT angiography study on lung window (axial image) shows a mosaic attenuation pattern, cylindrical bronchiectasis, some cystic (more numerous in the right lower lobe). Furthermore, there is bronchial wall thickening."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010966/000004.png?itok=fyUM6_vb",
            "caption": "CT angiography study on lung window (axial image) shows a mosaic attenuation pattern, cylindrical bronchiectasis, some cystic (more numerous in the right lower lobe). Furthermore, there is bronchial wall thickening."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010966/000006.png?itok=wVN0kd4A",
            "caption": "CT angiography study on lung window (axial image) shows a mosaic attenuation pattern, cylindrical bronchiectasis, some cystic (more numerous in the right lower lobe). Furthermore, there is bronchial wall thickening."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010966/000008.png?itok=WaCOA4XJ",
            "caption": "CT angiography study on lung window (axial image) shows a mosaic attenuation pattern, cylindrical bronchiectasis, some cystic (more numerous in the right lower lobe). Furthermore, there is bronchial wall thickening."
          },
          {
            "number": "Figure 2e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010966/000009.png?itok=Nm91XitH",
            "caption": "CT angiography study on lung window (axial image) shows a mosaic attenuation pattern, cylindrical bronchiectasis, some cystic (more numerous in the right lower lobe). Furthermore, there is bronchial wall thickening."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010966/000010.png?itok=PxI6VsRj",
            "caption": "Axial image: The right pulmonary artery is decreased in size, while the left pulmonary artery shows slight compensatory enlargement."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010966/000011.png?itok=1j0yGf8L",
            "caption": "Coronal image: The right pulmonary artery is decreased in size, while the left pulmonary artery shows slight compensatory enlargement."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/10966",
    "time": "03.11.2013"
  },
  "10974": {
    "case_id": 10974,
    "title": "Bronchial atresia seen as a rounded opacity on a chest radiograph",
    "section": "Chest imaging",
    "age": "42",
    "gender": "male",
    "diagnosis": "Bronchial atresia.",
    "history": "A 42-year-old man, smoker without respiratory symptoms, presented with episodes of intense cramping pain in hypogastrium that usually lasted a few seconds and spontaneously yielded. He had recently been diagnosed with ileitis.",
    "image_finding": "Imaging for investigation of acute abdominal pain was undertaken. These included a posteroanterior chest radiograph.An oval or slightly tubular cylindrical opacity was seen in the right upper lung zone. A subtle hyperlucent area surrounded the opacity (Figure A). Bronchial mucus plug and bronchial atresia was suspected as the patient had no respiratory symptoms. A chest CT was performed in order to confirm this suspicion and to exclude the presence of a solitary pulmonary nodule or endobronchial lesion taking into account the smoking history of the patient (Figure B).CT revealed a tubular hypodense lesion extending cephalad from the hilum with marked hypodensity in the surrounding lung located in the right upper lobe (Figure C, D). A cul-de-sac appearance was seen at the end of the sacular lesion. No signs of endobronchial tumour, foreign body or proximal stricture were seen. No other anomalies were seen.",
    "discussion": "Bronchial atresia is a rare congenital abnormality characterised by focal interruption of the proximal lumen of a bronchus. It is associated with mucus impaction (bronchocele) and peripheral hyperinflation of the distal lung segment, due to collateral air drift [1-3]. Some authors have reported that it is more common in young men [1].As in the presented case, bronchi of the upper lobes are more often involved than those of the lower lobes [4]. The exact cause is unknown [1].Histologic findings vary depending on whether there is an infection distal to the atretic bronchus. Microscopic analysis typically reveals intact distended alveoli, a finding indicative of lobar hyperinflation [4]. The proximal blind-ending bronchus is used as a diagnostic macroscopic indicator. Mucocele is characteristically found just distal to the atresia. Surrounding lung parenchyma appears normal or hyperinflated [1].Bronchial atresia is usually asymptomatic and incidentally discovered. If symptomatic, clinical manifestations may be related to pulmonary infections [4].A classic radiographic finding is a well-defined branching tubular or nodular area of increased opacity that extends from the hilum surrounded by hyperlucent lung parenchyma. [4]CT is the most sensitive imaging modality and its characteristic findings include mucocele, occlusion of the bronchus central to the mucocele and surrounding areas of air trapping. CT scan on expiration confirms the air-trapping. The diagnosis is confirmed if all three are present and acquired proximal bronchial obstruction by tumour, foreign body or inflammatory stricture is excluded [1, 2]. As opposed to other authors we think that fiberoptic bronchoscopy is not usually needed because identification of a blind-ending bronchus can be easily made with CT [1].CT and MRI are useful in depicting the absence of vascularity and enhancement within the lesion and exclude a vascular cause [4].Radiography and CT can be useful in the follow-up of these patients [3].Differential diagnosis includes other causes of mucous impaction like bronchiectases (allergic bronchopulmonary aspergillosis, cystic fibrosis), bronchial strictures or endobronchial tumours. Other anomalies such as bronchial cysts, intralobar sequestration or cystic adenomatoid malformation may present with low attenuation but do not maintain a close relation with the bronchus and do not have either a cul-de-sac appearance or air trapping [1, 4]. Most cases do not necessitate surgery because bronchial atresia is a benign disease, asymptomatic with no other serious complications. Minimal invasive surgery should be reserved only for patients with serious complications [1, 4]. The major indication for surgery is recurrent infection [2].",
    "differential_diagnosis": "Bronchial, atresia., Bronchiectasies, Endobronquial, tumours, Bronchial, cysts, Intralobar, sequestration, Adenomatoid, malformation, Congenital, lobar, emphysema",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010974/000004.jpg?itok=fh1b9JOP",
            "caption": "An oval opacity (white arrow) is seen on right upper lung zone surrounded by subtle hyperlucent area (yellow arrows). Note paucity of vessels seen on upper right lung zone compared to the left."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010974/000005.jpg?itok=dXv7sLLl",
            "caption": "A nonenhancing tubular lesion with water attenuation values that seems to arise from the hilum (arrow)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010974/000006.jpg?itok=hmzoyPzU",
            "caption": "Hypodense lung parenchyma with diminished vasculature is seen on the right upper lobe (arrows). These findings are consistent with air trapping. Expiratory CT scan would greatly enhance this finding (had it been acquired)."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010974/000007.jpg?itok=dsmqeDDo",
            "caption": "Coronal MinIP reconstruction confirms the air trapping in the right upper lobe."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT",
      "Conventional radiography"
    ],
    "link": "https://www.eurorad.org/case/10974",
    "time": "21.08.2013"
  },
  "10994": {
    "case_id": 10994,
    "title": "Hyperlucent unilateral lung: Swyer-James McLeod syndrome",
    "section": "Chest imaging",
    "age": "41",
    "gender": "female",
    "diagnosis": "Swyer-James-McLeod syndrome",
    "history": "A 41-year-old woman with chronic myeloid leukaemia underwent a chest radiograph.",
    "image_finding": "Chest radiograph showed a subcentimetric nodule in left upper lobe (already present in a film taken 3 years before). Moreover her left lung appeared rather small and more hyperlucent when compared to the right one (Fig 1).Unenhanced chest CT confirmed that both lobes in the left lung were smaller and hyperlucent compared to the three normal lobes in the right lung (Figs 2, 3, and 4). Left lung had clearly diminished vascularity, and left pulmonary artery was only slightly smaller (Fig 5).",
    "discussion": "Hyperlucent unilateral lung can result from many causes. Before considering the existence of underlying pathology, one should rule out technical issues (patient positioning and heel effect). In most cases, hyperlucent unilateral lung is derived from extra-pulmonary problems, and only in a small proportion of cases is caused by a pulmonary disease.Between the extra-pulmonary causes one should consider:- thoracic wall alterations: mastectomy, Poland syndrome (congenital pectoral muscle absence), and scoliosis are the most common.- pleural pathology: pneumothorax and contra-lateral pleural effusion are frequent causes of hyperlucent unilateral lung. Pulmonary diseases are less common causes of hyperlucent unilateral lung. Emphysema, bullae, air trapping due to endobronchial obstruction, thromboembolism, pneumatocele, pulmonary artery or vein atresia or stenosis, compensatory distension, and Swyer-James- McLeod syndrome should be considered, and differential diagnosis usually requires chest X-ray and chest CT. In this case, unenhanced chest CT (Fig. 2) showed that the left lung was smaller, hyperlucent and presented diminished vascularity, consistent with Swyer-James-McLeod syndrome [1]. Since CT findings were highly conclusive of this condition, they sufficed to reach the final diagnosis, and also ruled out alternative causes [2, 3, 4]. In the CT sections on lung windowing there were no findings of intrabronchial lesions, mucus plugs or foreign bodies. Chest wall was entirely normal and no pleural pathology was observed.This rare condition is usually asymptomatic, although respiratory infections can appear if bronchiectasis are present [2]. Due to the scarcity of clinical expression, it is usually first suspected on the basis of radiographic findings: smaller and hyperlucent lobe or lung, air trapping that can be proved on expiratory X-ray or CT, and diminished number and size of distal pulmonary artery branches. Its cause remains uncertain, although it is believed that following an adenoviral respiratory infection in infancy or early childhood, post-infectious obliterative bronchiolitis hampers the normal development of the affected lung and pulmonary vessels [5]. Depending on the extent and degree of compromised lung parenchyma, the findings can affect one or more lobes, and are usually but not always confined to one lung. Bronchiectases can be present, but their absence does not preclude the diagnosis of Swyer-James-McLeod syndrome.",
    "differential_diagnosis": "Swyer-James-McLeod, syndrome, Technical, issues:, patient, rotation, Technical, issues:, heel, efect, Mastectomy, Poland, syndrome, Pneumothorax, Emphysema, Scoliosis, Pulmonary, thromboembolism, Endobronchial, obstruction:, foreign, body, (children), Endobronchial, obstruction:, mucus, plug, Endobronchial, obstruction:, neoplasm",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010994/000001.jpg?itok=0_Lay1kM",
            "caption": "A subcentimetric nodule in left upper lobe (already present in a film taken 3 years before) was noted. More subtly, her left lung appeared rather small and hyperlucent when compared with the right one."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010994/000002.jpg?itok=J5i7VSGo",
            "caption": "Chest CT showed that the left lung was smaller, hyperlucent and presented diminished vascularity."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010994/000003.jpg?itok=zxAjbYRM",
            "caption": "Note the slightly decreased size of the left pulmonary artery."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010994/000004.jpg?itok=hOy7nq5a",
            "caption": "Chest CT showed that the left lung was smaller, hyperlucent and presented diminished vascularity."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000010994/000005.jpg?itok=2ZbX4Ygf",
            "caption": "Chest CT showed that the left lung was smaller, hyperlucent and presented diminished vascularity."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT",
      "Digital radiography"
    ],
    "link": "https://www.eurorad.org/case/10994",
    "time": "21.08.2013"
  },
  "11002": {
    "case_id": 11002,
    "title": "xtra medullary haematopoiesis (ECR 2013 Case of the Day)",
    "section": "Chest imaging",
    "age": "45",
    "gender": "female",
    "diagnosis": "Extramedullary haematopoiesis (EMH), here due to thalassaemia major",
    "history": "A 45-year-old woman of Italian descent presented with dyspnoea. The physical examination revealed 26 respirations per minute, a heart rate of 103 beats per minute, clear lungs. Laboratory analyses showed a haemoglobin level of 8g per decilitre. She had chronic anaemia and had undergone splenectomy several years before.",
    "image_finding": "Posteroanterior chest-X ray (Fig. 1)Comment: Posteroanterior chest radiograph demonstrates smooth soft-tissue masses projecting along the lower dorsal spine behind the cardiac silhouette. CT angiography mediastinal window (Fig. 2 and 3)Comment: Bilateral paravertebral soft-tissue masses are demonstrated and are associated with soft tissue masses along the inner part of the anterior part of right rib, with focal cortical erosion.Coronal reformation, bone window (Fig. 4)Comment: The vertebral cortexes are thinned due to medullary expansion.",
    "discussion": "A. BackgroundExtramedullary haematopoiesis (EMH) is regarded as a physiologic compensatory mechanism that occurs when the bone marrow is unable to maintain sufficient red cell production to supply body demand, particularly in congenital haemolytic anaemia such as thalassaemia and hereditary spherocytosis. The CT appearance is characterised by the presence of homogeneous round or lobulated soft tissue density masses usually in the posterior mediastinum. It has also been reported in various extra thoracic locations, most commonly in the liver, spleen, and thorax [1, 2]. Though symptoms related to intrathoracic EMH are uncommon, there are reported cases of spinal cord compression [3].B. Clinical PerspectiveThe thalassaemia syndromes are inherited disorders of haemoglobin synthesis, typically seen in individuals of Mediterranean descent. Most patients with thalassaemia have the homozygous form (thalassaemia major). The total annual incidence of symptomatic individuals is estimated at 1 in 100,000 throughout the world [4].C. Imaging PerspectiveThoracic EMH characteristically appears on the plain chest radiograph as posterior mediastinal masses that are lobulated and smooth. They may be unilateral or bilateral and exhibit a predilection for the lower thoracic spine region. On computed tomography scans, EMH appears as an area of soft-tissue attenuation adjacent to the posterior ribs [5]. Calcification and associated vertebral anomalies are rare, which helps distinguish EMH from many other causes of posterior mediastinal masses. EMH may also manifest as masses at expanded anterior rib ends as in the present case, though this site is less common.D. OutcomeComplications include those due to iron overload, post splenectomy infectious complications and spinal cord compression. Pulmonary arterial hypertension is another complication in patients with thalassaemia major and is due to chronic anaemia, haemolysis, and to an increased tendency for microscopic thrombi to form within the pulmonary vasculature.E. Take Home Message, Teaching PointsPosterior mediastinal masses of soft-tissue attenuation, in the lower part of the thorax in patients with chronic haemolytic anaemia are highly suggestive of EMH and must be distinguished from other causes of posterior mediastinal masses.",
    "differential_diagnosis": "Extramedullary, haematopoiesis, (EMH),, here, due, to, thalassaemia, major, Lymphoma, Pleural, plaques, Sarcoidosis, Pleural, metastatic, disease",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011002/000001.jpg?itok=B-pwF4iz",
            "caption": "Posteroanterior chest radiograph demonstrates smooth soft-tissue masses projecting along the lower dorsal spine behind the cardiac silhouette"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011002/000002.jpg?itok=f-NyiNoQ",
            "caption": "There is a soft tissue mass along the inner part of the anterior part of right rib, with focal cortical erosion."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011002/000003.jpg?itok=laqqtzZK",
            "caption": "Bilateral paravertebral soft-tissue masses are demonstrated."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011002/000004.jpg?itok=p7kHbnm2",
            "caption": "The vertebral cortexes are thinned due to medullary expansion."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax",
      "Mediastinum",
      "Musculoskeletal bone"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT-Angiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/11002",
    "time": "21.05.2013"
  },
  "11036": {
    "case_id": 11036,
    "title": "Thymic carcinoma with pleural metastases and superior vena caval invasion",
    "section": "Chest imaging",
    "age": "55",
    "gender": "female",
    "diagnosis": "Thymic carcinoma with pleural metastases and SVC invasion",
    "history": "A 55-year-old female non-smoker presented with a two month history of shortness of breath preceded by a 4-month history of myasthenia gravis. She has had previous aortocoronary bypass surgery but had been stable from a cardiac perspective. Apart from previous cosmetic breast augmentation, there was no other significant clinical history.",
    "image_finding": "The chest radiographs (Fig. 1a-b) demonstrate a lobulated anterior mediastinal mass with further ill-defined shadowing overlying the right lower and left mid zones. Bilateral pleural effusions are also present. Post-contrast axial CT images confirmed a large lobulated anterior mediastinal mass with bilataral paramediastinal extension. This mass is homogeneously iso-attenuating to chest wall musculature. The selected axial CT image (Fig. 2) also demonstrates SVC compression accompanied by subtle irregularity along its concave compressed margin towards the right (arrow); the latter feature is concerning for vascular invasion. Additional pleural based metastases are shown on the image more inferiorly (Fig. 3) and some of these demonstrate evidence of chest wall invasion. The sagittal image (Fig. 4) demonstrates contrast within the paraspinal veins from collaterals draining into the azygos venous system (arrow).No lung retraction or pleural plaques are seen. Percutaneous biopsy of one of the pleural based lesions revealed metastatic thymic carcinoma.",
    "discussion": "A thymic carcinoma is a neoplasm which lies at the malignant end of the spectrum of thymic epithelial tumours (classified as a type C thymic epithelial tumour under the WHO classification system) [1]. It is one of the imaging differential considerations for an invasive anterior mediastinal based intrathoracic mass lesion. At least ten histological types have been described with the most common subtypes being squamous cell carcinoma and lymphoepithelial-like carcinoma (previously classified as atypical thymoma) [2, 3]. As a general rule, thymic carcinomas tend to be larger in size than their benign counterparts [4].On CT, a thymic carcinoma is typically seen as a large, poorly marginated soft tissue attenuating mass. It is often seen invading adjacent structures on imaging. While areas of necrosis, haemorrhage, calcification and/or cyst formation may be seen [5], most tumours (as in this case) are homogenous and isoattenuating to chest wall musculature [6].An irregular contour +/- irregular invasion into adjacent organs (inclusive of the great vessels) are features which have been described as being useful in differentiating a thymic carcinoma from more benign thymic epithelial tumours [6, 7, 8]. Pericardial or pleural involvement and pleural effusions can also be frequent findings at diagnosis. Hilar lymph nodal enlargement, diaphragmatic elevation (suggesting underlying phrenic nerve palsy) [9] and presence of lung nodules (suggestive of metastases) are additional findings that would favour towards thymic carcinoma over an invasive thymoma on imaging. Thymic carcinomas are biologically aggressive and can frequently metastasise haematogenously to lungs, liver, brain and bone. Most patients (as in this case) typically present around the fifth decade of life. The presenting symptoms are generally secondary to mediastinal compression and/or invasion or related to distant metastases. Patients with thymic carcinoma have a very poor prognosis with mean survival rates at around 60% at 10 years [10].The presence of an anterior mediastinal based mass with gross invasion of vascular structures and pleural based metastases makes thymic carcinoma highly likely on imaging grounds. It is important for the radiologist to know that there is a very wide spectrum of thymic epithelial tumours (ranging from benign to malignant) as well as have an understanding on the significance of vascular invasion. Although the incidence of associated paraneoplastic syndromes such as myasthenia gravis has been described to be low (usually seen with more benign thymic epithelial tumours), it was interestingly present in this particular case as an initial presenting symptom.",
    "differential_diagnosis": "Thymic, carcinoma, with, pleural, metastases, and, SVC, invasion, Thymic, lymphoma, with, intrathoracic, spread, Primary, occult, bronchogenic, lung, cancer, with, intrathoracic, metastases, Mediastinal, lymphoma, with, intrathoracic, spread, Invasive, mediastinal, germ, cell, tumours, with, intrathoracic, spread, Mass-like, mesothelioma, with, anterior, mediastinal, involvement",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011036/000002.jpg?itok=j9ZnCl9i",
            "caption": "Axial CT images confirm a large lobulated anterior mediastinal mass-like conglomeration with evidence of SVC compression. The concave margin of compressed SVC shows subtle irregularity (arrow) which is suggestive of vascular invasion."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011036/000003.jpg?itok=6wFtT-Ik",
            "caption": "Axial CT image more inferiorly demonstrates large bilateral pleural metastases, some of which show blurring of fat planes with the chest wall which is concerning for chest wall invasion. Incidental bilataral breast implants are shown."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011036/000004.jpg?itok=p4v9zhuZ",
            "caption": "Sagittal image demonstrates contrast within the paraspinal veins from collaterals which then drain into the azygos venous system (arrow)."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011036/000005.jpg?itok=D6_BbLbX",
            "caption": "PA chest radiograph demonstrates a bulky mediastinal mass with a hilum-overlay sign suggesting either an anterior or posterior location. There are also added hazy densities overlying the lower zones and bibasal pleural effusions."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011036/000006.jpg?itok=C4soRjwe",
            "caption": "Lateral projection confirms  the anterior location of the mediatinal mass. Sternotomy wires are noted consistent with the known prior coronary arterial bypass surgery. Bibasal pleural effusions are also present."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "CT",
      "Conventional radiography"
    ],
    "link": "https://www.eurorad.org/case/11036",
    "time": "27.10.2013"
  },
  "11090": {
    "case_id": 11090,
    "title": "Proximal absence of the right pulmonary artery",
    "section": "Chest imaging",
    "age": "22",
    "gender": "male",
    "diagnosis": "Proximal absence of the right pulmonary artery",
    "history": "A 22-year-old man who presented with dry cough and mild dyspnea for several months. No other significant history.",
    "image_finding": "Chest X-ray was performed, which showed decreased volume of the right haemithorax, with elevated haemidiaphragm, and heart and mediastinal deviation toward the affected side (Figure 1).Chest CT scan revealed the absence of the right pulmonary artery (Figure 2a). Also, enlarged systemic collateral vessels were observed (Figure 2b). High-resolution CT (HRCT) scan showed thickened interlobular septa, with some nodularity in certain areas (Figure 3), presenting a central and peripheral distribution associated with thickening of the major and minor fissure (Figure 3b).",
    "discussion": "The main pulmonary artery is derived from the sixth aortic arches during the first 16 weeks of intrauterine development [1, 2, 3]. Proximal interruption of the right or left pulmonary artery is an uncommon anomaly [2, 4, 5]. Right-side compromise is the most frequent, and generally an isolated finding. Development of the bronchial tree is normal, and no air trapping is observed [2, 3, 4, 5]. The right pulmonary artery ends blindly at the hilum, while the systemic collateral vessels irrigate the lung [1, 3, 4, 5]. Diagnosis is generally made in adulthood [2, 6]. It may be asymptomatic or associated to: recurrent pulmonary infections, decreased exercise tolerance, mild dyspnea and haemorrhage [1, 2, 6]. Haemoptysis is attributable to the rupture of hypertrophied collateral vessels (10% of cases) [4, 5]. Pulmonary function is normal, or it may show a slightly restrictive pattern [2]. Pulmonary hypertension affects 25% of patients, and it is the most important prognostic determinant [1]. In these patients, surgical revascularisation can improve pulmonary arterial pressure [1, 6].Radiological findings on chest radiograph are the following: volume loss in the affected hemithorax with elevated hemidiaphragm, and heart and mediastinal deviation toward the affected side. There is hyperinsuflation of contralateral lung [1, 4, 5]. A thin peripheral reticular pattern can be observed, together with pleural thickening and costal notches [1].CT scan shows absence of the mediastinal portion of the affected pulmonary artery, enlargement of collateral vessels, pleural thickening and thin peripheral reticular opacities attributed to transpleural collateral vessels anastomosing with peripheral branches of the pulmonary artery [1, 4]. HRCT scan shows smooth septal thickening, associated to venous, lymphatic congestion or interstitial edema. It is speculated that pleural thickening and adhesions may cause lymphatic drainage disorder, and secondarily produce septal thickening [1].Magnetic resonance imaging can also show proximal interruption of the right pulmonary artery [2, 5]. The affected lung shows a reduction in size and increased signal intensity. An advantage of CT scanning is that it allows a better evaluation of the bronchial tree and lung parenchyma [5].Angiography is reserved for patients with a doubtful diagnosis with CT or MRI [2].Treatment includes pneumonectomy, ligature of abnormal vessels and anastomosis of the remaining pulmonary artery with the main pulmonary trunk. In patients with massive hemoptysis, embolisation of systemic collateral vessels is indicated [3, 7].",
    "differential_diagnosis": "Proximal, absence, of, the, right, pulmonary, artery, Swyer-James, or, McLeod, s\u00edndrome., Chronic, thromboembolism., Hypogenetic, lung, syndrome.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011090/000001.png?itok=hkfs1LRV",
            "caption": "Decreased volume of the right haemithorax, elevated haemidiaphragm, and heart and mediastinal deviation toward the right side are observed. Absence of the right pulmonary hilum (arrows) and thickened lower fissure (arrowhead) is also noted."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011090/000002.png?itok=khuZcDNI",
            "caption": "Absence of the mediastinal portion of the right pulmonary artery is shown."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011090/000003.png?itok=Hkzr1w3j",
            "caption": "Collateral circulation: Enlarged right internal mammary artery is observed (arrow). Compare with the normal contralateral side (arrowhead)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011090/000004.png?itok=yYZMVsS6",
            "caption": "Nodular septal thickening at apical segment of right upper lobe is shown (arrowheads)."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011090/000005.png?itok=Rhl8Z69c",
            "caption": "Nodular thickening in the major fissure is observed (arrows)."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011090/000006.png?itok=XIK2Vl0_",
            "caption": "Septal thickening is also observed at the lung bases (arrowheads)"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "CT",
      "Digital radiography"
    ],
    "link": "https://www.eurorad.org/case/11090",
    "time": "27.09.2013"
  },
  "11098": {
    "case_id": 11098,
    "title": "Man with pneumorrhachis due to rupture of oesophagus after motor vehicle accident",
    "section": "Chest imaging",
    "age": "42",
    "gender": "male",
    "diagnosis": "Pneumorrhachis due to rupture of oesophagus caused by vehicle accident.",
    "history": "A 42-year-old man was admitted with a stretcher to our Emergency Department after a motor vehicle accident. He complained about chest and back pain. His level of consciousness was normal and so were his laboratory examinations including haematocrit.",
    "image_finding": "The patient underwent head and cervical spine CT. This examination was normal except for the existence of air in the paraspinal soft tissues in the lower slices of the cervical spine (Fig. 1, 2). Thereby, we performed chest and abdominal CT. There were small lung contusions, fractures from the 4th to the 10th right rib and a small pleural effusion on the right (Fig. 2). However, there was no pneumothorax. We found air in the paraspinal soft tissues from the C7 to the T7 vertebrae and in the epidural space at the levels of T3 to T6 vertebrae (Fig. 1, 2, 3). Trachea, bronchi and oesophagus were imaged intact. Due to the distribution of the free air we supposed that it had come from a small oesophageal rupture. Thus, we administered gastrografin per os and we discovered a small rupture of the oesophagus at the level of carina (Fig. 4).",
    "discussion": "Pneumorrhachis is the presence of air in the spinal canal. It comprises epidural air and subarachnoid air and is caused by iatrogenic, nontraumatic and traumatic causes. Iatrogenic causes may refer to surgery, anaesthesia or diagnostic techniques. Non-traumatic causes include malignancy, coughing, CPR, physical exertion and vomiting. Trauma is a less frequent cause and may be located in the head, cervical or thoracic spine, abdomen, pelvis or may affect a degenerated intervertebral disc with air due to the vacuum phenomenon. Sometimes, pneumorrhachis may be spontaneous or with no apparent cause. Air in the spinal canal may be found along with air in other compartments of the body like in pneumocephalus, pneumothorax, pneumomediastinum, pneumopericardium, subcutaneous emphysema or pneumoopticus [1, 2, 3]. The distribution of intraspinal air depends on the point of its entry, its quantity, the intraspinal canal's capacity and positioning of the patient [2]. In general, pneumorrhachis is asymptomatic and thus of little clinical significance. Rarely, it can cause pain or neurological deficits. However, the presence of air in the subarachnoid space should prompt surgeons to search and treat any underlying conditions. For example, in our case, the pneumorrhachis was caused by a rupture to the oesophagus which should be identified and treated [1, 2].Plain radiography detects only great amounts of air within the spinal canal and thus is used only to detect coexisting injuries or fractures. Lateral chest radiographs may show linear lucencies along the spinal canal representing pneumorrhachis. This image becomes more highlighted because the air acts as a negative contrast agent. CT is probably the best tool to detect pneumorrhachis. After initial diagnosis, follow up of patients can rely on clinical examination. MRI and myelography are more rarely used for differential diagnosis [1, 2].Pneumorrhachis in itself resolves automatically and is treated conservatively. However, surgeons should always treat any underlying cause. For example, a chest tube must be placed for pneumothorax, dural-enteric fistulas must be treated surgically and neurosurgical intervention is needed when there is leak of cerebrospinal fluid or pneumocephalus with increased intracranial pressure [1]. Pneumorrhachis may rarely cause cord compression and require decompressive surgery [4].In conclusion, when pneumorrhachis is found, we should always search for any underlying injuries in trauma patients or other pathological situations in non-trauma patients. Subarachnoid pneumorrhachis is worse than epidural pneumorrhachis and must be differentiated as it is associated with more severe injuries and is more often complicated by pneumocephalus or meningitis [1].",
    "differential_diagnosis": "Pneumorrhachis, due, to, rupture, of, oesophagus, caused, by, vehicle, accident., traumatic, pneumorrhachis, free, intraspinal, gas, collections, due, to, degenerative, causes, malignant, causes, inflammatory, causes, infectious, causes, by, gas-forming, organisms",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011098/000001.gif?itok=uDjimyCd",
            "caption": "Three of the lower  images of the otherwise normal CT examination of the cervical spine, which show the free air in the epidural space and in the paraspinal soft tissues."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011098/000002.gif?itok=SFtvuDIO",
            "caption": "Three of the lower  images of the otherwise normal CT examination of the cervical spine, which show the free air in the epidural space and in the paraspinal soft tissues."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011098/000003.gif?itok=WTZ7gd8a",
            "caption": "Three of the lower  images of the otherwise normal CT examination of the cervical spine, which show the free air in the epidural space and in the paraspinal soft tissues."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011098/000004.gif?itok=-0uYPEtO",
            "caption": "Chest CT image showing the free air in the epidural space and in the paraspinal soft tissues."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011098/000005.gif?itok=L-6MRiFI",
            "caption": "Chest CT image showing the free air in the epidural space and in the paraspinal soft tissues."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011098/000006.gif?itok=68KfsERl",
            "caption": "Chest CT image showing that there was also a fracture in the 5th right rib which seemed to be internally displaced."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011098/000007.gif?itok=PWekO_kL",
            "caption": "Chest CT slices which show the presence of free air in the paraspinal soft tissues in the level of C7 to T7 vertebrae."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011098/000008.gif?itok=bxt43lgX",
            "caption": "Chest CT slices which show the presence of free air in the paraspinal soft tissues in the level of C7 to T7 vertebrae."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011098/000009.gif?itok=UqHl4BFY",
            "caption": "Transverse image of the chest CT after the administration of gastrografin per os. Free air is seen next to the irregular wall of the oesophagus where the small oesophageal tear was considered to be."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011098/000010.gif?itok=xsKjJWRv",
            "caption": "Transverse image of the chest CT after the administration of gastrografin per os. Free air is seen next to the irregular wall of the oesophagus where the small oesophageal tear was considered to be."
          },
          {
            "number": "Figure 4c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011098/000011.gif?itok=5y0xJ0R4",
            "caption": "Coronal  image (MPR) of the chest CT after the administration of gastrografin per os. Free air is seen next to the irregular wall of the oesophagus where the small oesophageal tear was considered to be."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Emergency"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/11098",
    "time": "04.07.2013"
  },
  "11099": {
    "case_id": 11099,
    "title": "Double drain",
    "section": "Chest imaging",
    "age": "73",
    "gender": "male",
    "diagnosis": "Left-sided superior vena cava",
    "history": "This 73-year-old male patient presented with a sudden history of slurred speech and left sided weakness. A chest X-ray was performed on admission showing a right basal mass lesion, required cross sectional characterisation.",
    "image_finding": "The patient had a chest radiograph on admission, which showed a right basal rounded mass lesion (Figure 1). This required CT for characterisation. On CT, the right basal lesion was sharply demarcated and heavily calcified, likely an incidental granuloma (Fig. 2). The CT also showed absence of the left brachiocephalic vein crossing the midline to form the superior vena cava with the right brachiocephalic vein (Fig. 3-5). There was a left-sided vena cava draining into the coronary sinus (Fig. 4, 5).",
    "discussion": "A persistent left superior vena cava (PLSVC) is the most frequent thoracic venous anomaly, with a prevalence of 0.3-0.5% in the general population increasing to 10-12.9% in patients with congenital heart defects [1, 2, 3]. It occurs when the left anterior cardinal vein fails to occlude during early embryological development. The majority of cases are discovered as an incidental finding during routine investigations or procedures and patients are usually asymptomatic. In 80-90% of cases, a PLSVC will drain via a dilated coronary sinus into the right atrium (Figures 3-5). However, a small number of PLSVC can drain directly into the left atrium causing an anatomical right-to-left shunt, which may become symptomatic [1, 3]. It is for this reason that there should be an awareness of the potential incidental finding of a PLSVC such as during pacemaker insertion [4, 5, 6], central venous catheter placement [7, 8, 9] and benign calcification, which would warrant further evaluation. Consequently, knowledge of this embryological variant is particularly important for these and other cardiac procedures including surgery.",
    "differential_diagnosis": "Left-sided, superior, vena, cava, Collateral, venous, anatomy, Aneurysm, of, sinus, of, Valsalva, Surgical, bypass",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011099/000008.jpg?itok=6Xc8SY1V",
            "caption": "CXR on admission, showing a right basal density (black arrow)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011099/000009.jpg?itok=ZelbxDQb",
            "caption": "Coronal reconstruction of CT thorax showing a calcified lesion in the right base, likely a granuloma."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011099/000010.jpg?itok=s7aHwVJG",
            "caption": "Coronal reformat of CT thorax, showing an incidental finding of bilateral SVC.  The white arrows are depicting the left sided SVC."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011099/000011.jpg?itok=uHTi2Irj",
            "caption": "Coronal reformat of CT thorax, the arrows are highlighting the left sided SVC draining into the coronary sinus"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011099/000012.jpg?itok=fUELWisB",
            "caption": "Sagittal reconstruction of CT thorax.  White arrows highlighting the left SVC course through the thorax to drain into the coronary sinus."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011099/000013.jpg?itok=9xSnYy6a",
            "caption": "Axial CT thorax, showing both SVC, short white arrow right and long white arrow, left."
          },
          {
            "number": "Figure 5b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011099/000014.jpg?itok=HX5iE8Ow",
            "caption": "Axial CT thorax, showing the left SVC draining into the coronary sinus, white arrow."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Cardiovascular system",
      "Lung"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/11099",
    "time": "21.08.2013"
  },
  "11167": {
    "case_id": 11167,
    "title": "Scimitar -Venolobar Syndrome",
    "section": "Chest imaging",
    "age": "22",
    "gender": "female",
    "diagnosis": "Venolobar/ Scimitar Syndrome",
    "history": "A 22 year old female was admitted with cough not responding to antibiotics. There was no significant past medical history. A chest radiograph was undertaken and showed volume loss. MR study and subsequent pulmonary artriogram were performed to rule out any cardiac or vascular anomalies explaining the shortness of breath.",
    "image_finding": "Chest radiograph shows volume loss in the right hemithorax and mediastinal displacement to the right (Fig 1). There is no obscuration of right heart border or right hemidiaphragm to explain a lobar collapse or presence of mass as the cause of volume loss. MR Arteriogram confirms radiographic suggestion of volume loss with heart occupying right hemithorax (dextrocardia). There is compensatory expansion of left lung. Paucity of arterial vasculature on the right suggests hypoplasia. Aorta and inferior vena cava are normally  positioned (Fig 2).MR Venogram shows heart occupying right lower hemithorax and small right pulmonary venous confluence converging towards right atrium (fig 3). High-density contrast reaches the posterior portion of right atrium directly from the right pulmonary veins (fig 4).Selective right pulmonary arteriogram shows right lower lobe arterial hypoplasia (fig 5). Venous phase shows short right pulmonary venous confluence draining directly into right atrium (fig 6).",
    "discussion": "Imaging studies confirmed asymptomatic venolobar syndrome also known as scimitar syndrome but in this case the term \"venolobar syndrome\" is probably more appropriate to use.In Scimitar or Venolobar Syndrome [1], the two main components are lobar agenesis, aplasia, or hypoplasia and an abnormal draining pulmonary vein usually into the systemic circulation or right side of the heart. There are other minor associations (as this is a congenital anomaly), which are present to a varying degrees like dextrocardia, congenital heart disease (e.g. ASD, VSD, tetralogy of Fallot, PDA) / accessory diaphragm, diaphragmatic hernia/bronchiectasis/horseshoe lung/vertebral anomalies /genitourinary tract abnormalities [2, 3].Left sided scimitar syndrome although described in the literature, is very rare [1]. The common differentials being hypoplastic lung (not associated with abnormal venous drainage) and Macleod syndrome (without cardiovascular anomalies and ipsilateral transradiancy) [4].This case shows the main components of the syndrome i.e. lobar hypoplasia and abnormal venous drainage (direct drainage into right atrium being uncommon amongst reported cases) and the only minor association was azygos continuation of the IVC. There were no significant associated anomalies which is not surprising considering presentation in adulthood.The common differentials include anomalies originating from broncho-pulmonary structures especially in a paediatric age group [5].Presentation in childhood is usually symptomatic and associated with other congenital anomalies, while presentation in adulthood is usually an incidental finding or associated with less severe anomalies [4].Treatment is tailored to associations and symptoms.",
    "differential_diagnosis": "Venolobar/, Scimitar, Syndrome, Hypolastic, Lung, Swyer, James, Macleod, Syndrome",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011167/000001.jpg?itok=R3GVIPBJ",
            "caption": "Dextrocardia and volume loss in right hemithorax are noted."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011167/000002.jpg?itok=4YtuL6tJ",
            "caption": "Dextrocardia and paucity of right pulmonary arterial tree are noted  suggesting hypoplasia. The left pulmonary arterial tree is normal. No abnormal arterial supply to the lungs is seen."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011167/000003.jpg?itok=DVs9fVi9",
            "caption": "A short venous confluence of the right upper and middle lobe veins coursing towards right atrium is seen. The liver is normally sited but at a high position due to right lower lobe hypoplasia."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011167/000004.jpg?itok=ELLpPa2_",
            "caption": "Sequential MR image from figure 3 showing drainage/entry of the right pulmonary venous confluence into the right atrium."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011167/000005.jpg?itok=Gi5UBAH6",
            "caption": "Formal selective right Pulmonary arteriogram shows normal calibre upper and middle lobe arteries with hypoplastic lower lobe pulmonary artery."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011167/000006.jpg?itok=74c0IeQr",
            "caption": "Delayed images from the selective right pulmonary arteriogram showing short  right pulmonary venous confluence draining directly into the right atrium as depicted on MR."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "Catheter arteriography",
      "Conventional radiography",
      "MR-Angiography"
    ],
    "link": "https://www.eurorad.org/case/11167",
    "time": "14.09.2013"
  },
  "11194": {
    "case_id": 11194,
    "title": "Tracheobronchial aspergillosis",
    "section": "Chest imaging",
    "age": "49",
    "gender": "female",
    "diagnosis": "Tracheobronchial aspergillosis",
    "history": "A 49 year-old female presented  with neutropenic fever without antibiotic response. The patient suffered from myeloblastic acute leukemia and she was on the 14th week after the allogeneic transplant.",
    "image_finding": "Unenhanced thorax CT scan on mediastinal window shows circumferential diffuse thickening of the wall of the trachea and the main bronchi (narrow arrows) and stranding of the mediastinal fat (wide arrow). These findings were compatible with tracheobronchitis (in this context probably infectious) (Figure 1). Coronal CT reconstruction on lung window demonstrates diffuse and nodular thickening of the wall of the trachea was observed (arrows) (Figure 2).GM (galactomannan) test on BAL was positive.Transbronchial biopsy showed an inflammatory-mucoid material with septate hyphae, compatible with the clinical suspicion of aspergillosis.Five weeks later, after treatment with voriconazole, there was a complete resolution of the signs of tracheobronchitis on MDCT (Figure 3).",
    "discussion": "Tracheobronchial aspergillosis (TBA) is considered an uncommon clinical form of invasive Aspergillus infection confined to the tracheobronchial tree. This entity occurs most commonly in immunocompromised, neutropenic and AIDS patients. Other forms of pulmonary aspergillosis include: allergic bronchopulmonary aspergillosis, aspergilloma, and semi-invasive and invasive aspergillosis. The immunological state of the host influences the type of aspergillosis presentation.There are three forms of TBA based on clinical and pathological features [1, 2, 3]: -Obstructive: mucous plugs of Aspergillus spp. are present with extensive inflammation and absence of invasion of the tracheobronchial tree. This is a saprophytic form of infection.-Ulcerative: focal and ulcerative areas are described with histological invasion of Aspergillus hyphae into the bronchial mucosa and/or cartilage.-Pseudomembranous: there is extensive involvement of the tracheobronchial tree, with a membranous layer (containing Aspergillus) overlying the mucosa.Clinical features are in general non-specific: fever, cough (mostly unproductive), wheezing and hemoptysis [2, 3].Tracheobronchial aspergillosis can be present with normal radiology.CT reveals nonspecific findings: multifocal or diffuse tracheobrochial wall thickening which can be smooth or nodular. Clinical suspicion and bronchoscopic evaluation are the key to the diagnosis. Bronchoscopy with bronchial biopsy and culture is the diagnostic procedure recommended by many authors, enabling the confirmation of the diagnosis [1, 3, 4].The differential diagnosis of the diffuse wall thickening of the trachea and/or the main bronchi are: amyloidosis, Wegener`s granulomatosis,  tumoral infiltration, traqueobronchopathia osteochondroplastica, relapsing polychondritis and infectious tracheobronchitis (virus, bacteria, tuberculosis, Aspergillus) [5, 6].Prognosis of TBA in immunocompromised hosts is poor, mortality rate up to 70%. Treatment options consist of antifungal antibiotherapy. Voriconazole is recommended as initial therapy in the treatment of tracheobronchial aspergillosis and besides reduction of immunosuppression improves therapeutic outcome [7].The nonspecific clinical presentation and imaging findings can delay the diagnosis of this disease, increasing the patient`s risk. Therefore, radiologists play an important role in including this entity in the differential diagnosis in the appropriate context.",
    "differential_diagnosis": "Tracheobronchial, aspergillosis, Amyloidosis, Wegener\u00b4s, granulomatosis, Tumoral, infiltration, Traqueobronchopathia, osteochondroplastica, Relapsing, polychondritis, Infectious, tracheobronchitis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011194/000001.png?itok=GmcomotV",
            "caption": "Unenhanced thorax CT scan, axial mediastinal window image.  The images show circumferential diffuse thickening of the wall of the trachea and the main bronchi (narrow arrows) and stranding of the mediastinal fat (wide arrows)."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011194/000003.png?itok=HrMFs_L-",
            "caption": "Unenhanced thorax CT scan, axial mediastinal window image.  The images show circumferential diffuse thickening of the wall of the trachea and the main bronchi (narrow arrows) and stranding of the mediastinal fat (wide arrows)."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011194/000004.png?itok=d4YpI7uY",
            "caption": "Unenhanced thorax CT scan, axial mediastinal window image.  The images show circumferential diffuse thickening of the wall of the trachea and the main bronchi (narrow arrows) and stranding of the mediastinal fat (wide arrows)."
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011194/000005.png?itok=7wd5g2Vz",
            "caption": "Unenhanced thorax CT scan, axial mediastinal window image.  The images show circumferential diffuse thickening of the wall of the trachea and the main bronchi (narrow arrows) and stranding of the mediastinal fat (wide arrows)."
          },
          {
            "number": "Figure 1e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011194/000006.png?itok=-qdhd9bI",
            "caption": "Unenhanced thorax CT scan, axial mediastinal window image.  The images show circumferential diffuse thickening of the wall of the trachea and the main bronchi (narrow arrows) and stranding of the mediastinal fat (wide arrows)."
          },
          {
            "number": "Figure 1f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011194/000007.png?itok=rRPcTz4f",
            "caption": "Unenhanced thorax CT scan, axial mediastinal window image.  The images show circumferential diffuse thickening of the wall of the trachea and the main bronchi (narrow arrows) and stranding of the mediastinal fat (wide arrows)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011194/000008.png?itok=TG4soTQ-",
            "caption": "Coronal CT reconstruction, lung window image. Diffuse and nodular thickening of the wall of the trachea was observed (arrows)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011194/000009.png?itok=6HaSEsvT",
            "caption": "Chest CT, axial mediastinal window image. Five weeks later, after treatment with voriconazole, there was a complete resolution of the signs of tracheobronchitis on MDCT."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011194/000010.png?itok=dS3X7fS8",
            "caption": "Chest CT, coronal lung window image. Five weeks later, after treatment with voriconazole, there was a complete resolution of the signs of tracheobronchitis on MDCT."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/11194",
    "time": "27.09.2013"
  },
  "11217": {
    "case_id": 11217,
    "title": "Typical bronchial carcinoi",
    "section": "Chest imaging",
    "age": "51",
    "gender": "female",
    "diagnosis": "Typical bronchial carcinoid",
    "history": "Asymptomatic 51-year-old woman with prior history of Hodgkin lymphoma underwent MDCT for clinical follow-up. There was no clinical evidence of recurrence.",
    "image_finding": "Routine post-contrast thoracic CT obtained with 5 mm slice demonstrated a well-defined 13 mm nodular lesion located at the origin of the right medial basilar bronchus (B7).The nodule was homogeneous and with attenuation numbers similar to thoracic vessels (Fig. 1).There was no lymphadenopathy, pleural effusion or other radiological findings. The nodule had no calcifications.Following the MDCT examination a conventional bronchoscopy was carried out, which demonstrated a vascular endobronchial lesion in the basal pyramid covered with bronchial epithelium (Fig. 2).The biopsy confirmed the diagnosis of neuroendocrine carcinoid tumour.Before surgery another CT was performed including an arterial phase, looking for other carcinoids or metastases with no additional findings.Retrospectively the nodule was present at least 5 years before diagnosis with no significative growth.A lobectomy was performed and on follow-up CT there was no evidence of relapse (Fig. 3).",
    "discussion": "Bronchial carcinoid is a neuroendocrine neoplasm originating from Kulchitzky cells in bronchial and bronchiolar wall. Carcinoids can arise at different sites through the body including thymus, lung, gastrointestinal tract and ovaries, with the lung representing the second most common location [1] after gastrointestinal tract, accounting for up to 2% of all pulmonary neoplasms [2]; 75% arise in a lobar bronchus, 10% in the main stem bronchi and 15% originate in the periphery of the lung.Histologically there are two different types: The first and most common is referred to as typical carcinoid, it is a low-grade tumour with 10-year survival rates approaching 90% [1], it is capable of local invasion but rarely develops metastases. The second type or atypical carcinoid is much more aggressive with 5-year survival rates from 25-70% [1, 2, 3]. Typical carcinoids are found more commonly centrally within the major bronchi whereas atypical carcinoids arise in peripheral and central locations with equal frequency.The most common onset includes lobar obstruction, haemoptysis, dyspnoea, cough and lobar pneumonia secondary to obstruction, 25% are asymptomatic; rarely patients may exhibit syndromes related to ectopic hormone production like ACTH. Carcinoid syndrome is not frequent (2-4%) and occurs only when liver metastases are present [1, 3].Radiological findings include hilar and perihilar masses, endobronchial nodules, mediastinal nodes and findings related to bronchial obstruction [1]. Both typical and atypical carcinoid have the same radiological features, although atypical carcinoids are more likely to occur in the lung periphery [3]. On CT central carcinoids appear as well-defined round nodules frequently lobulated within the lumen of a bronchus. Carcinoids tend to be vascular and may enhance intensely after iv contrast. Calcification occurs in up to 30% of cases [1, 2].The main differential diagnosis includes hypervascular lesions such as metastases of melanoma, thyroid, breast and renal carcinoma, and pulmonary artery aneurysm, and also bronchial malignancies like mucoepidermoid and adenoid cystic carcinoma. Metastases usually show a more aggressive behaviour compared to the primary tumour. To diagnose aneurysm a thin slice multiplanar reconstruction following the artery has to be done. Malignancies such as mucoepidermoid and adenoid cystic carcinoma are not normally hypervascular.Carcinoid is treated surgically with sleeve resection, segmentectomy, lobectomy or pneumonectomy, the approach depending on the size and location; intraluminal typical carcinoid may be removed by bronchoscopy [1].The prognosis is related to the pathological grade and stage of the tumour. Typical carcinoids have and excellent outcome even with mediastinal lymph node metastases.",
    "differential_diagnosis": "Typical, bronchial, carcinoid, Metastases, from, melanoma, and, breast, and, renal, carcinoma, Adenoid, cystic, carcinoma, Mucoepidermoid, carcinoma, Pulmonary, artery, aneurysm",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011217/000006.jpg?itok=9EYtH9bm",
            "caption": "Post-contrast 2006 axial CT on mediastinal window. Retrospectively the lesion was already seen."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011217/000012.jpg?itok=RbBEjFyD",
            "caption": "Post-contrast axial CT on mediastinal window 7 years later (2013) showing the same lesion grossly unchanged."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011217/000008.jpg?itok=t86x07U2",
            "caption": "Bronchoscopy showing the nodular lesion protruding into pyramid basal bronchi."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011217/000011.jpg?itok=NRswYgi1",
            "caption": "Lung window post-lobectomy image showing no sign of relapse."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax",
      "Lung"
    ],
    "imaging_technique": [
      "CT",
      "PACS"
    ],
    "link": "https://www.eurorad.org/case/11217",
    "time": "30.08.2014"
  },
  "11239": {
    "case_id": 11239,
    "title": "Tension bull",
    "section": "Chest imaging",
    "age": "48",
    "gender": "male",
    "diagnosis": "Tension bulla",
    "history": "A 48-year-old male patient was admitted to the emergency department presenting acute dyspnoea without chest pain. Clinical examination revealed decreased left basal breath sounds. The patient's saturation was 97% on oxygen therapy. His past medical history was noteworthy for tobacco use and chronic obstructive pulmonary disease (COPD) with bullous emphysema.",
    "image_finding": "The admission chest radiograph (Fig. 1) revealed an increased lucency of the left lung, particularly pronounced in the left upper lung field where no vasculature could be identified, left-sided paracardiac atelectatic bands, and a right medistinal shift, simulating tension pneumothorax. However, no visceral pleural line was seen and a CT was requested, to rule out bullous rupture with loculated pneumothorax. On this CT there was no evidence of pneumothorax (Fig. 2a, b). However, in comparison with a previous CT study (Fig. 3a, b), a giant left apical emphysematous bulla had increased in size, occupying the entire left upper lobe with increased mass effect responsible for lingular compressive atelectasis and a progressed contralateral mediastinal shift.",
    "discussion": "A bulla is defined as an airspace greater than 1 cm in diameter demarcated by a thin wall of parenchymal remnants [1]. It is called a giant bulla when lit involves more than one third of a hemithorax, typically located in an upper lobe. A tension bulla is a giant bulla that increases in size by a check-valve mechanism of air trapping and has a growing mass effect on the underlying lung parenchyma as well as the mediastinum. Bullae are associated with tobacco-related emphysema, other COPD findings like asthma and bronchiectasis, as well as collagen-vascular diseases [1].Clinical presentation of tension bulla usually includes acute dyspnoea and chest pain but is nonspecific. On standard radiographs giant bulla, tension bulla, tension pneumothorax, and atypical (clustered) pneumothorax can be difficult to distinguish, making CT necessary to establish the accurate diagnosis [2, 3].On chest radiographs, bullae appear as well delineated areas of avascularity. A bulla has a thin curvilinear fibrous wall that may not be perceptible on radiographs but only on CT. Surrounding lung parenchyma typically collapses if the bulla is under tension, whereas a nonfunctional giant bulla exerts less mass effect. A pneumothorax on the other hand represents a pleural collection of air, surrounded by visceral pleura on one side, and parietal pleura on the other. If there is an increasing accumulation of air in the pleural space, due to limited egress, the pneumothorax gets under tension with similar haemodynamic consequences as a tension bulla. An atypical pneumothorax may occur in a setting of pleural adhesions. In this case, the lung collapses toward the hilum, but remains partially attached to the chest wall [4]. A single non-enhanced CT series acquired during inspiration breath hold is usually sufficient to establish the diagnosis of pneumothorax.Bullectomy is the treatment of choice for tension bulla, whereas pleural drainage is indicated for tension pneumothorax [4]. Non-complicated giant bullae may be treated conservatively, with bronchoscopic intervention with deployment of bronchial valves, or lung volume reduction coils. Surgical lung reduction is less often indicated. The natural evolution of bullae is slow progression although there are few cases reported in the literature of spontaneous resolution of giant bullae [5].In conclusion, a tension bulla may mimic an atypical pneumothorax, a tension pneumothorax, or a non-complicated giant bulla. Its correct diagnosis has an impact on treatment which differs from that of the other three entities.",
    "differential_diagnosis": "Tension, bulla, Tension, pneumothorax, Atypical, pneumothorax, Giant, bulla",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011239/000004.jpg?itok=RGkHM2GG",
            "caption": "Axial view CT shows the left upper lobe bulla with associated mass effect on atelectatic lingula and mediastinum. A thin wall demarcating the bulla can be appreciated but no detached visceral pleural line."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011239/000006.jpg?itok=_6Lmg_tE",
            "caption": "Coronally reconstructed non-enhanced CT shows a voluminous emphysematous bulla  in the left upper lobe with mass effect responsible for mediastinal shift to the right and linguar collapse. Note other bullae at the left lung base."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011239/000005.jpg?itok=1x8Q9dNd",
            "caption": "The radiograph reveals increased lucency of the left lung, particulary pronounced in the upper lung field with no vasculature visible. There is a right medistinal shift simulating pneumothorax, however, no visceral pleura can be identified."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011239/000007.jpg?itok=pGCRL9qH",
            "caption": "A previous CT performed a couple of months ago at our hospital confirmed a lesser mass effect on the adjacent pulmonary parenchyma."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011239/000008.jpg?itok=hqNo9ug4",
            "caption": "The giant bulla is already seen on this coronal reformatted image, however, there is less mass effect on adjacent lung and less pronounced mediastinal shift to the right side."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax",
      "Lung"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT",
      "CT-High Resolution"
    ],
    "link": "https://www.eurorad.org/case/11239",
    "time": "13.12.2013"
  },
  "11242": {
    "case_id": 11242,
    "title": "A rare cause of bilateral pulmonary nodules",
    "section": "Chest imaging",
    "age": "35",
    "gender": "male",
    "diagnosis": "Pulmonary epithelioid haemangioendothelioma",
    "history": "A 35-year-old man, non-smoker, without symptoms or prior history of lung diseases. His past medical history was not significant, without occupational exposures or family history of clinical relevance. The physical examination was unremarkable.",
    "image_finding": "A routine chest X-ray showed diffuse and bilateral micronodular pattern - multiple small, round noncalcified nodules in both lungs (Fig. 1). Serum levels of neoplastic markers and angiotensin converting enzyme were normal. Pulmonary function tests were also normal. Bronchoscopy performed with bronchoalveolar lavage, brushing and transbronchial biopsies were nondiagnostic. Chest HRCT examination showed multiple, bilateral small pulmonary nodules (< 10mm). These nodules were present in all pulmonary lobes and adjacent to bronchioles and medium/small vessels (Fig. 2 a, b). There were no enlarged lymph nodes, pleural effusion or other relevant pulmonary changes (Fig. c). Abdominal and pelvic CT revealed no malignant lesions (Fig. 3). Radiological skeletal study showed no bone involvement. Surgical lung biopsy and histological examination of the nodules revealed epithelioid cells with eosinophilic cytoplasm and intracytoplasmic vacuolization (Fig. a, b, c). On immunohistochemical studies, the tumour cells were immunoreactive to CD34 and negative for cytokeratin (Fig. 4 d).",
    "discussion": "Pulmonary epithelioid haemangioendothelioma (EH) is a rare neoplasm of vascular origin, previously known as intravascular bronchioloalveolar tumour.It is a low- to-intermediate tumour, with a borderline malignancy and a clinical course usually between haemangioma and angiosarcoma.Pulmonary EH is more common in women than men and many patients are asymptomatic at presentation, so it is often an incidental finding on imaging studies.The prognosis is very variable, with survival ranging from less than one year up to 30 years. Pulmonary symptoms and, especially, pleural haemorrhagic effusions and haemoptysis are generally considered the worst prognostic factors [1].EH can affect many organs simultaneously or sequentially, and lungs and liver are the two organs most frequently involved. In patients with additonal hepatic involvement knowledge of the CT manifestations in the liver may be helpful to narrow the differential diagnoses.There are three different patterns of CT findings identified in thoracic manifestation of EH: 1) multiple pulmonary nodules; 2) multiple pulmonary reticulonodular opacities; and 3) diffuse infiltrative pleural thickening [2].The presence of multiple discrete pulmonary perivascular nodules with well- or ill-defined margins in both lungs on chest radiographs or CT is the characteristic finding. The nodules can range in size up to 3 cm, but most are less than 1 cm in diameter, and are usually found in relation to small and medium-sized vessels and bronchi. This presentation may appear in many lung diseases and is easily mistaken for metastatic carcinoma, which is usually the initial radiologic interpretation. However, little growth is shown on serial chest CT examinations [3]. Although histologic calcifications are common, radiologic visible calcifications are rare. In long-standing cases or after treatment, extensive calcification of the nodules can be seen.PET/CT findings can demonstrate increased FDG-uptakes, but usually are not a pivotal tool for the diagnosis, and a negative PET cannot exclude pulmonary EH [4].Histologic characteristics of EH include epithelioid cells with abundant eosinophilic cytoplasm in a fibromyxoid stroma, some of them with intracytoplasmic vacuoles, having a signet ring-like appearance. The diagnosis usually requires a lung biopsy, and is made on the basis of these histopathological features and confirmed by positive immunohistochemistry staining for vascular-endothelial markers, like CD31, CD34 and factor VIII [2].There is no established standard treatment. Spontaneous partial regressions are reported, particularly in asymptomatic patients [5]. Surgery when tumour resection is feasible is usually the treatment of choice. Chemotherapy/immunostimulants in patients with disseminated disease and lung transplantation can also be an option [6].",
    "differential_diagnosis": "Pulmonary, epithelioid, haemangioendothelioma, Pulmonary, metastases, Miliary, granulomatous, infection, Sarcoidosis, Silicosis, Primary, lung, malignancy, Lymphangitic, carcinomatosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011242/000001.jpg?itok=98tmwkI-",
            "caption": "The chest radiograph showed a diffuse micronodular pattern in both lungs."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011242/000002.jpg?itok=wL7TuGq5",
            "caption": "The chest radiograph showed a diffuse micronodular pattern in both lungs."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011242/000003.jpg?itok=390hHoGd",
            "caption": "Multislice chest CT-images on lung window showed innumerous, well-defined, small, round and noncalcified pulmonary nodular opacities, scattered in both lungs."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011242/000004.jpg?itok=oPqGCLJu",
            "caption": "These nodules were present in all pulmonary lobes and typically adjacent to bronchioles and medium/small vessels."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011242/000005.jpg?itok=fopwW116",
            "caption": "Contrast-enhanced multislice CT of the chest on mediastinal window showed no thoracic lymphadenopathy."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011242/000006.jpg?itok=1nRhs31g",
            "caption": "Multislice abdominopelvic CT with intravenous contrast admninistration showed no significant findings, excluding focal liver lesions."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011242/000007.jpg?itok=dKOaVyFG",
            "caption": "Multislice abdominopelvic CT with intravenous contrast admninistration showed no significant findings, excluding focal liver lesions."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011242/000008.jpg?itok=fCXAr5e3",
            "caption": "Low-magnification of the specimen obtained from pulmonary wedge resection reveals a sub-pleural nodule that extends to adjacent alveoli, with vascular proliferation in the peripheral zone and areas of recent and old haemorrhage."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011242/000009.jpg?itok=tUWRc5ia",
            "caption": "Neoplastic nodule showing tumour cells with an eosinophilic stroma at the periphery. The lesion contains blood filled spaces and respiratory epithelium \u201ctrapped\u201d within the lesion."
          },
          {
            "number": "Figure 4c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011242/000010.jpg?itok=68E0x-qD",
            "caption": "Higher magnification of the tumour reveals vacuolation of some of the tumour cells, representing primitive angiogenesis. One of these epithelioid cells can be observed, with intracytoplasmic lumen and an erythrocyte inside, indicating their vascular nature."
          },
          {
            "number": "Figure 4d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011242/000011.jpg?itok=AKmpiZwE",
            "caption": "Immunostaining for CD34 revealed positivity of the neoplastic cells (brown colour), confirming the endothelial lineage of the tumour."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax",
      "Abdomen",
      "Lung"
    ],
    "imaging_technique": [
      "Digital radiography",
      "CT-High Resolution",
      "CT-Angiography",
      "CT",
      "Experimental"
    ],
    "link": "https://www.eurorad.org/case/11242",
    "time": "22.11.2013"
  },
  "11285": {
    "case_id": 11285,
    "title": "Boerhaave\\&#039;s syndrome - case report",
    "section": "Chest imaging",
    "age": "83",
    "gender": "female",
    "diagnosis": "Boerhaave's syndrome",
    "history": "An 83-year-old man came to the emergency department complaining of sudden anterior chest and abdominal pain followed by haematemesis, without dyspnoea. He had suffered from severe vomiting over the past few hours. On physical examination, he was sweaty, tachycardic, pale and with mild hypertension.",
    "image_finding": "Figures 1 to 5 show an oesophageal rupture with a right-sided paraoesophageal collection accompanied by mediastinal air and extravasation of oral contrast.",
    "discussion": "Boerhaave's syndrome was first described in 1724. It corresponds to the transmural perforation of the oesophagus wall after a sudden rise in intra-oesophageal pressure, as a result of neuromuscular incoordination, combined with relatively negative intrathoracic pressure caused by straining/vomiting. It is usually associated with overindulgence of food and alcohol, but straining, childbirth, weightlifting, severe cough, blunt trauma, seizures, and asthma are other possible causes [1].BS is more common in men (2/5:1) at the age of 50-70. The typical tear location is the left posterolateral wall (90%) of the lower third oesophagus (90%), 2-4cm proximal to cardia, due to lack of striated muscle and the vertical arrangement of longitudinal muscles. Subdiaphragmatic and upper thoracic areas are not so common (atypical) [2, 3].Oesophageal perforation is the most lethal perforation of the GI tract, usually due to infection (mediastinitis, pneumonitis, pericarditis or empyema) [4].Physical examination is not very useful because typical subcutaneous crepitation emphysema is only present in 27% of cases, and Meckler triad in 30-50% [5, 6]. Tachycardia, diaphoresis, fever and hypotension are common. Haematemesis isn\u2019t usually seen, unlike in Mallory-Weiss tear.Therefore, an adequate clinical history is mandatory: excessive food/alcohol intake, vomiting and sudden severe chest pain are highly suggestive. When the diagnosis is made in the first 12h, mortality is about 30-40%, but if it takes more than 48h, it rises to 90% [7].Chest radiography is normal in 10% of the cases, but may show pleural effusions, pulmonary infiltrates and/or mediastinal emphysema, usually in the left chest [8].A fluoroscopic esophagram with water-soluble contrast can also be done. If not diagnostic, dilute-barium should be used [9] to detect subtle leaks, despite the risk of mediastinitis [10]. It usually shows the parietal tear or extravasation [8]. However, we should take into account the 10% false-negative rate [11]. Computed tomography (CT) shows oesophageal wall oedema and thickening, extraoesophageal air, perioesophageal fluid with or without gas bubbles, mediastinal widening, and air and fluid in the pleural spaces, retroperitoneum or lesser sac [9, 12]. By demonstrating perioesophageal air tracks suggestive of oesophageal perforation, CT reveals the decisive criteria for diagnosing BS and should therefore be performed in the diagnostic work-up of patients in whom this syndrome is part of the differential diagnosis [13].Boerhaave's syndrome constitutes a life-threatening and potentially surgical condition. A high clinical suspicion and the knowledge of the most common imaging signs play an important role in the initial diagnosis, treatment and prognosis of these patients.",
    "differential_diagnosis": "Boerhaave's, syndrome, Aortic, dissection, Esophageal, rupture, of, other, cause, Mallory-Weiss, tear, Myocardial, infarction, Acute, pancreatitis, Peptic, ulcer, disease, Pneumothorax, Pulmonary, embolism",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011285/000001.gif?itok=Ja-wmBgX",
            "caption": "Nonenhanced axial CT image shows pneumomediastinum, left pleural effusion, and small amount of fluid surrounding the distal oesophagus."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011285/000002.gif?itok=vqYmEpoD",
            "caption": "Nonenhanced axial CT image of the upper abdomen shows small amount of fluid surrounding the distal oesophagus and gastric hyperdense fluid content (40 HU) related to haemorrhage."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011285/000003.gif?itok=elyTMiEL",
            "caption": "Axial contrast-enhanced CT image shows pneumomediastinum and better delineates the peri-oesophageal fluid collection. After administration of oral contrast, mediastinal extravasation was noted. No air is identified within the oesophageal wall."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011285/000004.gif?itok=iK2_MSVO",
            "caption": "Coronal contrast-enhanced CT image also shows pneumomediastinum and extravasation of oral contrast. No pneumoperitoneum is found."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011285/000005.jpg?itok=Q9dAXQO-",
            "caption": "Axial CT (lung window) better depicts the pneumomediastinum."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Oesophagus"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/11285",
    "time": "28.02.2014"
  },
  "11286": {
    "case_id": 11286,
    "title": "Unilateral pulmonary agenesis",
    "section": "Chest imaging",
    "age": "73",
    "gender": "female",
    "diagnosis": "Unilateral pulmonary agenesis",
    "history": "A 73-year-old woman presented with a 3-day history of progressive prostration. Physical examination revealed absence of breath sounds in the right hemithorax. She had no relevant medical history besides arterial hypertension.",
    "image_finding": "Chest radiography performed at emergency department revealed an opaque right hemithorax and a mediastinum entirely displaced to the right side. The trachea was also displaced to the right and the left main bronchus is depicted; however, the right main bronchus is not seen. The right intercostal spaces seem reduced relatively to the left ones, indicating volume reduction; the left lung appears radiolucent due to compensatory overinflation (Fig. 1). She underwent a CT scan, which showed a complete absence of the right lung, a normal hyperinflated left lung and a clear shift of the mediastinum to the right (dextrocardia). Absence of the right pulmonary artery and of the right main bronchus was also shown (Fig. 2 and 3).",
    "discussion": "Unilateral pulmonary agenesis is a rare congenital malformation with an incidence of 1:10,000-15,000 [1, 2]. Pulmonary agenesis is part of the lung agenesis-hypoplasia complex (lung underdevelopment) and consists of a complete absence of lung parenchyma, its bronchus and vascular supply [1, 3]. The aetiology of pulmonary agenesis remains unknown. Genetic, teratogenic, and mechanical factors, notably abnormal blood flow in the dorsal aortic arch during the 4th week of gestation, have been proposed as possible causes [1, 3-5]. Associated malformations and the location of the missing lung are the main prognostic determinants. More than 50% of cases have associated congenital anomalies that involve the cardiovascular, gastrointestinal, musculoskeletal, and genitourinary systems [1, 3]. The disorder occurs on either side with almost equal frequency [6]. Patients with right lung agenesis have a shorter life expectancy [3], related to a more severe mediastinal and cardiac displacement and greater frequency of associated cardiac anomalies [1-3]. The clinical presentation depends on the degree of pulmonary abnormality and the presence of other congenital malformations. In some cases, symptoms manifest at birth as respiratory distress syndrome. In others, patients remain asymptomatic until adulthood, when lung agenesis can be an incidental \ufb01nding [1, 6]. If not complicated by other abnormalities, patients are usually asymptomatic, do not require intervention and can have a normal life [1].Imaging studies are essential for the diagnosis of pulmonary agenesis. The diagnosis is usually first suspected on chest radiography, which demonstrates a diffuse opacity of the affected hemithorax and an ipsilateral mediastinal shift [1, 6, 8]. A normal contralateral lung with compensatory hyperinflation and herniation across the midline is a common finding [6]. CT confirms the absence of lung parenchyma, pulmonary artery, and bronchial structures on the affected side [4, 6, 7]. CT angiography and MR angiography are currently the imaging modalities of choice in the diagnosis of this entity [6]. Other ancillary tests, such as echocardiography to rule out cardiac anomalies may be indicated [1].There are few case reports regarding patients with right lung agenesis living to old age because of both severe mediastinal and cardiac displacements [8]. Our patient didn\u00b4t have other thoracic abnormalities, besides dextrocardia, which probably explains the previous unawareness of this anomaly.",
    "differential_diagnosis": "Unilateral, pulmonary, agenesis, Total, atelectasis, from, any, cause, Pneumonectomy, Pulmonary, aplasia, or, hypoplasia, Lung, infection/pneumonia, Diaphragmatic, hernia, Severe, bronchiectasis, with, collapse, Advanced, fibrothorax",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011286/000001.png?itok=6ADElBOr",
            "caption": "There is complete opacification of the right hemithorax with volume loss and an ipsilateral shift of the mediastinum. The trachea (T) is displaced to the right and the left main bronchus is depicted (asterisk)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011286/000003.jpg?itok=rToyO3NY",
            "caption": "On lung windowing there is a complete absence of the right lung parenchyma. The left lung occupies part of the right hemithorax (herniation)."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011286/000002.png?itok=d93V3MSR",
            "caption": "On mediastinal windowing note the main pulmonary artery (P) giving rise to left pulmonary artery (asterisk) and absence of the right pulmonary artery. The heart and great vessels are clearly displaced to the right."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011286/000004.jpg?itok=pXJBJzSf",
            "caption": "The displaced trachea gives rise to the left main bronchus; note the absence of the right main bronchus making the distinction with pulmonary aplasia, in which there is a rudimentary bronchus without lung tissue."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/11286",
    "time": "06.10.2013"
  },
  "11306": {
    "case_id": 11306,
    "title": "Absence of the left lung: agenesis, aplasia or hypoplasia?",
    "section": "Chest imaging",
    "age": "72",
    "gender": "female",
    "diagnosis": "Pulmonary hypoplasia caused by a large congenital diaphragmatic hernia.",
    "history": "A 72-year-old female patient had a severe pneumonia and she underwent thorough imaging. She suffered from frequent respiratory infections (usually not severe) but had never had any kind of accident.",
    "image_finding": "The chest radiograph showed a radiopaque left hemithorax with righ shift of the mediastinum. (Fig 1) Double-contrast barium enema demonstrated the presence of large part of the intestine inside the left hemithorax (Fig 2).CT examination revealed complete occupation of the left hemithorax by abdominal organs. Namely, the left hemithorax contained the spleen, small and large intestine and a large quantity of mesenteric fat. The small and large intestine lied in the periphery of the thoracic cavity while its central part was occupied by mesenteric fat (Fig 3a, b, c). CT also revealed a hypoplastic left lung, the presence of left pulmonary artery and a blind-ended left main bronchus (Fig 3b). Finally, the CT examination demonstrated a defect in the left hemidiaphragm, which caused the intrathoracic displacement of the abdominal organs (Fig 3d). Multi-planar reconstructions (MPR) and Volume Rendering Techniques (VRT) were performed to better delineate the findings (Fig 4, 5).",
    "discussion": "Schneider and Schwalbe classified pulmonary underdevelopment into three categories: agenesis, aplasia and hypoplasia [1]. Agenesis of the lung refers to the complete absence of lung parenchyma along with its bronchus and vasculature. Pulmonary aplasia represents the existence of a rudimentary blind-ended bronchus without lung parenchyma and pulmonary vasculature. Hypoplasia describes the existence of a hypoplastic bronchus with a hypoplastic lung tissue containing alveoli, airways and pulmonary vasculature [2].Pulmonary hypoplasia (PH) is characterised by underdevelopment of the lung which is caused by any situation that limits the space of the thoracic cavity available for lung growth. The longer the underlying cause exists and the more intense it is, the more hypoplastic the lung will be. As in our case, a congenital diaphragmatic hernia is one of the most common causes of PH as the defect of the hemidiaphragm allows the abdominal organs to move into the thorax, thus compressing the developing lung. Other intrathoracic causes of lung hypoplasia include sequestration, mediastinal masses, complete absence of the diaphragm and a large pleural effusion. Other causes include decreased pulmonary blood supply and extrathoracic diseases like oligohydramnios [2, 3]. Pulmonary hypoplasia may also be primary with a very low frequency (0.8-1.6 per 10000 births) [4]. Clinical presentation of PH comprises early respiratory distress after birth, cyanosis, tachypnoea, hypoxia with hypercapnea and acidosis. PH can be complicated by pneumothorax or pulmonary hypertension.Chest radiograph of a patient with PH will show decreased radiolucency in the affected lung (more often the right). The mediastinum may be displaced towards the affected side due to compensatory ventilation of the normal lung and in some cases congenital bronchiectasis can be seen. On lateral chest radiograph, hyperclarity may be seen behind the sternum due to herniation of the normal lung. Prenatal diagnosis with US is difficult but can be more easily done with MRI where the volume of the two lungs can be measured and the hypoplastic lung usually has lower signal intensity than normal [3, 5]. The majority of patients with PH die but there are also patients who survived and were diagnosed with imaging [4].When surgery is planned, CT is the imaging modality of choice for preoperative planning as it describes better the anatomic extent of pathology [6].Recent papers report that early fetoscopic tracheal occlusion increases the survival rate of infants with severe pulmonary hypoplasia and congenital diaphragmatic hernia [7].",
    "differential_diagnosis": "Pulmonary, hypoplasia, caused, by, a, large, congenital, diaphragmatic, hernia., Cystic, adenomatoid, malformation, Pulmonary, agenesis, Pulmonary, aplasia, Pulmonary, hypoplasia, Congenital, diaphragmatic, hernia",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011306/000001.jpg?itok=JY0IAszy",
            "caption": "A radiopaque left hemithorax with shift of the mediastinum to the right is noted. There may be some intestinal loops in the left upper lung zone."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011306/000002.jpg?itok=WJy18BJT",
            "caption": "Displacement of the large intestine into the left hemithorax is noted."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011306/000003.gif?itok=dbo2zdVi",
            "caption": "Occupation of the left hemithorax by abdominal organ is noted. Namely, mesenteric fat and small intestine in the posterior part of the hemithorax is seen while large intestine is seen in the anterior part."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011306/000004.gif?itok=3YGSQZTG",
            "caption": "The left branch of the pulmonary artery along with the left main bronchus being blind-ended inside the hypoplastic left lung is demonstrated. Small and large intestine are also seen inside the left hemithorax."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011306/000005.gif?itok=nvYyIen6",
            "caption": "Spleen with its hilum being over the left hemidiaphragm and inside the thoracic cavity is seen."
          },
          {
            "number": "Figure 3d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011306/000006.gif?itok=iKT4z_ml",
            "caption": "A diaphragmatic defect which allows the abdominal organs to move into the thoracic cavity is revealed. The two separate parts of the left hemidiaphragm are pointed out (orange arrows)."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011306/000007.jpg?itok=-KREPUpa",
            "caption": "Coronal reconstructed image shows the left hemithorax occupied by abdominal organs. Namely, the spleen, intestinal loops, the right - displaced mediastinum, the hypoplastic lung (arrow head) and the diaphragmatic defect (arrow)."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011306/000008.gif?itok=ZksFAJ_C",
            "caption": "3D Volume Rendering Technique (VRT) shows the normal right lung, the displaced mediastinum and the displaced abdominal organs."
          },
          {
            "number": "Figure 4c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011306/000009.gif?itok=Lyzt6W6t",
            "caption": "Sagittal view shows the diaphragmatic defect which allows the displacement of abdominal organs."
          },
          {
            "number": "Figure 4d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011306/000010.gif?itok=9kY-7kSV",
            "caption": "Oblique reconstructed image shows the hypoplastic lung in its entity and reveals the existence of both left pulmonary artery (LPA) and left main bronchus (LB)."
          },
          {
            "number": "Figure 4e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011306/000011.gif?itok=6lNshden",
            "caption": "VRT image demonstrates the normal aortic arch, the pulmonary artery and the presence of the left pulmonary artery (LPA) which leads to the hypoplastic left lung (LL)."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011306/000012.gif?itok=ddIihV-c",
            "caption": "This VRT image shows the right lung having a normal volume. On the contrary, the left lung is seen hypoplastic with the existing left bronchus having some blind-ended branches. Bowel loops are also seen."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Abdomen",
      "Anatomy",
      "Cardiac",
      "Colon",
      "Gastrointestinal tract",
      "Arteries / Aorta",
      "Computer applications"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/11306",
    "time": "06.10.2013"
  },
  "11316": {
    "case_id": 11316,
    "title": "Lymphangiomatosis",
    "section": "Chest imaging",
    "age": "33",
    "gender": "female",
    "diagnosis": "Lymphangiomatosis",
    "history": "A 33-year-old woman presented with slowly progressive shortness of breath, cough with abdominal fullness. There was no prior history of surgery. On clinical examination there were features of superior vena cava syndrome with splenomegaly.",
    "image_finding": "CECT scan of thorax shows hypodense lesion of fluid attenuation with barely perceptible wall or enhancement filling precarinal, prevascular space, aortopulmonary window, azygoesophageal recess, middle and posterior mediastinum encircling the pulmonary veins, ascending and descending aorta without luminal narrowing, involving pericardium and extending across midline (Fig. 1-3). SVC and azygous vein are dilated (Fig. 1). The lesion has few thin septae and is filling the lesser sac, hepatogastric ligament, encasing portal vein with similar cystic lesions in splenic parenchyma. Spleen is enlarged with dilated portosplenic axis (Fig. 4).Coronal CECT images show extensive thoracoabdominal extension of nonenhancing lesion involving multiple compartments and spaces without obvious mass effect over other visceral organs (Fig. 5). Thickening of interlobular septa and peribronchovascular interstitium seen without any ectatic airways, radiolucent cystic areas or air space disease (Fig. 6, 7). Mildly prominent right oblique fissure and focal right lateral pleural thickening was noted (Fig. 8).",
    "discussion": "Lymphangiomas are congenital lesions which occur due to failure of developing lymphatic tissue to establish normal communication with remainder of the draining lymphatic system [1, 4]. Histologically they are of three types: capillary, cavernous and cystic [4]. They are most commonly seen as cervical, axillary masses while mediastinum and retroperitoneum are uncommon locations [4]. Lymphatic disorders of thorax have been classified into four types: lymphangiectasis, localized lymphangioma, diffuse lymphangioma, lymphangioleiomyoma [2].Diffuse non-localized proliferation of lymphatic spaces with wide spread involvement of multiple anatomical compartments and visceral organs without proliferation of smooth muscles is termed lympahngiomatosis [2]. Mediastinal involvement is common in young adults with coexistence of chylous pleural and pericardial effusions [2].Variable clinical findings include cough, dyspnoea, dysphagia, superior vena cava syndrome, organomegaly, features related to secondary infection, or may be completely asymptomatic [1]. They may involve peritoneal and retroperitoneal compartments in abdomen [3].Cross sectional imaging reveals diffuse distribution of the disease. On CECT the lesion appears as an insinuating mass of fluid attenuation without any enhancement or perceptible wall enveloping normal mediastinal structures, peritoneal organs without any obvious mass effect [3]. Elongated nature of the tumour and involvement of multiple compartments in peritoneal cavity or spaces in the mediastinum without any invasiveness support the fact that these are developmental anomalies of dilated lymphatic channels [3]. HRCT may reveal diffuse reticular interstitial lung disease due to proliferation of lymphatics along interlobular septae and bronchovascular interstitium although cystic radiolucent areas are rarely seen because normally arranged smooth muscles line the wall of the lymphatic spaces, unlike that of lymphangioleiomyomatosis [2].MR imaging depicts anatomic extent of the lesion better than CT, gives information about the nature of the possible fluid content (proteinaceous/haemorrhagic) and helps in detecting recurrences [4]. Sonography is useful in delineating septations, loculations in the lesions and debris in cases of secondary infection [3].Preoperative exact anatomical extent and location of the lesions needs to be determined for therapeutic approach. Though complete surgical excision is treatment of choice, palliative procedures need to be considered at times owing to the diffuse widespread nature of the disease [2].Lymphangiomatosis should be considered as an important differential diagnosis in cases of diffuse cystic lesions of the mediastinum not localized to a particular anatomical space, encircling organs without any displacement or invasion [1, 2]. Despite the extensive involvement imaging findings are quite specific when correlated with clinical presentation and help to rule out other differential diagnoses.",
    "differential_diagnosis": "Lymphangiomatosis, Pancreatic, pseudocyst, Mediastinal, abscess",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011316/000001.jpg?itok=3-xJ5JV0",
            "caption": "Hypodense lesion of fluid attenuation filling the precarinal and prevascular space with dilated SVC and azygous vein."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011316/000002.jpg?itok=BMOnF1oF",
            "caption": "The lesion is seen in  aortopulmonary window, azygoesophageal recess  circumferentially surrounding  the ascending and descending aorta."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011316/000003.jpg?itok=0mW-KQ8F",
            "caption": "The same lesion in middle and posterior mediastinum encircling the pulmonary veins, descending aorta without luminal narrowing, involving the pericardium and extending across the midline."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011316/000004.jpg?itok=BRQSNZ3Q",
            "caption": "The lesion is seen in  lesser sac, hepatogastric ligament, encasing the portal vein with multiple large cystic lesions  in spleen. Spleen is enlarged."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011316/000005.jpg?itok=mVAKMeUc",
            "caption": "CECT reformatted images show extensive thoracoabdominal extension of the lesion involving multiple compartments without obvious mass effect."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011316/000006.jpg?itok=5Myz8A7H",
            "caption": "Thickening of the  connective tissue sheath along central bronchovascular bundles  and interlobular septa bilaterally, better observed on right side due to proliferation of lymphatic spaces."
          }
        ]
      },
      {
        "number": "Figure 7",
        "subfigures": [
          {
            "number": "Figure 7",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011316/000007.jpg?itok=nuc8w8RK",
            "caption": "Thickening of the  connective tissue sheath along bilateral central   bronchovascular bundles  in caudal section at the level of right middle lobe bronchus."
          }
        ]
      },
      {
        "number": "Figure 8",
        "subfigures": [
          {
            "number": "Figure 8",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011316/000008.jpg?itok=tshz_4cg",
            "caption": "Mildly prominent right oblique fissure and  focal thickening of right lateral pleura and bilateral  bronchovascular bundles."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Mediastinum",
      "Abdomen",
      "Lung"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/11316",
    "time": "22.11.2013"
  },
  "11322": {
    "case_id": 11322,
    "title": "Long oesophageal leiomyom",
    "section": "Chest imaging",
    "age": "65",
    "gender": "male",
    "diagnosis": "Oesophageal leiomyoma",
    "history": "A previously healthy 65-year-old male patient presented with a five-year history of mild dysphagia and occasional nausea and vomiting. Physical examination and blood work were unremarkable. A barium swallow and a thoracic MRI were performed.",
    "image_finding": "Barium swallow oesophagogram showed a circumferential and symmetric filling defect, smoothly tapering, approximately 10 cm in length, localized at the mid and distal third of the oesophagus. The lesion had obtuse implantation angles and there was no irregularity of the overlying mucosa, which strongly favoured an extramucosal origin. There was weak distensibility throughout the lesion, which caused moderate obstruction to the flow of barium (Figure 1, 2).Thoracic MRI was performed and demonstrated circumferential parietal thickening with soft tissue intensity, isointense relative to the skeletal muscle, in the mid third of the oesophagus, approximately 10 cm in length (Figure 4). There were no signs of invasion of the lung, other organs of the mediastinum or the thoracic spine (Figure 5). There was mild dilation of the proximal oesophagus (Figure 6, 7).",
    "discussion": "Oesophageal leiomyoma is a rare benign tumour. It is the most common mesenchymal tumour of the oesophagus, unlike in the remainder of the gastrointestinal tract, where GISTs predominate. It is more common in men, between 20 and 50 years of age. It is found more often in the lower two thirds of the oesophagus, which is consistent with the normal anatomical distribution of smooth muscle within the oesophageal wall. It is usually an accidental finding but can be symptomatic (epigastric pain, dysphagia, pyrosis, oesophageal obstruction and reflux) when very large. It consists of an encapsulated lesion of intersecting bands of muscle (spindle cells) and fibrous tissue. The cells have a bland appearance without nuclear pleomorphism, and there is little to no mitotic activity. Leiomyomas occasionally may contain dense areas of calcification, but cystic degeneration, necrosis, and ulceration almost never occur. The potential for malignant degeneration of leiomyomas is extremely small.It habitually presents as a discrete, spherical or oval submucosal mass, ranging from 2 to 8 cm in size. Occasionally, it can encircle the oesophagus in a circumferential way and cause obstructive symptoms (as in our case). In about 5% of cases it can be multiple [1, 2, 3].An oesophageal leiomyoma may appear as a posterior mediastinal mass on a chest radiography, with an abnormal azygoesophageal line.On a barium meal, an oesophageal leiomyoma typically manifests as a smoothly marginated, round or lobulated intramural extramucosal mass, which typically forms right angles or slightly obtuse angles with the adjacent oesophageal wall.Because oesophageal leiomyomas are submucosal lesions, conventional endoscopy is not a reliable diagnostic method.Oesophageal ultrasound establishes either the muscularis mucosa or muscularis propria origin of the mass, without invasion of the mucosa or adventitia.On CT examination, a homogeneous intramural mass or oesophageal wall thickening is found. Surrounding mediastinal fat and adjacent organs are not usually disrupted or invaded. It has a homogeneous iso or low attenuation before and after intravenous contrast administration.MR examinations usually show isointensity or slight hyperintensity in T2-weighted images (in contrast with oesophageal carcinoma which is hyperintense) [4, 5].Local enucleation is the recommended treatment choice for all symptomatic or larger than 5 cm oesophageal leiomyomas. When it involves the oesophagus in a diffuse fashion (like our case), a complete oesophagectomy is required. Resection is the only way to confirm that the tumour is not malignant. Barium meal follow-up is advised for smaller or asymptomatic lesions [5].",
    "differential_diagnosis": "Oesophageal, leiomyoma, Oesophageal, carcinoma, Oesophageal, lymphoma, Oesophageal, GIST, Oesophageal, leiomyomatosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011322/000001.jpg?itok=0izKwQzz",
            "caption": "Long, circumferential and symmetric filling defect, smoothly tapering, in the mid third of the oesophagus."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011322/000002.jpg?itok=PJygPPUX",
            "caption": "Obtuse implantation angles can be seen and there is no irregularity of the mucosa.\nMild stasis of contrast above the lesion can also be appreciated."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011322/000003.jpg?itok=62aJpuyG",
            "caption": "Severe circumferential parietal thickening with soft tissue intensity, isointense relative to the skeletal muscle, in the mid third of the oesophagus."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011322/000004.jpg?itok=QNteNuvh",
            "caption": "There is a fine uninterrupted hypointense line in the centre of the oesophagus, which indicates sparing of the mucosa."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011322/000005.jpg?itok=BYXOwMsr",
            "caption": "The mucosal sparing is better seen with a fat supression sequence.\nThere are no signs of invasion of adjacent organs."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011322/000006.jpg?itok=SSNrZgYT",
            "caption": "There is mild dilation of the proximal third of the oesophagus."
          }
        ]
      },
      {
        "number": "Figure 7",
        "subfigures": [
          {
            "number": "Figure 7",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011322/000007.jpg?itok=Lio0VHSX",
            "caption": "The sagittal view better depicts  the long extension of the tumour.\nThe mucosal lining can also be seen in the lower border of the lesion."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Gastrointestinal tract"
    ],
    "imaging_technique": [
      "MR",
      "Fluoroscopy"
    ],
    "link": "https://www.eurorad.org/case/11322",
    "time": "04.11.2013"
  },
  "11340": {
    "case_id": 11340,
    "title": "An unusual cause of an unexpected difficult airway intubation",
    "section": "Chest imaging",
    "age": "85",
    "gender": "male",
    "diagnosis": "Dislodged fixed dental prosthesis in the oropharynx.",
    "history": "An 85-year-old man was admitted to the intensive care unit with respiratory failure requiring ventilatory support (Fig. 1). Non-invasive positive pressure ventilation (NiPPV) was started with a full-face mask. During admission the patient\u2019s condition deteriorated and tracheal intubation was required. Tracheal intubation was unexpectedly difficult due to an obstruction.",
    "image_finding": "Chest radiograph upon admission showed a pleural effusion on the right with lower lobe volume loss. The perihilar vasculature was accentuated on both sides (Fig. 1).The patient's condition deteriorated and a 4 day follow-up chest radiograph showed an increase of the pleural effusion and volume loss of the right lung, suggestive of increased obstruction (Fig. 2).A radiograph of the upper chest and neck obtained after the difficult tracheal intubation showed that the tube was correctly positioned and a foreign body was situated in the oropharynx (Fig. 3). A flexible fiberoptic laryngoscopy was performed and a dental prosthesis was atraumatically retracted. The dental prosthesis with 3 molar teeth fitted in a small metal plate (5\u00d73 cm) appeared to have been dislodged from the left upper cheek (Fig. 4). In retrospect, the foreign body in our patient could already have been detected on the chest radiograph prior to the intubation (Fig. 2).",
    "discussion": "BackgroundManagement of a difficult airway is challenging for intensivists on an intensive care unit as this could have fatal consequences. Precise data on the incidence of a difficult airway intubation are not clear [1]. Clinical perspectiveA difficult intubation can be defined as one that requires multiple or prolonged attempts, multiple operators, multiple intubating devices or excessive lifting force; it can also be defined as one that is performed with a poor view of the vocal cords [1]. Factors related to difficult tracheal intubation increase with age [1]. In elderly patients difficult tracheal intubation is often due to low head and neck movement, a short thyromental distance and poor dentition [1]. Loose crowns and bridges are a well-known cause of difficult airway management, especially in the elderly. However, cases involving dislocated fixed dental prostheses are rare [1]. Imaging perspectiveChest radiographs on an intensive care unit are made on a daily basis [2]. Especially chest radiography after endotracheal tube placement is still known to be a necessity [3], but more attention should be focussed on the role of chest radiographs prior to intubation [1]. OutcomeIn this case a chest radiograph was performed to elucidate the cause of the unexpected difficult airway intubation. This radiograph showed a foreign body situated in the oropharynx. A fixed dental prosthesis appeared to have been dislodged from the upper cheek and was removed. After this intervention, the patient could be treated successfully.Take home messageThe foreign body in our patient could already have been detected on previous chest radiographs; however, the difficulty of discerning an unknown foreign body on a standard chest radiograph may have hampered early diagnosis. We hypothesize that the tight fitting straps of the NiPPV mask and delirium-related restlessness and agitation of the patient contributed to the dislodgement and displacement of the dental prosthesis.This case report shows that chest radiographs are helpful in elucidating airway complications and detecting coincidental conditions prior to intubation. A thorough inspection of previous chest radiographs can provide clues regarding the cause of difficult airway management. In all suspected difficult airway intubations a chest radiograph should be considered.",
    "differential_diagnosis": "Dislodged, fixed, dental, prosthesis, in, the, oropharynx., Anatomical, obstruction, Corpus, alienum",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011340/000004.jpg?itok=5e0pzyp7",
            "caption": "The retrieved dental prosthesis."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011340/000005.jpg?itok=om39XgtQ",
            "caption": "Conventional radiograph of the thorax on day 4, the patient\\'s condition deteriorated."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011340/000006.jpg?itok=-tMN0_08",
            "caption": "Conventional radiography of the thorax upon admission to the hospital (day 1)."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011340/000007.jpg?itok=FjigvIn2",
            "caption": "Conventional radiography of neck and upper thoracic region after intubation (day 4) to identify the (location of the) foreign body."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax",
      "Ear / Nose / Throat"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "Experimental"
    ],
    "link": "https://www.eurorad.org/case/11340",
    "time": "14.11.2013"
  },
  "11345": {
    "case_id": 11345,
    "title": "nd-stage pulmonary fibrosis in sarcoidosis",
    "section": "Chest imaging",
    "age": "38",
    "gender": "male",
    "diagnosis": "End-stage pulmonary fibrosis in sarcoidosis.",
    "history": "A 38-year-old man was admitted to our hospital because of progressive dyspnoea, non-productive cough, fatigue and non-quantified weight loss for the last year. He denied any recent travel or occupational exposure. The lag time between onset of symptoms and medical visit was explained by a history of unemployment and homelessness.",
    "image_finding": "Posteroanterior chest radiograph demonstrated bilateral dense fibrosis causing elevation of both hila and deviation of the trachea to the right indicating a greater degree of volume loss on the right. In the mid zones there is widespread nodularity with relative sparing of the bases. Bilateral lymph nodes were also evident (Figure 1).The Computed Tomography (CT) of the thorax confirmed bilateral architectural distortion and a fibrotic pattern of disease, with multiple micronodules mainly in a peribronchovascular distribution in the upper lobes. Volume loss and coalescent mass-like peribronchovacular opacities were depicted with central traction bronchiectasis. There was mediastinal shift and upper-lobe bronchi were displaced posteriorly. No honeycombing was seen (Figure 2).Additionally non-enhanced CT showed extensive bilateral eggshell-like calcifications of hilar and mediastinal lymph nodes (Figure 3).A high suspicion of sarcoidosis was raised and confirmed by bronchoalveolar lavage and transbronchial biopsy of one of the lymph nodes.",
    "discussion": "Sarcoidosis is a systemic disorder of unknown aetiology that is characterized by the presence of noncaseating granulomas, in which lung and/or thoracic lymph nodes are involved in 90% of cases. It typically affects young to middle-aged adults and there is a slight female predominance [1, 2].Presentation as an incidental radiographic finding is common and symptoms are nonspecific, including fatigue, weight loss, low-grade fever, skin lesions, musculoskeletal or ocular symptoms. The clinical course varies widely and it is commonly staged according to its appearance on the chest radiograph. The staging system ranges from stage 0 (normal) to stage IV (lung fibrosis), with varying degrees of lymph nodes and parenchymal abnormalities in between [1].Lymph node enlargement is the most common finding and is usually seen as bilateral and symmetric in hilar, right paratracheal and tracheobronchial regions [3]. Calcification is depicted in up to 50% of cases and may have an amorphous, punctuate or eggshell-like appearance. This latter finding is also common in patients with silicosis and coal-worker\u2019s pneumoconiosis warranting their inclusion in the differential diagnosis [4]. Often showing a middle and upper lung predominance, CT reveals sharply defined, small nodules usually in a bilateral distribution, with about 15% showing significant asymmetry. As sarcoid granulomas in the lung are typically distributed along the lymphatic vessels (perilymphatic distribution) they are characteristically found along bronchovascular margins, subpleurally and interlobular septa. The nodules range in size from just 1mm to over 5mm but conglomeration into irregular opacities or masses is not uncommon [1-3].The presence of lung \ufb01brosis (stage IV) at the time of presentation on a radiograph occurs in 5% of patients and is correlated with a poor prognosis. Such fibrosis has fairly characteristic findings in CT, such as linear opacities radiating from the hilum mainly to the upper and middle regions associated with volume loss, traction bronchiectasis, superior retraction of the hilum and fissural displacement. This fibrosis is commonly linked with conglomerate parahilar masslike lesions that resemble those seen in progressive massive fibrosis of pneumoconiosis [5].Corticosteroids remain the corner stone in therapy but for those with end-stage fibrosis lung transplantation remains the only effective option.The role of the radiologist is to recognize the common patterns of sarcoidosis on HRCT in order to suggest the correct diagnosis in the appropriate clinical setting and eventually obviate the need for biopsy.",
    "differential_diagnosis": "End-stage, pulmonary, fibrosis, in, sarcoidosis., Silicosis, Tuberculosis, Coal, Workers`s, pneumoconiosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011345/000001.jpg?itok=7jBLzhpm",
            "caption": "Posteroanterior radiograph shows bilateral volume loss with mediastinal displacement to right. Note is made for bilateral elevation of the hila and distortion of the lung architecture, characteristic of fibrosis, with relative sparing of the bases."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011345/000013.jpg?itok=DehorcJK",
            "caption": "A negative magnified view enhances an enlarged lymph node with peripheral eggshell calcification (arrows)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011345/000003.jpg?itok=q2aXo-X7",
            "caption": "Axial CT images  obtained at the upper lobes level reveal multiple micronodules mainly in a peribronchovascular distribution. Volume loss and coalescent mass-like peribronchovacular opacities were depicted with severe central traction bronchiectasis."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011345/000004.jpg?itok=ikxI_vy3",
            "caption": "Axial CT images  obtained at the upper lobes level reveal multiple micronodules mainly in a peribronchovascular distribution. Volume loss and coalescent mass-like peribronchovacular opacities were depicted with severe central traction bronchiectasis."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011345/000005.jpg?itok=MEw1QbCT",
            "caption": "Axial CT images  obtained at the upper lobes level reveal multiple micronodules mainly in a peribronchovascular distribution. Volume loss and coalescent mass-like peribronchovacular opacities were depicted with severe central traction bronchiectasis."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011345/000006.jpg?itok=HvVQ9ed5",
            "caption": "CT at a lower level shows fewer lung nodules."
          },
          {
            "number": "Figure 2e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011345/000007.jpg?itok=i2jEbaNw",
            "caption": "Coronal reformations enhance upper lobe predominance."
          },
          {
            "number": "Figure 2f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011345/000008.jpg?itok=hLB1DkZ1",
            "caption": "Coronal reformations enhance upper lobe predominance"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011345/000014.jpg?itok=yf3jc-js",
            "caption": "Axial and coronal CT reveal parahilar masslike lesions that resemble those seen in progressive massive fibrosis of pneumoconiosis. Note is made for peripheral calcifications of hilar and mediastinal nodes, characteristic of sarcoidosis or silicosis."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011345/000015.jpg?itok=7sysAfNl",
            "caption": "Axial and coronal CT reveal parahilar masslike lesions that resemble those seen in progressive massive fibrosis of pneumoconiosis. Note is made for peripheral calcifications of hilar and mediastinal nodes, characteristic of sarcoidosis or silicosis."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011345/000016.jpg?itok=8R2njMZZ",
            "caption": "Axial and coronal CT reveal parahilar masslike lesions that resemble those seen in progressive massive fibrosis of pneumoconiosis. Note is made for peripheral calcifications of hilar and mediastinal nodes, characteristic of sarcoidosis or silicosis."
          },
          {
            "number": "Figure 3d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011345/000017.jpg?itok=TaCAU29O",
            "caption": "Axial and coronal CT reveal parahilar masslike lesions that resemble those seen in progressive massive fibrosis of pneumoconiosis. Note is made for peripheral calcifications of hilar and mediastinal nodes, characteristic of sarcoidosis or silicosis."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Lymphatic",
      "Lymph nodes",
      "Thorax"
    ],
    "imaging_technique": [
      "CT",
      "Conventional radiography"
    ],
    "link": "https://www.eurorad.org/case/11345",
    "time": "04.11.2013"
  },
  "11384": {
    "case_id": 11384,
    "title": "Idiopathic Hypereosinophilic Syndrome manifest with Deep Vein Thrombosis and Pulmonary Embolism",
    "section": "Chest imaging",
    "age": "39",
    "gender": "male",
    "diagnosis": "Idiopathic Hypereosinophilic Syndrome",
    "history": "Patient presented with abdominal pain and fever (38.2 \u02daC). Medical history was insignificant. Laboratory tests showed elevated leukocyte count:13, 170/mm [3] with 43% eosinophils, 0.1% basophils, and decreased platelet count: 55, 000/mm [3]. Erythrocyte sedimentation rate and C-reactive protein level were elevated. On the second hospital day, he experienced left leg swelling.",
    "image_finding": "Chest radiograph showed bilateral patchy opacities, in middle and lower zones, with no clear pattern of distribution (Fig.1). There was no pleural effusion. Axial chest CT scan revealed peripheral left upper lobe infiltrates (arrowheads) and right upper lobe ground-glass opacity (asterisk) tending towards consolidation (Fig. 2). Lower extremity venous ultrasonography revealed thrombosis of the common and superficial femoral veins as well as the popliteal vein. In addition, CT pulmonary angiogram revealed an intraluminal filling defect in the right main pulmonary artery, consistent with pulmonary thrombus (Fig. 3).",
    "discussion": "Idiopathic Hypereosinophilic Syndrome (IHS), a rare disorder, has been defined as persistent idiopathic eosinophilia greater than 1500 cells/mm [3] for more than 6 months or death within 6 months; absence of parasitic, allergic, or other known causes of eosinophilia; and signs or symptoms of organ damage related to eosinophilic infiltration [1]. Onset usually occurs in the third or fourth decade of life, with a male-female ratio of 7:1 [2]. Cardiac involvement including mural thrombosis, endocardial fibrosis, which may lead to restrictive cardiomyopathy is the major cause of morbidity and mortality in IHS [2]. Pulmonary involvement is observed in 40% of patients. Pleural effusion is seen in 50% of affected patients [3, 4]. Thromboembolic disease, peripheral neuropathy, and involvement of the GI tract, kidneys, joints, and skin have also been reported [1, 2]. Although biopsy is generally not required for the diagnosis of IHS, histopathologic analysis demonstrates eosinophilic infiltration of involved organs with associated disruption of organ architecture and necrosis [2]. Radiographic findings in IHS are often non-specific and consist of focal or diffuse interstitial or alveolar non-lobar opacities, with most pulmonary opacities being related to severe cardiac failure, although lesions from the eosinophilia itself may be seen [1]. CT shows single or multiple nodules with or without surrounding ground-glass opacity and focal or diffuse areas of ground-glass opacity or interstitial infiltrates.Treatment of IHS is empirical based on systemic corticosteroids. Currently, there are no randomised controlled trials to establish dosing regimens. Our patient was treated with per os prednisone (25 mg four times a day) and subcutaneous heparin. Clinical improvement was rapid, with normalisation of body temperature within four days after initiation of treatment. Lung infiltrates subsided and he was discharged on the eighth hospital day. Prednisone dose was tapered down over the next eight weeks. There was no recurrence of symptoms during tapering of steroids, or upon discontinuation of therapy at a 2-year follow-up.",
    "differential_diagnosis": "Idiopathic, Hypereosinophilic, Syndrome, Infectious, diseases, (invasive, pulmonary, aspergillosis, Mucormycosis, Candidiasis, Wegener, granulomatosis, Primary, and, metastatic, hemorrhagic, tumors, Bronchioloalveolar, carcinoma, Pulmonary, lymphoma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011384/000001.jpg?itok=SPO5X15E",
            "caption": "Chest radiograph shows bilateral patchy opacities, in middle and lower zones."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011384/000002.jpg?itok=yOyH2wCp",
            "caption": "Axial chest CT scan obtained the same day as the chest radiograph, shows peripheral infiltrates in the left upper lobe (arrowheads), and right upper lobe ground-glass opacity (asterisk) tending towards consolidation."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011384/000003.jpg?itok=tUphi65X",
            "caption": "Sequential CT image at the level of carina shows thrombosis of right pulmonary artery (arrow)."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011384/000004.jpg?itok=zkWk6yvo",
            "caption": "Transverse thin-section CT scan (mediastinal window) shows a filling defect in the right main pulmonary artery consistent with pulmonary thrombus (arrowheads)."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "Digital radiography",
      "CT",
      "CT-Angiography"
    ],
    "link": "https://www.eurorad.org/case/11384",
    "time": "27.12.2013"
  },
  "11394": {
    "case_id": 11394,
    "title": "Acquired Immune Deficiency Syndrome-related Pulmonary Lymphom",
    "section": "Chest imaging",
    "age": "66",
    "gender": "male",
    "diagnosis": "Acquired Immune Deficiency Syndrome-related Pulmonary Lymphoma",
    "history": "A 66-year-old man with no significant past medical history presented with a two-month duration of asthenia and unquantified weight loss. During hospitalisation, he complained of progressive dyspnea, which was not associated with fever or cough.When HIV-1 was detected the CD4 count was 53 cell/microliter.",
    "image_finding": "The admission chest radiograph revealed faint nodular densities involving both lower lung fields (Figure 1). The subsequent Computed Tomography (CT) confirmed variable-sized bilateral nodules of soft tissue density with a lower lobe predominance and non-specific distribution (Figure 2).Without overt evidence of infection or malignancy but due to worsening dyspnea a new chest radiograph after 10 days showed that the extent of overall lung involvement had rapidly progressed (Figure 3). CT exhibited significant increase in size and number of innumerable non-calcified nodules with well-defined margins (2-27mm in diameter), many surrounded by ground-glass opacities \u2013 the halo sign. No cavitated lesions were found. Several mediastinal and hilar enlarged lymph nodes were noted as well (Figure 4).CT-guided biopsy of a lower-lobe nodule revealed high grade non-Hodgkin's lymphoma (Burkitt's type). Chemotherapy was initiated, but the patient ultimately expired on the 29th hospital day.",
    "discussion": "Lymphoma is the second most common tumour occurring in patients with AIDS (after Kaposi\u2019s sarcoma) and its prevalence is approximately 40\u2013100 times that of the general population [1]. Non-Hodgkin\u2019s rather than Hodgkin\u2019s predominate in HIV-infected patients being invariably high-grade B-cell malignancies, such as Burkitt or diffuse large B-cell lymphoma. Furthermore, the risk increases with lower CD4 cell counts, usually less than 100 cell/mm3 [2]. There is conflicting data regarding the effect of Highly Active Antiretroviral Therapy in AIDS-related lymphoma (ARL) and some recent investigations have found relatively unchanged incidence or clinical outcome [3, 4]. The disease is frequently extranodal and at presentation most patients are symptomatic, with cough, dyspnea, pleuritic pain and weight loss [3].Thoracic manifestations of ARL are reported in up to 30% of cases and pulmonary involvement may present with variable patterns. The most common one consists of multiple well-circumscribed pulmonary nodules diffuse in distribution that tend to be non-cavitated, ranging in size from 5-50mm in diameter [1, 5]. Discrete air bronchograms are frequently present and a rim of ground-glass attenuation may be observed (halo sign) representing an in\ufb01ltration of the surrounding parenchyma by less densely arranged tumour cells. Despite being a nonspecific sign it is important because this, associated with ancillary findings, may help to narrow the differential diagnosis [6]. Areas of consolidation or pleural effusions are often found and lymph node enlargement is also a prominent feature [1, 3, 5].Positron emission tomography is positive but this is not of diagnostic value since other processes that mimic ARL may be positive as well. The overall prognosis remains severe in patients with ARL as this group frequently has more aggressive disease and even antiretroviral agents may interact with the chemotherapeutic agents used in the treatment making multidisciplinary approach of prime importance.The diagnosis is not always straightforward given the spectrum of coexistent pulmonary diseases and, though not pathognomonic, the presence of pulmonary nodules mainly if well-defined and supracentimetric, pleural effusion and lymph node enlargement in a HIV-patient with very low CD4 counts should always raise the suspicion for ARL that will then require histological correlation to confirm the diagnosis.",
    "differential_diagnosis": "Acquired, Immune, Deficiency, Syndrome-related, Pulmonary, Lymphoma, Fungal, infections, Kaposi, sarcoma, Lymphomatoid, granulomatosis, Hematogeneous, metastases, Wegener\u00b4s, granulomatosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011394/000003.jpg?itok=3FrJQSwZ",
            "caption": "In the admission posteroanterior\u00a0and\u00a0lateral chest radiographs depict faint nodular opacities were in both lower lung fields (arrows)."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011394/000002.jpg?itok=ToumHSzw",
            "caption": "In the admission posteroanterior\u00a0and\u00a0lateral chest radiographs depicts faint nodular opacities in both lower lung fields (arrows)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011394/000004.jpg?itok=csUekcsd",
            "caption": "CT\u00a0confirmed multiple random nodules of soft tissue density and well-defined margins with a discrete predominance in the lower\u00a0lung\u00a0zones, ranging from 2-18mm in diameter."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011394/000005.jpg?itok=lQjcn-EW",
            "caption": "CT\u00a0confirmed multiple random nodules of soft tissue density and well-defined margins with a discrete predominance in the lower\u00a0lung\u00a0zones, ranging from 2-18mm in diameter."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011394/000006.jpg?itok=A9RCiSGP",
            "caption": "CT\u00a0confirmed multiple random nodules of soft tissue density and well-defined margins with a discrete predominance in the lower\u00a0lung\u00a0zones, ranging from 2-18mm in diameter."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011394/000007.jpg?itok=QLQdLYO1",
            "caption": "CT\u00a0confirmed multiple random nodules of soft tissue density and well-defined margins with a discrete predominance in the lower\u00a0lung\u00a0zones, ranging from 2-18mm in diameter."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011394/000008.jpg?itok=uSpZKTpU",
            "caption": "A chest posteroanterior radiograph performed 10 days after the initial radiograph reveals marked increase in the number and size of pulmonary nodules."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011394/000009.jpg?itok=hE-QbtY0",
            "caption": "On the follow-up CT, obtained 13\u00a0days\u00a0after the initial radiograph, marked progression in the number and size of the innumerable, randomly\u00a0dispersed, non-cavitating nodules were confirmed (2-27 mm in diameter)."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011394/000010.jpg?itok=jQqFlbtP",
            "caption": "On the follow-up CT, obtained 13 days after the initial radiograph, marked progression in the number and size of the innumerable, randomly dispersed, non-cavitating nodules were confirmed (2-27 mm in diameter)."
          },
          {
            "number": "Figure 4c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011394/000011.jpg?itok=rsfrwnmm",
            "caption": "On the follow-up CT, obtained 13 days after the initial radiograph, marked progression in the number and size of the innumerable, randomly dispersed, non-cavitating nodules were confirmed (2-27 mm in diameter)."
          },
          {
            "number": "Figure 4d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011394/000012.jpg?itok=qSWIyv_X",
            "caption": "Selected axial view shows some pulmonary nodules surrounded by a rim of ground-glass opacity (CT halo sign, arrow)."
          },
          {
            "number": "Figure 4e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011394/000013.jpg?itok=AM8XuzpL",
            "caption": "Linear, discrete air bronchogram was exhibited in some of the nodular lesions."
          },
          {
            "number": "Figure 4f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011394/000014.jpg?itok=5JRhSUvn",
            "caption": "Linear, discrete air bronchogram was exhibited in some of the nodular lesions (arrows)."
          },
          {
            "number": "Figure 4g",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011394/000015.jpg?itok=U2qsbRbw",
            "caption": "Note is made for the several mediastinal and hilar enlarged lymph nodes."
          },
          {
            "number": "Figure 4h",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011394/000016.jpg?itok=XRK0NqI1",
            "caption": "Note is made for the several mediastinal and hilar enlarged lymph nodes."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Lymph nodes"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/11394",
    "time": "28.01.2014"
  },
  "11402": {
    "case_id": 11402,
    "title": "A rare case of endotracheal metastasis from lung cance",
    "section": "Chest imaging",
    "age": "60",
    "gender": "male",
    "diagnosis": "Endotracheal metastasis of a squamous cell carcinoma of the lung",
    "history": "A 60 year old asymptomatic male, ex-smoker with emphysema, underwent a follow-up thoracic CT, two years after a left upper lobectomy for a squamous cell carcinoma of the lung (T1N0M0).",
    "image_finding": "The two-year follow-up thoracic CT revealed (figure 1, 2, 3 and 4) thickening of the left lateral wall of the distal trachea, of soft tissue density, which caused approximately 50% luminal diameter reduction. There was no cartilage disruption or macroscopic invasion of adjacent structures, although the lesion was in close proximity to the aortic arch and left subclavian artery. There was slight mediastinal shift to the left, as a consequence of the prior upper left lobectomy. Diffuse areas of centrilobular and paraseptal emphysema were noted. There was no evidence of pulmonary metastasis, mediastinal or hilar lymphadenomegaly.A tracheal metastasis was diagnosed after biopsy. Laser ablation of the lesion was performed. A chest radiograph was taken, which confirmed the correct placement of the tracheal stent (figure 5).The patient had already underwent a thoracic CT six months earlier, where inconspicuous findings were noted, interpreted as endoluminal secretions  by mistake (figure 6).",
    "discussion": "Endotracheal/endobronchial metastases are a relatively common finding in patients with breast, colorectal, and renal carcinomas and melanoma, but, to our knowledge, under 10 cases of endotracheal metastasis from lung cancer have been reported worldwide [1, 2, 3, 4, 5]. The study with the most cases (six) found an overall incidence of tracheal metastasis of only 0.44% in surgically resected non-small cell lung cancer (0.77% in squamous cell carcinomas and 0.18% in adenocarcinomas) [1].The exact mechanism of endobronchial metastasis remains unknown. The possible mechanism may be the involvement of peribronchial lymphatics with subsequent invasion of the submucosa [6].The symptoms are the same as those of a primary tumour (dyspnoea, coughing, hemoptysis, stridor and frequent upper airway infections), but the fact that the patient is in a follow up CT protocol makes it more likely to find metastasis before there are clinical manifestations (i.e. before there is significant airway narrowing) [1].It usually manifests as an endotracheal nodule or eccentric thickening of the tracheal wall on CT, similarly to squamous cell carcinoma and adenoid cystic carcinoma, which are the two most common primary tracheal malignancies. Distinguishing between an endotracheal tumour and endotracheal phlegm can be a challenging task. The presence of disrupted cartilaginous rings, enhancement after contrast administration, no change with coughing manoeuvre [1], no air inside the \"lesion\", a non-dependent position, and growth in-between scans all may indicate a real endoluminal tumour.CT is the standard imaging tool for diagnosis and evaluation of tumour extent.There are no reliable histologic criteria to differentiate primary from metastatic tumours. Most studies consider endobronchial metastasis to be histopathologically identical to the primary tumour (which was the case with our patient) [1].There are several options for treating tracheal tumours, some meant for cure (benign and primary tumours) and some only palliative (inoperable tumours or metastasis). In the latter cases, laser therapy with insertion of a tracheobronchial stent to keep the airway open is one of the options (and the one used in our patient, because it was unresectable due to its proximity to the carina).In conclusion, a high degree of suspicion is warranted when an endotracheal nodule or eccentric thickening of the tracheal wall is found in a patient on CT follow-up for lung cancer.",
    "differential_diagnosis": "Endotracheal, metastasis, of, a, squamous, cell, carcinoma, of, the, lung, Endotracheal, phlegm, Squamous, cell, carcinoma, Adenoid, cystic, carcinoma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011402/000001.jpg?itok=Y_030Q1u",
            "caption": "Thickening of the left lateral wall of the distal trachea, of soft tissue density, with 30 x 13 mm of axial diameters. It causes a 50% luminal stenosis."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011402/000002.jpg?itok=ojUFEkM0",
            "caption": "The longitudinal extension of the tumour and its location in the distal trachea - 2 cm from the carina - is better appreciated on this coronal reformat."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011402/000003.jpg?itok=B0MGXvce",
            "caption": "In this sagittal reformation, the anteroposterior extension of the tumour and the close proximity with the left subclavian artery is better depicted."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011402/000004.jpg?itok=HxTHrxXj",
            "caption": "At this level the tracheal luminal reduction is more than 50%.\nThere is mediastinal shift to the left because of prior left upper lobectomy.\nDiffuse centrilobular emphysema as a consequence of smoking."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011402/000005.jpg?itok=0kgnA-r2",
            "caption": "Tracheal stent inserted after laser ablation of the lesion.\nMediastinal shift to the left."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011402/000006.jpg?itok=SG7GIx0H",
            "caption": "Mild thickening of the left lateral wall of the trachea,   misinterpreted as endotracheal secretions."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/11402",
    "time": "27.01.2014"
  },
  "11427": {
    "case_id": 11427,
    "title": "Broncholith",
    "section": "Chest imaging",
    "age": "54",
    "gender": "male",
    "diagnosis": "Broncholithiasis of the lateral part of the intermediate bronchus",
    "history": "\u0391 54 year-old man, heavy smoker suffered pneumonia of the RLL. One year later, he developed empyema of the right pleural cavity (fig. 1e, 1f) and partial segmentectomy of the RLL was performed. One and a half years later, he presented with decreased respiratory sounds, end inhalation wheezing.",
    "image_finding": "The CT-scan which followed revealed a calcified lesion within the intermediate bronchus and the proximal parts of the lower and middle lobe bronchi, possibly a broncholith (Fig. 2), which was also present on three previous CT-scans (Fg. 1) with no significant change. This finding had not been reported at the previous CT-scans, either because it was missed or because it was misinterpreted as calcified bronchial walls. Other significant radiological findings included: cicatrization atelectasis, scarring and ground-glass opacification of the RLL (Fig. 2). Enlarged lymph nodes were not noted.Bronchoscopy revealed the broncholith at the lateral part of the intermediate bronchus (Fig. 3a, 3b). Its diameter was more than 1cm and it had a trapezoid shape. After removal, granulation tissue was revealed at the bronchial walls (Fig. 3c). Histology revealed a calcified lesion which consisted of trabecular formations with many bacterial colonies.",
    "discussion": "Broncholithiasis is a condition in which calci\ufb01ed or ossi\ufb01ed material is present within the bronchial lumen. An extended definition includes patients with peribronchial calci\ufb01c nodes with distortion of the bronchi [1]. The most common cause is erosion and extrusion of calci\ufb01ed peribronchial lymph node into the bronchial lumen, which is generally associated with necrotizing granulomatous lymphadenitis. Other pathophysiological mechanisms include: aspiration of a bone fragment, in situ calcification of an aspirated foreign object, erosion by and extrusion of calci\ufb01ed or ossi\ufb01ed bronchial cartilage plates and migration to a bronchus of calci\ufb01ed material from a distant site [2].The clinical symptoms are caused by the presence of the broncholith and by the irritation, erosion or obstruction of the airway. The most common are chronic cough (100%), fever (50%-60%) hemoptysis (45-50%) and these are followed by localised wheezing (25-60%) chest pain (20%) and lithoptysis i.e. the actual expectoration of the broncholith (15-26%). Rarely broncholiths can cause acute symptoms by penetrating into a major vessel or into the esophagus [3]. Hence the recurring respiratory infections that our patient had suffered before the extraction of the broncholith can be closely correlated with the presence of the broncholith and the obstruction of the airway. HRCT is needed to confirm the diagnosis of broncholithiasis. X-ray findings are rarely diagnostic. Conventional CT can be strongly suggestive of broncholithiasis [4] when there is a calci\ufb01ed nodule that is either endobronchial or peribronchial and is associated with \ufb01ndings of bronchial obstruction, such as atelectasis, obstructive pneumonitis or bronchiectasis.Treatment includes bronchoscopic extraction or surgery. Occasionally a broncholith can be expectorated via lithoptysis [5]. Bronchoscopic removal should be considered in cases of an uncomplicated and loose broncholith, whereas surgery should be considered in complicated cases [6].Differential diagnosis includes endobronchial infections with calcified fungus ball, calcified endobronchial tumours, tracheobronchial diseases with mural calci\ufb01cation (most commonly tracheobronchial amyloidosis), and hypertrophied bronchial artery with intraluminal protrusion [2].",
    "differential_diagnosis": "Broncholithiasis, of, the, lateral, part, of, the, intermediate, bronchus, calcified, endobronchial, tumours, calcified, endobronchial, fungus, ball, tracheobronchial, diseases, with, mural, calci\ufb01cation, most, commonly, tracheobronchial, amyloidosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011427/000001.jpg?itok=j0dP7MKJ",
            "caption": "Coronal image, mediastinal window: broncholith inside the intermedius bronchus which was not reported at the time."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011427/000002.jpg?itok=x9sKwQbe",
            "caption": "Coronal image, lung window: broncholith inside the intermedius bronchus."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011427/000012.jpg?itok=xgrpgd0X",
            "caption": "Axial image, lung window:\nbroncholith inside the intermedius bronchus."
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011427/000013.jpg?itok=7uwco7iA",
            "caption": "Axial image, lung window:\nmucus plug into RLL bronchus, peripheral to the broncholith."
          },
          {
            "number": "Figure 1e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011427/000014.jpg?itok=oOWKT3Db",
            "caption": "Axial image, mediastinal window: empyema in the periphery of the RLL."
          },
          {
            "number": "Figure 1f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011427/000011.jpg?itok=nl3GfKMF",
            "caption": "Axial image, mediastinal window:empyema with air bubbles in the periphery of the RLL."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011427/000007.jpg?itok=TwTDrQYp",
            "caption": "Bronchoscopy image of the Right main bronchus: the broncholith can be identified inside the intermedius bronchus."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011427/000008.jpg?itok=9_tSBq0T",
            "caption": "Bronchoscopy image of the\nintermedius bronchus: the broncholith obstructs the intermedius bronchus."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011427/000009.jpg?itok=gFCMvGMV",
            "caption": "Bronchoscopy image of the\nintermedius bronchus and proximal parts of the inferior lobaris and medius lobaris bronchus. After the removal of the broncholith granulation tissue is revealed at the bronchial walls."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011427/000015.jpg?itok=kgt-T1ij",
            "caption": "Coronal image, lung window:\nthe broncholith remains in the intermedius bronchus after segmentectomy for empyema. A few fibrous bands in the right lower lobe after surgery."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011427/000016.jpg?itok=h31ZFd0C",
            "caption": "Coronal image, lung window:\nthe broncholith is completely and successfully removed, no signs of peripheral atelectasis."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT",
      "Image manipulation / Reconstruction"
    ],
    "link": "https://www.eurorad.org/case/11427",
    "time": "28.02.2014"
  },
  "11491": {
    "case_id": 11491,
    "title": "Alveolar sarcoidosis",
    "section": "Chest imaging",
    "age": "33",
    "gender": "female",
    "diagnosis": "Sarcoidosis, pulmonary involvement",
    "history": "A 33-year-old female patient presented with productive cough, fevers, night sweats, polyarthralgia and anterior uveitis. Serum angiotensin converting enzyme level was elevated. Bronchial washings were negative for bacteria (including mycobacteria), fungi and pneumocystis jiroveci. Cytology of the lavage fluid revealed 87% macrophages and no evidence of malignancy.",
    "image_finding": "On chest radiograph there are multiple nodular airspace opacities in both lungs (Figure 1); the lesion in the right lower zone lung shows central hypo-attenuation. There is symmetrical hilar shadows lymph node enlargement. Enlarged nodes are present in the aorto-pulmonary window. There is no pleural abnormality.Chest CT reveals multifocal consolidation with fine nodularity surrounding a number of the lesions (Figure 2). In the right lower lobe there is consolidation surrounding a central area of ground-glass attenuation (the \u2018reversed halo\u2019 sign). On the soft tissue windows, there is symmetrical hilar and mediastinal (subcarinal, paratracheal, subaortic, para-aortic and pre-vascular) lymph node enlargement (Figure 3).",
    "discussion": "The presentation is non-specific, but biopsy showed numerous discrete non-caseating granulomata without lymphocytic inflammation, suggesting sarcoidosis, a systemic granulomatous disease. The most frequent sites of involvement include lymph nodes, skin, lungs and eyes, although virtually any organ can be affected. In patients with a compatible clinical history, thoracic imaging (usually in the form of chest radiograph) is used for confirmation and staging. CT is only necessary in cases of atypical clinical and/or chest radiographic findings; high clinical suspicion of sarcoidosis without typical imaging findings; and suspected complications, including airway disease, fibrosis and mycetoma [1]. The common chest radiograph finding is symmetrical bilateral hilar and right paratracheal lymph node enlargement. About 60% of the patients will also display some pulmonary involvement on chest X-ray. High-resolution CT is superior for detecting and characterizing parenchymal disease. There is a wide range of reported findings [2].  Airspace opacities are non-specific findings on chest radiography and CT. The list of possible diagnoses is broad but the typical causes of this radiological pattern include infection, intra-alveolar blood and some tumours. This radiological pattern is an uncommon finding in patients with sarcoidosis and is also a misnomer: in contrast with other pathologies which cause a pattern of consolidation, histological examination in patients with this appearance on imaging indicate that the predominant abnormality is significant thickening of the interstitium, with displacement of alveolar air [3].  The reversed halo sign was first reported in patients with cryptogenic organizing pneumonia. [4] However, it is now known that this pattern can also be seen in tuberculosis, invasive fungal infection, sarcoidosis, adenocarcinoma, Wegener\u2019s granulomatosis and also pulmonary thromboembolism [5]. It has been suggested that the combination of an irregular halo with peripheral nodularity, should raise the possibility of a granulomatous disease (including tuberculosis and sarcoidosis) [5-6]. Patients with sarcoidosis, without findings of overt lung fibrosis usually respond well to corticosteroid therapy. However, some will relapse and a subset of patients will show progression to lung fibrosis despite treatment.  The take home points are:1)\tSarcoid lung involvement may present as airspace or alveolar opacities. This is caused by predominant interstitial thickening, as opposed to filling of the alveoli. 2)\tSarcoidosis is a cause of the reversed halo sign.",
    "differential_diagnosis": "Sarcoidosis,, pulmonary, involvement, Infection, including, pulmonary, tuberculosis, and, fungi, Lymphoma, Organizing, pneumonia",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011491/000001.jpg?itok=H9t6ch1O",
            "caption": "PA chest radiograph with multiple nodular airspace opacities. Mediastinal lymph node enlargement is also noted."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011491/000002.jpg?itok=NlxyUZ4s",
            "caption": "Sagittal image displaying an opacity in the right lower lobe which shows the \\'reversed halo\\' sign."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011491/000003.jpg?itok=qWoLTcBs",
            "caption": "Sagittal image displaying airspace opacities in the left lung"
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011491/000005.jpg?itok=yYr6m7Vo",
            "caption": "Set of axial images displaying airspace opacities."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011491/000006.jpg?itok=rnyUihq4",
            "caption": "Set of axial images displaying airspace opacities."
          },
          {
            "number": "Figure 2e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011491/000007.jpg?itok=ovlP_96G",
            "caption": "Set of axial images displaying airspace opacities."
          },
          {
            "number": "Figure 2f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011491/000008.jpg?itok=vuYkF5zp",
            "caption": "Set of axial images displaying airspace opacities."
          },
          {
            "number": "Figure 2g",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011491/000009.jpg?itok=aEEAQpY2",
            "caption": "Set of axial images displaying airspace opacities. In this image we can see an opacity with the \\'reversed halo\\' sign."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011491/000010.jpg?itok=lR50hsj2",
            "caption": "Images through the chest with mediastinal window settings. Note is made of intra-thoracic lymph node enlargement."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011491/000011.jpg?itok=nKAnJ-MN",
            "caption": "Images through the chest with mediastinal window settings. Note is made of intra-thoracic lymph node enlargement."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011491/000012.jpg?itok=Vm59_e8q",
            "caption": "Images through the chest with mediastinal window settings. Note is made of intra-thoracic lymph node enlargement."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Thorax"
    ],
    "imaging_technique": [
      "CT-High Resolution",
      "Conventional radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/11491",
    "time": "20.01.2014"
  },
  "11504": {
    "case_id": 11504,
    "title": "Finger-in-glove sign",
    "section": "Chest imaging",
    "age": "28",
    "gender": "male",
    "diagnosis": "Segmental bronchial atresia with secondary bronchocele",
    "history": "A 51-year-old man was referred to our hospital because of a pulmonary nodule detected on a chest radiograph. He was a non-smoker with a history of chronic dry cough.",
    "image_finding": "Imaging investigation undertaken at our hospital included a chest CT.Nonenhanced (Fig. 1a) and enhanced (Fig. 1b, 1c) axial soft-tissue window CT images, axial (Fig. 2a) and coronal lung window (Fig. 2b), and coronal maximum (Fig. 3a) and minimum-intensity-projection (Fig. 3b) showed a tubular non-enhancing lesion extending caudally from the left hilum. The findings were consistent with mucus impaction of the left posterior basal and lateral basal segmental bronchus (bronchocele). Computed Tomography attenuation of the lesion was 29 HU (Fig. 1a) and no enhancement after intravenous administration of contrast medium was noted (Fig. 1b, 1c). Decreased attenuation was seen throughout these segments of the left lower lobe (Fig. 2 and 3b), suggestive of associated air trapping and decreased vascularity. These CT features were diagnostic of bronchocele secondary to bronchial atresia.",
    "discussion": "Airway filling by mucoid secretions is termed mucoid impaction, mucocele or bronchocele and can be caused by obstructive or non-obstructive diseases.The secretions may be depicted on chest radiographs or CT images as tubular or branching opacities that radiate from the hilum toward the periphery of the lung. This characteristic finger-like appearance of mucous plugs within dilated bronchiectatic bronchi is named finger-in-glove or gloved finger sign [1].The differential diagnosis of the finger-in-glove sign includes mucus impaction due to segmental bronchial atresia (as in this case), cystic fibrosis, allergic bronchopulmonary aspergillosis, broncholithiasis, foreign body aspiration and benign and malignant neoplastic conditions [1].In this case it was caused by segmental bronchial atresia. This is a rare congenital abnormality that results from focal obliteration of a proximal segmental or subsegmental bronchus. The development of distal structures is normal, so the bronchi distal to the stenosis become filled with mucus. The mucus plug is surrounded by hyperlucent or hypoattenuating lung, which is a result of a combination of air trapping (dilated air spaces) and focal parenchymal oligoemia, secondary to intrapulmonary vascular compression and hypoxic vasoconstriction [2]. CT imaging is diagnostic and the most frequently involved bronchus is the apicoposterior segmental bronchus of the left upper lobe. The lower lobe bronchi (as in this case) are the least frequently involved [3].Treatment with surgical resection is warranted only if the patient is symptomatic (history of recurrent pneumonia), but the majority of patients are asymptomatic [4].",
    "differential_diagnosis": "Segmental, bronchial, atresia, with, secondary, bronchocele, Segmental, bronchial, atresia, Arteriovenous, malformation, Cystic, fibrosis, Allergic, bronchopulmonary, aspergillosis, Broncholithiasis, Foreign, body, aspiration, Benign, and, malignant, neoplastic, conditions, Pulmonary, sequestration",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011504/000001.png?itok=yU7zqFWe",
            "caption": "Axial non-enhanced CT image in soft tissue window shows a low-attenuation left lower lobe branching lesion, with well-defined borders and its longitudinal axis oriented toward ipsilateral hilum."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011504/000002.png?itok=1TlS3tzu",
            "caption": "Axial arterial phase CT image \nshows absence of contrast enhancement in the lesion, enabling the distinction from vascular lesion such as arteriovenous malformation, and allowing the diagnosis of a bronchocele."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011504/000003.png?itok=RuvxZOEL",
            "caption": "Axial venous phase CT image.\nAfter exclusion of a central obstructing neoplasm or foreign body causing the mucous plug (bronchocele), the imaging findings are diagnostic of bronchial atresia."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011504/000004.png?itok=lEttxBfL",
            "caption": "Axial lung window CT image demonstrates the branching lesion. Note the low attenuation wedge-shaped area surrounding the lesion.\nThe hyperlucent peripheral lung is related to collateral ventilation, air-trapping and hypoperfusion."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011504/000005.png?itok=XfX1JnAi",
            "caption": "Coronal reformat on lung window settings."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011504/000006.png?itok=8DmC1o-W",
            "caption": "MIP coronal reformation from arterial phase showing the characteristic finger-in-glove sign."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011504/000007.png?itok=ZFdq1rLF",
            "caption": "Coronal MinIP image depicts better the hyperlucent lung surrounding the branching bronchocele."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/11504",
    "time": "16.03.2014"
  },
  "11513": {
    "case_id": 11513,
    "title": "Primary antiphospholipid antibody syndrome underlying diffuse pulmonary airspace consolidation",
    "section": "Chest imaging",
    "age": "57",
    "gender": "female",
    "diagnosis": "Primary antiphospholipid syndrome affecting the lung",
    "history": "A 57-year-old female patient presented with haemoptysis, chest pain, dyspnoea and no extrathoracic symptoms. Breathing sounds were diminished, with diffuse crackles. Raised CRP, erythrocyte sedimentation rate, INR and D-dimers were found. She had high serum levels of anticardiolipin antibodies-IgM, with negative lupus anticoagulant test, antinuclear antibodies and rheumatoid factor.",
    "image_finding": "The patient underwent radiographic evaluation of the chest. Chest radiographs showed bilateral, diffuse symmetric alveolar (airspace) filling pattern (Fig. 1), suggesting infection, embolism or other pathology (i.e., Wegener granulomatosis, vasculitis). CT examination of chest was then performed. On axial CT examination of the chest, extensive patchy areas of pulmonary consolidation with air bronchogram (arrowheads) were seen in both lungs (Fig. 2). As imaging findings were nonspecific and D-dimers and anticardiopipid antibodies were positive, a CT pulmonary angiography was requested in order to exclude acute pulmonary embolism, which proved negative for pulmonary embolism. Following rigorous treatment with intravenous steroids, rapid clinical improvement was achieved. Five days after initiation of therapy, the patient improved dramatically and was discharged upon resolution of the imaging findings of consolidation (Figs. 3, 4).",
    "discussion": "The antiphospholipid antibody syndrome is a disorder of unknown prevalence characterized by recurrent vascular thrombosis [1]. This rare disorder is composed of a diverse set of clinical manifestations including arterial and/or venous thrombosis, thrombocytopenia, and recurrent fetal loss. Diagnosis is confirmed by the presence of circulating lupus anticoagulant and/or positive anticardiolipin antibodies [1, 2]. There is a 2:1 female/male sex preponderance [1]. \tA variety of abnormalities of the skin, cardiac valves, central nervous system and other organ systems, as well as thrombocytopenia, have been described in association with the antiphospholipid antibody syndrome. Pulmonary involvement, as in our patient, is infrequent and presents mainly with pulmonary embolism, thromboembolic pulmonary hypertension, and primary pulmonary hypertension [3]. Microvascular pulmonary thrombosis, pulmonary capillaritis, alveolar haemorrhage and the adult respiratory distress syndrome (ARDS) have also been described [1]. Less commonly, a postpartum syndrome and fibrosing alveolitis have been reported [3]. The antiphospholipid syndrome is considered primary, if unassociated with any other underlying disease, or secondary if it appears in association with other systemic autoimmune disorders, mainly systemic lupus erythematosus (SLE), vasculitic syndromes, cancer, or drugs. However, some patients who present with features of antiphospholipid syndrome alone may later on develop features typical of SLE. Conversely, patients with SLE may develop antiphospholipid syndrome some time after the onset of SLE [1]. Our patient had primary antiphospholipid syndrome involvement. Laboratory diagnosis of antiphospholipid syndrome is based on a positive anticardiolipin antibody or lupus anticoagulant test [1, 2]. The anticardiolipin test is positive in about 80% of patients, the lupus anticoagulant is the only positive test in about 20%, and both are positive in about 60% of cases [1]. It is important that both tests be performed in patients suspected of antiphospholipid syndrome. From a pathophysiology standpoint, it has been shown that the anticardiolipin antibodies exhibit an affinity for phospholipids involved in the haemostasis process, inducing a procoagulant state that leads to microthrombosis. Although the anticardiolipin antibodies may contribute directly to a procoagulant state, other factors must act synergistically to cause thrombosis, as most patients with persistent elevated antibody levels only suffer thrombosis sporadically and others never suffer this complication. In our patient with anticardiolipin antibodies, alveolar bleeding secondary to microvascular thrombosis, was most likely the substrate of the patchy areas of pulmonary consolidation seen on CT.",
    "differential_diagnosis": "Primary, antiphospholipid, syndrome, affecting, the, lung, Vasculitis, (particularly, Goodpasture\u2019s, syndrome), Wegener, granulomatosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011513/000001.jpg?itok=iumYlKFZ",
            "caption": "Frontal chest radiograph demonstrates bilateral, symmetric, coarse nodular opacities throughout the lungs."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011513/000002.jpg?itok=IwhhHOqk",
            "caption": "Axial CT images at different levels through mid (A) and lower lobes (B) show bilateral, patchy areas of consolidation with air bronchogram (arrowheads)."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011513/000003.jpg?itok=fYac6KiR",
            "caption": "Axial CT images at different levels through mid (A) and lower lobes (B) show bilateral, patchy areas of consolidation with air bronchogram (arrowheads)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011513/000004.jpg?itok=uBMsELnz",
            "caption": "Frontal view of lung parenchyma following treatment shows resolution of infiltrates."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011513/000005.jpg?itok=yK8Ufti6",
            "caption": "Axial CT images (A and B) obtained the same day as Fig. 3 at levels corresponding to those in Fig. 2, display complete resolution after treatment."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011513/000006.jpg?itok=48ixzVGA",
            "caption": "Axial CT images (A and B) obtained the same day as Fig. 3 at levels corresponding to those in Fig. 2, display complete resolution after treatment."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "Digital radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/11513",
    "time": "19.03.2014"
  },
  "11527": {
    "case_id": 11527,
    "title": "sophageal achalasi",
    "section": "Chest imaging",
    "age": "89",
    "gender": "female",
    "diagnosis": "Primary oesophageal achalasia",
    "history": "An 89-year-old female patient presented to the emergency department with acute dyspnoea, dysphagia, dysphonia, neck swelling, and epistaxis. Her medical history was unremarkable with the exception of cognitive disorders.",
    "image_finding": "The frontal chest radiograph showed an enlarged mediastinum due to a tubular radiolucent structure occupying the entire mediastinal width (Fig 1a). This widening proved to be present already on a comparative film performed two years before (Fig 1b). Contrast-enhanced computed tomography (CT) revealed a significant dilatation of the oesophagus up to 7.5 cm proximally, with progressive narrowing towards the lower sphincter (Fig 2a-c). The trachea was displaced anteriorly. There was no evidence of an extrinsic mass effect. There was a patchy alveolar infiltrate in the superior segment of the left lower lung lobe, suggestive of aspiration. Videofluoroscopy was then performed. Although the patient managed to swallow only a small amount of contrast medium, the study confirmed the oesophageal dilatation with a progressive smooth, V-shaped narrowing at the level of the gastroesophageal junction, showing a \"bird beak\" sign (Fig 3a-c). Oesophageal stasis and gastroesophageal reflux was noted.",
    "discussion": "Oesophageal achalasia is a motility disorder of the oesophagus with loss of organized peristalsis and incomplete or absent relaxation of the lower oesophageal sphincter [1, 2]. The term achalasia is derived from the Greek words \"a-\" and \"chalasis\" meaning \"absence of relaxation\" [3]. Achalasia was first described by Thomas Willis in 1674 [1]. It typically becomes evident in adulthood at 25-60 years, the annual incidence being 0.6-2/100.000 [4]. The pathogenesis of achalasia encompasses loss of oesophageal myenteric plexus of Auerbach ganglion cells, resulting in hypertensive lower oesophageal sphincter [1, 4]. Primary idiopathic achalasia is the most common subtype [1]. Secondary achalasia (pseudoachalasia), is related to malignant conditions, Chagas disease (Trypanosoma cruzi infection), amyloidosis, or diabetes mellitus [1, 2, 4]. Clinical symptoms are dysphagia of liquids and solids, regurgitation, and retrosternal chest pain [1, 5]. Achalasia can be complicated by aspiration pneumonia, lung abscess, bronchiectasis, and haemoptysis [1]. It predisposes to oesophageal squamous cell cancer [1] with a per annum risk of 0.34% [6]. Achalasia can be suggested on radiography, videofluoroscopy/barium swallow studies, and CT [1, 2, 5]. Radiographs show a biconvex mediastinal opacity or lucency, depending on the filling of the dilated oesophagus. The trachea is anteriorly displaced on lateral views. On barium swallow studies, there is oesophageal dilatation and absence of primary peristaltism, with a smooth \"bird beak\" like tapering at gastroesophageal junction [1, 2, 5]. With widespread use of CT, achalasia may be found incidentally. Even if CT is not considered a routine study in diagnosis of achalasia, it is useful in detecting underlying intrinsic or extrinsic masses as well as pulmonary complications of the disease [7, 8]. CT shows uniform dilatation of a long oesophageal segment [1, 2] with normal wall thickness and preserved mediastinal fat [7]. There is abrupt short-segment narrowing at the gastroesophageal junction [1, 2]. Air-fluid levels are often visible in the dilated oesophagus [2]. Endoscopy and potentially biopsy serve to rule out cancer of the gastroesophageal junction that could cause pseudoachalasia [1, 5]. Other complementary studies are endoscopic ultrasound, manometry and pHmetry.Treatment options include pneumatic sphincter dilation and thoracoscopic or laparoscopic myotomy [1, 2]. Drugs like injected botulinum toxin, calcium antagonists or anticholinergics have been reported to have limited therapeutic outcome [1]. In conclusion, achalasia is a rare neurogenic motility disorder of the oesophagus. A typical finding on the oesophagogram is massive dilatation with a \"bird beak\" sign at the lower oesophageal sphincter.",
    "differential_diagnosis": "Primary, oesophageal, achalasia, Oesophageal, carcinoma, Oesophageal, lymphoma, Gastric, carcinoma, with, cardia, or, distal, esophageal, involvement, Peptic, stricture, Scleroderma, Post-vagotomy, state, Hiatal, hernia, (mimic), Post-oesophagectomy, state, (mimic), Oesophageal, leiomyoma, Extrinsic, compression, of, lower, oesophagus",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011527/000001.jpg?itok=_Mo5jJo6",
            "caption": "Posteroanterior chest radiograph shows mediastinal widening due to massive oesophageal dilatation (arrows)."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011527/000002.jpg?itok=f4hBwpDW",
            "caption": "Comparative posteroanterior chest radiograph realized two years earlier: The oesophageal dilatation was already present, although less obvious (arrows)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011527/000003.jpg?itok=bACZh1tX",
            "caption": "Paracoronal reconstruction of contrast-enhanced chest CT shows dilated oesophagus (asterisk) displacing the trachea (T) anteriorly."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011527/000004.jpg?itok=H2E5Ur_p",
            "caption": "Contrast-enhanced neck and chest CT, sagittal reconstruction: Dilated oesophagus (asterisk) with anterior displacement and bowing of the trachea."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011527/000007.png?itok=FTfsOaxi",
            "caption": "Axial contrast-enhanced chest CT with images in lung window setting illustrating the dilatated oesophagus. There is progressive narrowing of the oesophageal lumen towards the cardia. Note consolidation in left lower lobe due to bronchoaspiration (arrow)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011527/000005.jpg?itok=ss3hd9PS",
            "caption": "Frontal oesophagogram: Although the patient managed to swallow only a small amount of oral hydrosoluble contrast agent, the oesophagogram shows a dilatated and tortuous oesophagus (arrows)."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011527/000006.jpg?itok=Ez2D0Lvj",
            "caption": "Oblique esophagogram shows dilatation of the esophagus (arrow) and stagnation of contrast agent in the middle oesophagus (asterisk), with several small air-fluid levels."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011527/000008.png?itok=dQUQWt4m",
            "caption": "Oblique oesophagogram shows caracteristic \\\"bird-beak\\\" tapering of lower esophagus (arrows). In addition, the study showed delayed opening of the lower oesophageal sphincter and gastroesophageal reflux."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Mediastinum"
    ],
    "imaging_technique": [
      "CT",
      "Fluoroscopy"
    ],
    "link": "https://www.eurorad.org/case/11527",
    "time": "23.03.2014"
  },
  "11547": {
    "case_id": 11547,
    "title": "mpyema necessitans, a complication of tuberculosis",
    "section": "Chest imaging",
    "age": "78",
    "gender": "male",
    "diagnosis": "Empyema necessitans as manifestation of tuberculosis",
    "history": "77-year-old male Caucasian patient was admitted with left-sided chest mass, first noticed 15 days before admission. At physical examination a non-tender tumefaction on the mid-axillary line of left chest wall was perceived. There was no fever, chills or cough. The patient had a clinical history of pulmonary tuberculosis 50 years before.",
    "image_finding": "Chest radiography demonstrated a loculated left pleural effusion with associated soft-tissue opacity in the left chest wall (Fig. 1). An abdominal ultrasound (US) was performed in order to better characterize the radiographic findings, showing a subcutaneous fluid collection with fine internal debris, measuring 5 x 3 x 7 cm, that communicated with the pleural cavity through a well-defined tract (Fig. 2 a, b). Imaging findings were further investigated with contrast-enhanced computed tomography (CT) imaging. CT revealed a loculated left pleural effusion with thickened, contrast-enhanced and partially calcified pleural surfaces that communicated with an organized, subcutaneous chest-wall fluid collection (Figures 3a-i). Both the subcutaneous collection and the pleural effusion were drained and the fluid samples from both cavities were analyzed: they were positive for acid fast bacilli and cultures confirmed the presence of Mycobacterium tuberculosis. Anti-bacillary treatment was initiated and the patient was discharged totally asymptomatic. Consultation with the thoracic surgeon was scheduled.",
    "discussion": "Empyema necessitans (or empyema necessitatis) is a complication of pulmonary infection, most frequently secondary to Mycobacterium tuberculosis infection reactivation, although it can also occur with actinomycosis and pyogenic bacterial infection [1, 2]. It represents extension of pus from the pleural cavity to the chest wall (most frequently), but also to the bronchi, oesophagus, breasts or retroperitoneum [3, 4].The patients generally present with an enlarging, occasionally painful, erythematous chest wall mass, most frequently affecting the second through sixth intercostals spaces [5]. Associated respiratory symptoms such as cough or dyspnoea and pleuritic-type chest pain also occur. While chest radiography can suggest the diagnosis, demonstrating a loculated pleural effusion in a patient with past history of pulmonary tuberculosis presenting with an anterior chest wall mass, the definitive imaging findings are usually seen with CT. Contrast-enhanced CT clearly demonstrates the existence of a communication between the empyema (i.e.: a loculated pleural effusion with thickened and enhancing pleural surfaces) and a well-deliniated chest wall fluid collection with thickened and enhancing walls, representing an abscess [6].US and CT can also aid in the therapeutic process, guiding the thoracostomy necessary to drain the pleural cavity. Generally there is a good response to tube-thoracostomy and parenteral antibiotic therapy but, in some cases, there is necessity to perform a thoracotomy and pleural decortication to definitely solve the problem [4].Tuberculous empyema necessitans has a good clinical outcome when managed accurately and promptly, with an associated mortality rate less than 5% [7]. Accurate diagnosis based on imaging evaluation and adequate antibiotic therapy are crucial for management of this disease.",
    "differential_diagnosis": "Empyema, necessitans, as, manifestation, of, tuberculosis, Actynomycosis, Mesothelioma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011547/000001.png?itok=0-JFU303",
            "caption": "Chest radiograph (PA) demonstrates loculated left pleural effusion."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011547/000003.png?itok=Wu-At40z",
            "caption": "Ultrasound image demonstrates a large subcutaneous collection with fine internal debris."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011547/000002.png?itok=h0BN-57u",
            "caption": "Ultrasound image reveals communication between large subcutaneous collection and pleural effusion."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011547/000004.png?itok=eLL397Q_",
            "caption": "Contrast-enhanced chest CT axial image reveals a loculated pleural effusion with thick, enhancing and focally calcified pleural surfaces, suggestive of an empyema."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011547/000005.png?itok=vojCaMpe",
            "caption": "Contrast-enhanced chest CT axial image reveals a loculated pleural effusion with thick, enhancing and focally calcified pleural surfaces, suggestive of an empyema."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011547/000006.png?itok=iBz-3N5s",
            "caption": "Contrast-enhanced chest CT axial image reveals a loculated pleural effusion with thick, enhancing and focally calcified pleural surfaces, suggestive of an empyema."
          },
          {
            "number": "Figure 3d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011547/000007.png?itok=LDlT1aiQ",
            "caption": "Contrast-enhanced chest CT axial image reveals a loculated pleural effusion with thick, enhancing and focally calcified pleural surfaces, suggestive of an empyema."
          },
          {
            "number": "Figure 3e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011547/000008.png?itok=Fvag6MGM",
            "caption": "Contrast-enhanced CT axial image reveals communication between the empyema and a lateral chest wall inflammatory fluid collection consistent with presence of \\\"empyema necessitans\\\"."
          },
          {
            "number": "Figure 3f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011547/000009.png?itok=h3kT-rQD",
            "caption": "Contrast-enhanced CT axial image reveals communication between the empyema and a lateral chest wall inflammatory fluid collection consistent with presence of \\\"empyema necessitans\\\"."
          },
          {
            "number": "Figure 3g",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011547/000010.png?itok=B9cocNfr",
            "caption": "Contrast-enhanced CT axial image reveals communication between the empyema and a lateral chest wall inflammatory fluid collection consistent with presence of \\\"empyema necessitans\\\"."
          },
          {
            "number": "Figure 3h",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011547/000011.png?itok=7v0XJkyJ",
            "caption": "Contrast-enhanced CT axial image reveals communication between the empyema and a lateral chest wall inflammatory fluid collection consistent with presence of \\\"empyema necessitans\\\"."
          },
          {
            "number": "Figure 3i",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011547/000012.png?itok=3AGxk5YL",
            "caption": "Contrast-enhanced CT coronal reconstruction image reveals intimate contact between the empyema and a lateral chest wall inflammatory fluid collection."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT",
      "Ultrasound"
    ],
    "link": "https://www.eurorad.org/case/11547",
    "time": "25.02.2014"
  },
  "11574": {
    "case_id": 11574,
    "title": "Cystic Lymphangioma - not always a pediatric neoplasm",
    "section": "Chest imaging",
    "age": "52",
    "gender": "male",
    "diagnosis": "Cystic lymphangioma of the mediastinum",
    "history": "A 52-year-old man presented with mild dyspnoea and non-productive cough, not associated with fever. He had no previous medical history.",
    "image_finding": "Chest radiograph shows a sharply delineated mass located at the right of the trachea, presenting silhouette sign with the superior vena cava and the proximal aortic arch (Fig. 1). The hilum overlay sign is also present, as we see the right pulmonary hilum superimposed on the mass. It occupies the superior mediastinum in its entirety (Fig. 2). Unenhanced CT shows a hypodense lesion of fluid attenuation (0-20 UH), extending vertically from the thoracic outlet to the carina region and edged laterally by the lungs (Fig. 3-5). It has lobulated but sharp limits. It surrounds the mediastinal vascular structures and the trachea without invading or compressing these structures. Contrast-enhanced CT does not show any enhancement of the lesion's wall. No other abnormalities are seen (Fig. 6).MRI shows a heterogeneous intermediate intensity sign on T1WI (Fig. 7). T2WI shows a homogeneous high signal intensity with thin septa (Fig. 8-9).",
    "discussion": "The patient underwent bronchofiberoscopy, obtaining biologic material for cytologic analysis. The results showed large amounts of lymph-like material, without signs of malignant disease, confirming the diagnosis of lymphangioma.Lymphangiomas are benign congenital malformations of the lymphatic tissue, frequently occurring in children but extremely rare in adults [1, 2]. They usually appear in the head, neck, axilla and mediastinum although they can affect any part of the body [1, 3]. They can be classified histologically as simple, cavernous or cystic (also known as hygroma), the latter being the commonest, depending on the size of the lymphatic channels they contain. They have no malignant potential [4].Clinically, they rarely produce symptoms although there have been reported cases presenting with cough, dyspnoea, dysphagia or superior vena cava syndrome. [1, 5] The radiographic findings are nonspecific. However, a mediastinal mass was suspected on the first radiograph and thus a CT was performed.There are two distinctive characteristics seen on CT that point towards the correct diagnosis and narrow the differential diagnosis: 1) It is a cystic-like mass (0-20 UH); 2) It envelops the mediastinal structures without invading or compressing them.On contrast-enhanced CT there is little to no contrast uptake by the lesion, ruling out the possibility of a mediastinal haemangioma [1].On MRI, T1WI can show either low, intermediate or high signal intensity, depending on the amount of proteinaceous material in the cystic cavity [1, 3, 4]. T2WI almost invariably shows high-signal-intensity in a homogenous way, typical of cystic masses; sometimes, some thin septa are seen, although they are not required for the diagnosis [1, 4].A differential diagnosis of mediastinal cystic masses should include congenital cysts like bronchogenic or enteric duplication cysts, thymic and pericardial cysts, mediastinal abscess, haemangioma, teratoma or even pancreatic pseudocyst [1, 4]. In this particular case, the two distinctive characteristics seen on the CT rule out congenital, thymic and pericardial cysts (they usually compress adjacent structures) and teratoma (as it is usually heterogeneous). There is no evidence in the patient\u2019s history to support the abscess or pseudocyst alternative.Complete excision is the mainstay of therapy, although the patient refused it [1, 4, 5]. He remains asymptomatic to the present date. In conclusion, if a cystic mass is found that envelops adjacent structures without compressing or invading them, especially if located in the neck or mediastinum, cystic lymphangioma should always be considered in the differential diagnosis, even in an adult.",
    "differential_diagnosis": "Cystic, lymphangioma, of, the, mediastinum, Lymphangioma, Mediastinal, haemangioma, Mediastinal, abscess, Congenital, cyst",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011574/000001.png?itok=4c6Q-B_j",
            "caption": "Well-defined mass located at the right of the trachea, producing the silhouette sign with the superior vena cava and the proximal aortic arch. Visible hilum overlay sign."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011574/000002.png?itok=2CDQl1Pj",
            "caption": "Lateral view shows an opacity in the superior mediastinum."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011574/000003.jpg?itok=PAJ16nHp",
            "caption": "Cystic mass surronding the trachea and mediastinal vascular structures without compressing or invading them."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011574/000004.jpg?itok=oaisiEL_",
            "caption": "CT showed no abnormalities in the lung parenchyma."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011574/000005.jpg?itok=IkEyLcq3",
            "caption": "Extensive involvement of the superior mediastinum, from the thoracic outlet to the carina region. No compression of the trachea is seen."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011574/000006.png?itok=zPviyqxA",
            "caption": "A to D - Axial slices from thoracic outlet to carina region showing a lobulated mass with no contrast uptake. It does not compress or invade mediastinal vascular structures or the trachea."
          }
        ]
      },
      {
        "number": "Figure 7",
        "subfigures": [
          {
            "number": "Figure 7",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011574/000007.jpg?itok=6Kg-ARIM",
            "caption": "T1WI shows a mediastinal mass with intermediate signal intensity."
          }
        ]
      },
      {
        "number": "Figure 8",
        "subfigures": [
          {
            "number": "Figure 8",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011574/000008.jpg?itok=wgqdP2W2",
            "caption": "T2WI showing mediastinal mass with high signal intensity and thin septa."
          }
        ]
      },
      {
        "number": "Figure 9",
        "subfigures": [
          {
            "number": "Figure 9",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011574/000009.png?itok=TcIiJ5zY",
            "caption": "A and B show a mediastinal mass with very high signal intensity that is not composed of fat. The thin septa remain visible."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Mediastinum",
      "Thorax",
      "Lymphatic"
    ],
    "imaging_technique": [
      "CT",
      "CT-High Resolution",
      "MR",
      "Conventional radiography"
    ],
    "link": "https://www.eurorad.org/case/11574",
    "time": "13.03.2014"
  },
  "11580": {
    "case_id": 11580,
    "title": "Transverse colon through Morgagni foramen",
    "section": "Chest imaging",
    "age": "8",
    "gender": "female",
    "diagnosis": "Transverse colon herniated through Morgagni foramen",
    "history": "An 8-year-old girl presented to the hospital because of a light cough when she lay down. No other complains were presented by the girl and her mother. The paediatrician found bronchial rales during auscultation in base of the right side of her chest, so he requested further imaging investigation.",
    "image_finding": "Posteroanterior chest radiograph showed a rounded solid mass in the right cardiophrenic angle. The mass was heterogeneous but it had well-defined border (Fig. 1). Pulsed fluoroscopy revealed the presence of large colon within the anterior right hemithorax with peristalsis present. Computed tomography (CT) with multiplanar reconstruction (MPR), performed the following day showed a multilobulated heterogenous mass, with 9 cm at its maximal diameter, showing a regular thin border and entering (from the abdomen) the anterior and medial right hemithorax. The mass was filled with oral contrast medium taken one day before, and lot of free air was shown within it as well. The hepatic flexure and most part of transverse colon \u2013 non-incarcerated - was herniated through the Morgagni foramen (Fig. 2, 3, 4, 5). The diagnosis was confirmed surgically a few days later during surgical repair of the congenital defect (Fig. 6).",
    "discussion": "Intrathoracic herniation of abdominal contents occurs through congenital defects in the muscle, through traumatic tears or, most commonly, through acquired areas of weakness at the central oesophageal hiatus. Bochdalek and Morgagni hernia are the most frequently occurring congenital herniations of the diaphragm. Bochdalek hernias are located posterolaterally and are more frequent (9: 1) than the anteromedially located Morgagni hernias [1]. They are more frequently located on the left than on the right side (5:1). They are found in small children and usually contain retroperitoneal fat or a portion of kidney or spleen [2]. Morgagni hernias are due to an anteromedial diaphragmatic defect caused by maldevelopment of the transverse septum. Morgagni hernias are more frequent on the right than on the left (5: 1). They are seen in older children or adults and are usually small. These hernias frequently contain omentum and may contain gut. The incidence of Morgagni hernia detected in the neonatal period because of symptoms is low. In older children and adults, Morgagni hernia is often an incidental finding. Although the weak area at the fibrotendinous elements between the costal and the crural part of the diaphragm is congenital, Morgagni hernia can be acquired. Increase in abdominal pressure due to severe effort, trauma or obesity is probably responsible [3-6]. A Morgagni hernia presents in older children and adulthood as an anterior opacity at the right cardiophrenic angle. It frequently contains omentum and may contain gut. Its smooth, well-defined margin and soft tissue radiodensity usually allows its differentiation from the much more common fat pad collection at this site. It is more difficult to differentiate from a low-lying pericardial cyst. When bowel is herniated to the chest, the diagnosis can usually be made with conventional chest plain film and barium studies. But the diagnosis is more simply established by means of computed tomography (CT) which can identify diaphragmatic defect especially using MPR and it can also be helpful in determining the nature, relationship of the herniated organs, the precise side and size of the diaphragmatic defect in patients with non-traumatic acquired defects. CT-MPR is useful for the differential diagnosis with hiatal hernia, pericardial cyst, hemidiphragmatic bulging, cystic masses of lung or mediastinum, oesophageal diverticule etc, as well. Treatment of Morgagni hernia is reponation of the herniated material and diaphragmatic repair in surgery [6-10].",
    "differential_diagnosis": "Transverse, colon, herniated, through, Morgagni, foramen, Hiatal, hernia, Pericardial, cyst, Anterior, madiastinal, masses, Cystic, masses, of, lung",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011580/000001.jpg?itok=k78fErLp",
            "caption": "Note the heterogenous well-delineated mass on the base of right chest. There is no mediastinal shift."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011580/000002.jpg?itok=UZ_rCsRJ",
            "caption": "Coronal view. Note the large colon inside the anterior right chest, through foramen of Morgagni"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011580/000003.jpg?itok=AEIfUH_d",
            "caption": "Coronal view"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011580/000004.jpg?itok=f3ZJCdg8",
            "caption": "Note the hepatic flexure and the major part of transverse colon inside the right chest"
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011580/000005.jpg?itok=S66fl-fm",
            "caption": "The same as in figure 3a, in MIP 3D reconstruction"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011580/000006.jpg?itok=2KhUqx5Z",
            "caption": "Intraoperative picture of Morgagni foramen (arrows)."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/11580",
    "time": "23.03.2014"
  },
  "11583": {
    "case_id": 11583,
    "title": "Ultrasonographically detected infective endocarditis causing septic pulmonary embolism",
    "section": "Chest imaging",
    "age": "34",
    "gender": "female",
    "diagnosis": "Septic pulmonary embolism caused by tricuspid valve infective endocarditis.",
    "history": "A 34-year-old female patient with a history of IV drug abuse was admitted to the hospital with fever for ten days and worsening dyspnoea for two days. She had tachycardia, fever (41oC) and decreased respiratory murmur. Her laboratory examinations showed increased Erythrocyte Sedimentation Rate, CRP and WBC with neutrophilia.",
    "image_finding": "The patient\u2019s admission chest radiograph revealed bilateral widespread nodular infiltrates. The size of these nodules varied and some of them were cavitated (Fig. 1). The patient subsequently underwent heart echocardiography (both transthoracic and transoesophageal) where vegetations were found in the tricuspid valve (Fig. 2). Otherwise, the heart function was normal. The patient was then referred for chest Computed Tomography which confirmed the presence of multiple and widespread irregular pulmonary nodules in both lungs. Some of these nodules were cavitated. The \u201cfeeding vessel sign\u201d was also noted in some of the nodules which were directly connected with a vessel. There was also a small left pleural effusion. Multi-Planar Reconstruction further helped in interpreting the radiographic findings and in evaluating the extent of the disease (Fig. 3).",
    "discussion": "Pulmonary septic embolism (PSE) describes the blocking of a pulmonary artery by an infected thrombus which originates from endocarditis, infected catheters, abscesses, pulmonary or urinary infections. Risk factors include IV drug abuse, alcoholism, skin infection and immunodeficiency [1, 2, 3]. The commonest pathogen of endocarditis is Staphylococcus aureus [4]. Patients with PSE usually present with fever, dyspnoea, pleuritic chest pain and cough [5]. The findings in plain radiographies are usually nonspecific and include multiple bilateral, poorly marginated infiltrates located in the lower lobes which may be cavitated. There may also be signs of pleural effusion [3]. The typical CT image of PSE comprises multiple round densities with or without cavitation which are located diffusely in both lungs but with a lower lobe predilection. There may also be a pericardial or pleural effusion and air bronchogram within pulmonary nodules. Septic foci are less distinctly demarcated than metastases and may have a wedge-like shape with their base on the pleura [1, 2]. With the use of an IV contrast medium, the densities are enhanced in their periphery or in a rimlike pattern. When the septic infiltrates subside, follow-up CT examinations may reveal subpleural linear strands [3]. Empyema is a common complication of PSE which can be discovered by CT [6]. The \u201cfeeding vessel sign\u201d characterizes PSE and describes the connection of the density with a distinct pulmonary vessel leading into its centre and proves the haematogenous origin of the lesion. It is easily identified on CT when the feeding vessel lies in the same plane with the nodule [2, 3]. Albeit its high prevalence, the feeding vessel sign may not be true, as recent studies showed that MDCT mutliplanar images prove some feeding vessels to course around the nodules or to represent pulmonary veins. The same sign may also be caused by metastases [7]. Septic emboli can be differentiated from Wegener's granulomatosis as they are usually smaller, peripheral and may be combined with reactive lymphadenopathy [8]. Vascular filling defects along with the patient\u2019s history (deep vein thrombosis instead of endocarditis) help discriminate septic and thrombotic embolism. Other types of pulmonary embolism like fat or foreign body should be also included in the differential diagnosis [6]. Regarding endocarditis, heart ultrasonography is the primary imaging modality, as it visualises vegetations inside the heart and establishes the diagnosis [4]. Treatment includes antibiotics, removal of infected devices and in rare cases surgery [5].",
    "differential_diagnosis": "Septic, pulmonary, embolism, caused, by, tricuspid, valve, infective, endocarditis., Septic, pulmonary, embolism, Thromboembolism, Pneumonia, Metastases, Foreign, body, embolus, or, other, type, of, embolism, Wegener\\'s, granulomatosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011583/000001.jpg?itok=OoGZXzi9",
            "caption": "Admission chest X-ray demonstrated the presence of multiple, bilateral, widespread nodular infiltrates with variable size and occasional caviatation."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011583/000002.jpg?itok=3-tTW_Ji",
            "caption": "Transesophageal cardiac ultrasonography revealed vegetations in the tricuspid valve."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011583/000003.jpg?itok=OT7KyLus",
            "caption": "Transesophageal cardiac ultrasonography revealed vegetations in the tricuspid valve."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011583/000004.jpg?itok=nYob3_ie",
            "caption": "Axial chest CT on soft tissue windowing showed a small left pleural effusion along with multiple nodules."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011583/000011.gif?itok=SqwGhuUI",
            "caption": "Axial chest CT on lung windowing showed multiple, bilateral and widespread nodules, some of which were cavitated."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011583/000012.gif?itok=vpl8sTH-",
            "caption": "Axial chest CT on lung windowing at a lower level also showed multiple, bilateral and widespread nodules, some of which were cavitated."
          },
          {
            "number": "Figure 3d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011583/000013.png?itok=0mfkV5lK",
            "caption": "This 2 mm CT image showed a pulmonary vessel leading to the centre of a cavitary nodule in the right upper lobe (the feeding vessel sign - arrow)."
          },
          {
            "number": "Figure 3e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011583/000014.png?itok=LxcyYi4l",
            "caption": "Another 2 mm CT image also showed a pulmonary vessel branching into two smaller vessels leading to the centre of two nodules on the periphery of the right lung (the feeding vessel sign - arrow)."
          },
          {
            "number": "Figure 3f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011583/000015.png?itok=VQ6yWn_5",
            "caption": "Coronal reconstructed CT image showed the pulmonary nodules with the \u201cfeeding vessel sign\u201d in some cases and correlated the findings with the plain chest X-ray."
          },
          {
            "number": "Figure 3g",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011583/000016.jpg?itok=0D0-fwA6",
            "caption": "Sagittal CT reconstructed image showed the pulmonary nodules and demonstrated the course of some pulmonary vessels producing the \u201cfeeding vessel sign\u201d."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Cardiac",
      "Cardiovascular system",
      "Lung"
    ],
    "imaging_technique": [
      "Ultrasound",
      "Digital radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/11583",
    "time": "15.03.2014"
  },
  "11610": {
    "case_id": 11610,
    "title": "Pulmonary nocardiosis and pneumothorax with fatal outcome",
    "section": "Chest imaging",
    "age": "42",
    "gender": "male",
    "diagnosis": "Pulmonary nocardiosis complicated with pneumothorax.",
    "history": "A 42-year-old man presented with progressive dyspnoea and cough for 3 months and with haemoptysis and thoracic pain for two weeks. He was under corticotherapy for asthma.At presentation he had low grade fever (38.1\u00b0C). Laboratory examination showed an elevation of the serum inflammatory markers.",
    "image_finding": "Chest X-ray showed bilateral nodules and masses, almost all excavated, with thickened walls (Fig. 1 and 2).In addition, small centrilobular micronodules were present predominantly in the lower lobes (Fig. 2c).The lesions were evenly distributed in both lungs, there was no predilection for the lung bases. He developed a right pneumothorax at day 5 of the hospitalization (Fig. 3), necessitating a drainage.Nocardia farcinica was found on sputum culture. Laboratory testings for HIV, Aspergillosis, Toxoplasmosis, PCP were all negative. The general state of the patient declined even with maximal appropriate therapy and he died at hospitalization day 12. Post-mortem examination could not detect other Nocardia organ involvement.",
    "discussion": "Nocardia, named after the veterinarian Edmond Nocard, is a gram-positive bacteria, part of the order Actinomycetales [1]. Nocardia can be differentiated from Actinomyces by acid-fast staining and the ability to grow under aerobic conditions [2]. The microorganism is found in soil, decaying vegetable matter and aquatic environments [2]. Inhalation is the most common route of entry.Known risk factors are: glucocorticoid therapy, malignancy, organ transplant recipient, HIV infection. One-third of infected patients are immunocompetent [1, 2]. Nocardiosis can disseminate to any organ. Disseminated Nocardiosis occurs when 2 noncontiguous sites are involved. Single site involvement includes lung, central nervous system, skin.Pulmonary Nocardiosis (two-thirds of cases) can be acute, subacute or chronic [2]. The symptoms are non-specific (fever, anorexia, dyspnoea, cough, haemoptysis, pain) [2]. Contiguous spread to pleura, mediastinum, pericard and skin can occur. Haematogeneous spread to the brain is common.Imaging findings are non-specific: lung consolidation, masses or nodules with foci of decreased attenuation or cavitation, centrilobular nodules, pleural effusion and chest wall extension [3, 4]. A crazy paving pattern can be found surrounding the nodules or consolidations [5]. Bronchiectasis and pulmonary alveolar proteinosis are risk factors to develop Nocardiosis [3].Fungal, mycobacterial, bacterial infection and malignancy are part of the differential diagnosis and especially similar radiological findings can be found in tuberculosis and actinomycosis [3].Definite diagnosis requires isolation and identification of the organism. Routine aerobic cultures require at least 5 days for growth instead of the usual 2 or 3 days for most other organisms [1, 2]. PCR is accurate and rapid for diagnosis, but is most often not available.Nocardia farcinica is known for its resistance to third-generation cephalosporins and to Imipenem. Accurate treatment needs initial intravenous therapy for 6 to 8 weeks (Trimethoprim-Sulfamethoxazole, Imipenem and Amikacin) and oral therapy for at least 6 months.Poor clinical improvement can be due to delayed diagnosis, premature discontinuation of the appropriate therapy, drug resistance, poor penetration of the drug into the infected tissue and presence of abscesses, requiring surgical drainage.Noteworthy is the appearance of Nocardiosis in patients under prophylactic Pneumocystis Jirovecii pneumonia treatment (low-dose Trimethoprim) [6].Pneumothorax is a typical complication of excavated lung lesions.In conclusion, Nocardia can present as an overwhelming infection in patients under corticotherapy. It should be considered in the differential diagnosis of cavitating lung nodules. Specific search for this microorganism is required for final diagnosis.",
    "differential_diagnosis": "Pulmonary, nocardiosis, complicated, with, pneumothorax., Aspergillosis, Nocardiosis, Mucormycosis, Septic, emboli, (anaerobic), Staphylococcus, infection, Tuberculosis, Actinomycosis, Granulomatosis, with, polyangitis, (formerly, Wegener), Malignancy, (squamous, cell, carcinoma)",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011610/000001.jpg?itok=7U9uBUJd",
            "caption": "Chest X-ray at admission shows numerous excavated masses and nodules."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011610/000003.jpg?itok=HscqRSj7",
            "caption": "CT shows multiple thick-walled excavated lung masses and nodules."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011610/000004.jpg?itok=k0Z3BvpX",
            "caption": "Almost all lesions are excavated with variable wall thickening."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011610/000006.jpg?itok=rGQdrtWT",
            "caption": "Presence of some centrilobular micronodules in both lower lobes."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011610/000002.jpg?itok=IiLvxpfL",
            "caption": "Minimip reconstruction enhances the presence of numerous excavated lesions."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011610/000010.jpg?itok=rn_P_MtE",
            "caption": "Chest X-ray at day 5 shows right pneumothorax."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/11610",
    "time": "30.07.2014"
  },
  "11613": {
    "case_id": 11613,
    "title": "Pulmonary embolism presenting as pneumoni",
    "section": "Chest imaging",
    "age": "30",
    "gender": "female",
    "diagnosis": "Pulmonary embolism with pulmonary infarct.",
    "history": "A 30-year-old woman presented with a three-week history of cough and haemoptysis unsuccessfully treated as an atypical pneumonia. After developing pleuritic pain and fever, further investigation with thoracocentesis and VATS pleural biopsy failed to demonstrate tuberculosis. Non-specific chronic pleuritis led the medical team to order a CT chest.",
    "image_finding": "Posteroanterior chest radiograph (Fig. 1a) demonstrates left-sided pleural effusion and patchy consolidation in the left upper lobe.Lateral chest radiograph (Fig. 1b) shows a pleural effusion with an infiltrate in the posterior zone of the left upper lobe.Contrast-enhanced chest CT (Fig. 2a/b) shows a left-sided pleural effusion and a coexistent complete occlusion of the left pulmonary artery.",
    "discussion": "A.\tBackgroundFollowing pneumonia, malignancy and tuberculosis, pulmonary embolism (PE) is the fourth most common cause of pulmonary effusion. Although typically small, PE-associated pleural effusions occur in one-third of PE presentations and are often unilateral and haemorrhagic [1]. Untreated PE is associated with a mortality of 30%, underscoring the importance of prompt diagnosis and definitive treatment [2].B.\tClinical PerspectiveMost patients have at least one risk factor at the time of presentation\u2014immobilisation, previous surgery, malignancy, chronic heart disease, autoimmune disease, or coagulopathy. Our patient presented without signs of deep venous thrombosis (DVT), the common precursor to a PE. Common signs and symptoms include cough, haemoptysis, dyspnoea, and tachycardia. A meta-analysis of 19 studies demonstrated poor correlation between clinical symptoms and presence of acute PE\u2014in over 25, 343 patients, sensitivity was found to be 85% and specificity 51% [3]. Upon further questioning the patient admitted occasional smoking and using the vaginal hormonal contraceptive ring. C.\tImaging PerspectiveCXR appearance of a PE is not diagnostic\u2014a prospective study found pleural effusion in 47 and 39 percent of patients with and without PE, respectively [4]. Other findings included patchy, non-contiguous consolidation and cardiomegaly. The diagnostic standard for PE remains CT pulmonary angiography.D.\tOutcomeThe patient was found to be a heterozygous carrier of the G202110A prothrombin gene mutation. After one year of anticoagulation, further images failed to demonstrate recanalization of the pulmonary artery. Due to a borderline pulmonary arterial pressure of 25 mmHg in right cardiac catheterisation, the patient decided not to undergo surgical thromboendarterectomy. She remained anticoagulated in chest clinic follow-up.E.\tTeaching PointsAs a young, female patient presenting with haemoptysis, our patient should have had a d-dimer performed in her initial work-up - especially given her history of hormonal contraception use. This was omitted due to a presumed inflammatory diagnosis. Again, the CXR interpretation could have encouraged the medical team to consider PE in the differential, but, ultimately, our experience serves as a reminder of the varied and desultory presentations of pulmonary embolism in otherwise healthy patients.",
    "differential_diagnosis": "Pulmonary, embolism, with, pulmonary, infarct., Pneumonia, Tuberculosis, Thoracic, Trauma, Tumour",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011613/000001.jpg?itok=Aa4_AugP",
            "caption": "CXR PA demonstrates left-sided pleural effusion and patchy consolidation."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011613/000004.jpg?itok=nQ-X5H_c",
            "caption": "CXR lateral shows a pleural effusion with an infiltrate in the posterior zone of the left upper lobe"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011613/000005.jpg?itok=8n5-7Cvw",
            "caption": "Contrast-enhanced chest CT shows a left-sided pleural effusion with complete occlusion of the left pulmonary artery. Chest drain in place."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011613/000006.png?itok=uuAfPcFa",
            "caption": "Axial chest CT image on lung windowing demonstrates wedge-shaped pleural-based opacities in the lingula and left lower lobe in keeping with lung infarcts and a left pleural effusion. Chest drain in place."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Pulmonary vessels"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT-Angiography"
    ],
    "link": "https://www.eurorad.org/case/11613",
    "time": "07.03.2014"
  },
  "11624": {
    "case_id": 11624,
    "title": "Recurring pneumothorax secondary to a ruptured bronchogenic cyst",
    "section": "Chest imaging",
    "age": "38",
    "gender": "female",
    "diagnosis": "Recurrent pneumothorax secondary to a ruptured bronchogenic cyst.",
    "history": "A 38-year-old woman was referred to the emergency department with a 2-week history of progressive breathlessness with no chest pain. Past medical history of asthma. On examination she had reduced oxygen saturation (91%) on 2L oxygen, was slightly tachycardic (110 b.p.m.) and had reduced air entry in the left lung.",
    "image_finding": "An urgent chest X-ray revealed a large left-sided pneumothorax with evidence of tension and a cystic structure in the left lower zone (Fig. 1). A chest drain was inserted and a repeat chest X-ray was taken. The left lung had re-expanded but there was an opacity in the left costophrenic angle (Fig. 2).Clinically the patient improved and the chest drain was removed. Within 36 hours of removal the patient became symptomatic again and the chest X-ray was repeated. The pneumothorax had recurred and the left costophrenic angle opacity was still present (Fig. 3). A contrast-enhanced CT of the thorax was then performed and revealed a moderately sized left-sided pneumothorax and a well-defined, thick-walled air-filled structure arising from the left lower lobe and adherent to the parietal pleura (Fig. 4 a, b).",
    "discussion": "Background:Bronchogenic cysts are a congenital abnormality resulting from abnormal development of the tracheobronchial tube, they are part of the family of foregut duplication cysts, enteric cysts and neuroenteric cysts. Cysts are most commonly located in the lung parenchyma or mediastinum and if they communicate with the bronchial tree they will be air filled or contain an air-fluid level. Their location depends on the embryological stage of development at which the anomaly occurs. Cysts that arise later are more peripheral [1]. Clinical perspective:Previously thought to be asymptomatic and innocent anomalies, recent studies have reported symptoms and complications from bronchogenic cysts and advise surgical excision even in cases without symptoms [2, 3, 4]. Complications from bronchogenic cysts are not uncommon (45%) [5] and include compression of adjacent structures, infection, haemoptysis and not uncommonly pneumothorax as in this case. Imaging Perspective:In this case, after multi-disciplinary team discussion it was decided that excision was the best option to avoid repeated pneumothoraces and obtain histological diagnosis. A video-assisted thorascopic excision was performed with no complication. Histology revealed epithelial cells entirely consistent with a bronchogenic cyst. Appearances on imaging vary depending on the contents of the cyst whether it be fluid, air or a combination of both. CT imaging findings are characteristically of a well-circumscribed round or ovoid solitary lesion with uniform fluid attenuation on CT [7] although the attenuation value can vary with the amount of proteinaceous content. With the administration of IV contrast a non-enhancing or minimally enhancing thin wall is typically seen and the wall can calcify. Thick enhancing walls, septations, solid components and internal calcifications are not typically demonstrated [8]. A definitive diagnosis of a bronchogenic cyst is made when respiratory epithelium is histologically present.Outcome:Bronchogenic cysts are benign abnormalities and usually do not recur after excision. The prognosis after excision is excellent although incomplete excision can lead to recurrence and in some patients with pulmonary lesions lobectomy may be necessary [6]. This patient made a full recovery and was discharged by the cardiothoracic team.",
    "differential_diagnosis": "Recurrent, pneumothorax, secondary, to, a, ruptured, bronchogenic, cyst., Lung, abscess, Complicated, hydatid, cyst, Infected, bullae, Fungal, infection",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011624/000001.jpg?itok=k-1Sxnoc",
            "caption": "Initial Chest X-ray showing a large left-sided pneumothorax and left lower zone cystic abnormality."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011624/000002.jpg?itok=Cwm2ki-p",
            "caption": "Follow-up chest X-ray with an intercostal drain in-situ.  The left lung had re-expanded and a left lower zone opacity was now demonstrated."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011624/000003.jpg?itok=kiQwR2h6",
            "caption": "Repeat chest X-ray after intercostal drain was removed and the patient became symptomatic again. Demonstrates recurrent pneumothorax and persistent left lower zone abnormality."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011624/000004.jpg?itok=pAn4YA9S",
            "caption": "Contrast enhanced CT thorax demonstrating an air-filled cyst in the left lower zone and a moderately sized left-sided pneumothorax."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011624/000005.jpg?itok=6z2GAe_y",
            "caption": "Coronal Reformat of contrast enhanced CT chest."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "Digital radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/11624",
    "time": "24.05.2014"
  },
  "11638": {
    "case_id": 11638,
    "title": "Respiratory failure in a patient with McCune-Albright Syndrome",
    "section": "Chest imaging",
    "age": "33",
    "gender": "male",
    "diagnosis": "Respiratory failure due to restrictive lung disease in MAS",
    "history": "A 33-year-old male patient with a previous diagnosis of McCune-Albright syndrome (MAS) presented with respiratory distress that limited his daily activities. His medical history included hyperprolactinaemia due to pituitary adenoma, several previous fractures of the extremities and reconstructive surgery for craniofacial deformities.",
    "image_finding": "Physical examination showed the characteristic signs of MAS with extensive facial and extremities bone deformities, caf\u00e8 au lait cutaneous spots, walking difficulty and dyspnoea.Blood gas analysis demonstrated a mild respiratory acidosis, hypoxaemia and hypercapnia.Cardiological evaluation presented a chronic pulmonary heart disease with dilatation of right cardiac ventricle and atrium, right ventricular dysfunction and pulmonary artery hypertension.Chest plain radiography showed severe deformity of the chest wall due to abnormal proliferation of soft tissues with the involvement of ribs, both clavicles and humerus, enlargement of cardiac silhouette with severe decrease of lung volumes.A computed tomography (CT) examination with multiplanar and volume rendering reconstructions demonstrated diffuse developmental anomalies of chest bone components, characterized by abnormal hypodense fibrous tissue associated with diffuse thinning of bone cortex, which compressed the lung parenchyma and reduced its volume as a result. Pleural effusion was also present at the bases. No lung consolidations were seen.",
    "discussion": "MAS is a genetic, non-inheritable disease characterized by the association of polyostotic fibrous dysplasia (FD), caf\u00e8 au lait spots (typically located on the same side as the bone lesions) and endocrine dysfunctions [1, 2]. It represents less than 5% of patients with FD, while the monostotic form represents 60% of patients with FD. The prevalence of FD and MAS is unknown, but it has been estimated around 1 in 30,000. MAS is ten times more common in women [3].MAS is caused by a somatic postzygotic mis-sense mutation in the GNAS1 gene encoding the subunit of the signal-transducing G-protein. This mutation generates autonomous fibroblast proliferation, defective osteoblast differentiation, increased bone resorption and hormonal hypersecretion, responsible for corresponding clinical features [4].Endocrine tumours may coexist and include pituitary, adrenal, testicular, thyroid localizations [5]. Bone involvement in MAS is typically polyostotic. Upper and lower extremities are commonly affected together with pelvis and craniofacial locations, but every bone segment may be involved. Lesions expand typically from the medulla to the cortex and the surrounding cortical bone is thinned. Calcifications can be observed if a nucleus of cartilage is present. Radiological findings depend on the degree of ossification of bone lesions, showing an increased bone radiolucency in plain radiography, well demonstrated with CT as a mild density abnormal tissue replacing bone marrow, associated with reduction of bone cortex. The deep remodelling of woven bone and the development of abnormal tissue with poor mechanical strength cause several complications. Bone pain, usually spontaneous or after a mild trauma, often represents the first symptom of FD and MAS and reveals the presence of a pathological complete or incomplete fracture.Malignant degeneration is rare. The most common malignancy, in order of frequency, is osteosarcoma followed by fibrosarcoma and chondrosarcoma [6, 7]. In these cases CT and MRI are necessary to confirm clinical diagnosis.Medical therapy includes the use of bisphosphonates to improve function, decrease pain, and lower fracture risk. Surgery is indicated for confirmatory biopsy, correction of bone deformity, prevention of pathologic fracture, and eradication of symptomatic lesions [8, 9].The involvement of ribs and chest cage is not rare in patient with MAS, but the development of respiratory failure with a restrictive pattern, pulmonary heart disease and right ventricular failure have been described only in few cases in the literature [10 -12]. In these patients surgical resection should be performed to relieve respiratory failure and improve quality of life [10, 11].",
    "differential_diagnosis": "Respiratory, failure, due, to, restrictive, lung, disease, in, MAS, Simple, polyostotic, fibrous, dysplasia, Neurofibromatosis, type, I, Enchondromatosis, Paget, disease",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011638/000001.png?itok=CyyaSM_T",
            "caption": "Posteroanterior chest X-ray that shows limited lung volume especially on the right lung, associated with structural deformity of chest wall."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011638/000002.jpg?itok=bi6YZj2B",
            "caption": "Multiplanar reformatting images (a, b, c) showing structural deformities of  the entire chest wall with the involvement of ribs, sternum and a dorsal vertebra; (d) shows severe reduction of right lung parenchyma volume."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011638/000003.jpg?itok=1P7zSLM8",
            "caption": "Volume rendering CT reconstructions of chest wall that demonstrate the diffuse and bilateral involvement of ribs and sternum associated with severe deformities and reduction of bone tissue."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_video/2018-08/0000011638/000004F.png?itok=5Qzx1SMw",
            "caption": "Lung surface rendering shows reduction of pulmonary volumes, especially on the upper and medium right lobes."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Musculoskeletal system",
      "Thoracic wall"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/11638",
    "time": "30.03.2014"
  },
  "11659": {
    "case_id": 11659,
    "title": "Reccurent desmoid tumour of the chest wall",
    "section": "Chest imaging",
    "age": "45",
    "gender": "female",
    "diagnosis": "Reccurent desmoid tumor of the chest wall",
    "history": "A 45-year-old female patient with a history of surgically resected lipoma and desmoid tumour in the right chest wall, noticed a progressively growing lesion at the area of the scar two years later. Physical examination revealed a firm and fixed mass, the skin was movable with no sign of inflammation.",
    "image_finding": "Ultrasound of the right chest wall demonstrated a large hypoechoic mass in the subcutaneous tissue, poorly vascularized at colour Doppler (Fig. 1).Contrast-enhanced CT showed a homogeneous tumour of tissue density in the right chest wall, with irregular contours in some areas and lack of enhancement, invading the right serratus muscle, measuring 121x42 mm. The adjacent subcutaneous tissue, bone and the right pulmonary parenchyma were intact (Fig. 2). On chest MRI, the tumour was seen invading the right serratus muscle, demonstrating isosignal T1 intensity, low T2 signal intensity and enhancement post gadolinium administration without vascular compression (Fig. 3).CT guided trans-parietal biopsy before surgical resection and pathological result confirmed a desmoid tumour measuring 13 \u00d7 4 cm.",
    "discussion": "As described previously by MacFarlane in 1832 [1], desmoid tumour (aggressive fibromatosis) is an uncommon soft tissue tumour characterized by proliferation of fibroblasts and myofibroblasts. Women are most affected [2], and it frequently occurs during the second or third decades of life. [3]Desmoid tumours are associated with a history of traumatic or post-surgical scar in the site [2], high-oestrogen states or familial adenomatous polyposis (FAP ) [3], they are also characterized by their local invasive behaviour and frequent recurrences without metastatic potential [1]. Abdominal wall is the most frequent localization, but involvement of the chest wall is present in only 10 to 28% of the patients [2], that is usually characterized by a palpable mass (5 to 10 cm, rarely larger than 20 cm [1]) and pain secondary to the nerve involvement, while the intrathoracic involvement is exceptional [1]. Imaging allows to precisely define the degree of local extension. Chest X-ray can show a parietal opaque mass that has invaded the adjacent soft and bone tissues. Ultrasound is not specific [1]. On computed tomography, desmoid tumours have a variable attenuation similar to that of muscle with possibility of enhancement after contrast administration [2]. It usually reveals the size, location, and reaction of the adjacent bone; however, the soft tissue infiltration and the local recurrence are precisely detected on MR imaging [4], which shows a signal intensity similar to that of muscle on T1, and variable signal intensity on T2 [2].The final diagnosis requires histological assessment but the transparietal biopsy may not be sufficient because of the relative low cellularity of the tumour [2-5]. The principal therapeutic manoeuvre of the desmoid tumours is surgical excision [6] and radiation (indicated when the surgical excision cannot be performed) [5]; however, extra-abdominal desmoid tumours have a high local recurrence rate after resection [5].Our patient did not have a typical location (chest wall) and age of presentation (45 years old), but the size, slowly growing character and the local recurrence after resection of the tumour (frequent in the extra-abdominal localization [5]) were consistent with desmoid tumour. In our case, CT-guided transparietal biopsy confirmed the diagnosis of recurrent desmoid tumour.",
    "differential_diagnosis": "Reccurent, desmoid, tumor, of, the, chest, wall, Low, grade, sarcoma, Nodular, fascitis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011659/000007.jpg?itok=-V-ZyxQM",
            "caption": "Ultrasound of the right chest wall demonstrates a large heterogeneous hypoechoic mass in the subcutaneous tissue."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011659/000010.jpg?itok=JGXvFf7q",
            "caption": "Axial MRI of the chest wall:  T2-weighted image (a) shows isosignal tumour, which is strongly enhanced after gadolinium administration on T1-weighted sequence (b)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011659/000011.jpg?itok=O8gi3ov5",
            "caption": "A large hypoechoic mass in the subcutaneous tissue, poorly vascularized at colour Doppler."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011659/000012.jpg?itok=XvCit9Ra",
            "caption": "Contrast-enhanced CT shows homogeneous soft tissue tumour, located in the right chest wall, invading the right serratus muscle. The subcutaneous tissue and the underlying bone were intact."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thoracic wall"
    ],
    "imaging_technique": [
      "Ultrasound",
      "Ultrasound-Colour Doppler",
      "CT",
      "MR"
    ],
    "link": "https://www.eurorad.org/case/11659",
    "time": "08.05.2014"
  },
  "11675": {
    "case_id": 11675,
    "title": "CT features of unilateral agenesis of pulmonary artery",
    "section": "Chest imaging",
    "age": "25",
    "gender": "male",
    "diagnosis": "Agenesis of right pulmonary artery.",
    "history": "A 25-year-old male with history of heavy smoking for 10 years, presented initially with mild breathlessness on exertion. A chest radiograph was performed but the patient failed to return for consultation. 6 months later the patient returned with a history of mild haemoptysis. A contrast-enhanced CT chest was performed.",
    "image_finding": "Chest radiograph revealed signs of loss of right lung volume with ipsilateral mediastinal shift. Suggestion of reduced lung markings was also noted on the right side with hyperinflation of the left lung, likely compensatory in nature. Apparent widening of the right paratracheal stripe was seen, later proven to be normal mediastinal vascular structures on CT.  Contrast-enhanced CT showed complete absence of the right pulmonary artery and its branches, reduced right lung volume and mediasitnal shift to the right side. Multiple small vascular collaterals were seen surrounding the carina and along the right pleural surface with an enlarged right internal mammary artery, contributing to right lung blood supply. Lung window images revealed, subpleural and fissural nodularity in right lung due to vascular collaterals, mimicking interstitial lung disease. Mild emphysematous changes were also seen in right middle and lower lobe.",
    "discussion": "Unilateral agenesis of the pulmonary artery(UAPA) is a rare congenital anomaly that occurs due to an abnormality involving the development of the sixth aortic arch [1]. A prevalence of about 1 in 200000 young adults is suggested [3]. Right sided agenesis appears more frequent. Other congenital cardiac abnormalities may be associated, however are more commonly seen with left sided agenesis [2].      Median age at diagnosis is about 14 years, however many cases present during adulthood [1, 4]. Common presenting symptoms include dyspnoea, recurrent chest infections and reduced exercise tolerance. Haemoptysis has been reported in 10-20% of patients [1, 2]. Pulmonary hypertension occurs in about 25-44% of cases and affects survival [1, 3]. UAPA is commonly not considered during routine clinical examination. Unilateral reduced air entry and a mild restrictive pattern on pulmonary function tests may be the only clues [1]. Chest radiograph is often the first modality to raise suspicion of the condition.      Chest X-Ray shows ipsilateral mediastinal shift and elevated hemidiaphragm with non visualisation of the pulmonary artery shadow and contralateral hyperinflation [1, 2, 3]. Abnormal mediastinal rotation may mimic mediastinal lesions, as in our case. In the past, conventional pulmonary angiography confirmed the diagnosis, however in recent times contrast CT has emerged as the modality of choice. The primary CT finding is cut-off of the right or left branch of the pulmonary artery within 1 cm of its origin. Loss of ipsilateral lung volume, mediastinal shift and contralateral hyperinflation are also clearly visualised. Mosaic perfusion, emphysematous changes and bronchiectatic changes may be seen in both lungs due to compensatory changes or recurrent infections. The prominent transpleural collaterals may cause subpleural and fissural nodularity and mimic infection on Chest X-ray or interstitial lung disease on CT, as was seen in our case. Signs of systemic collateral circulation, pulmonary hypertension and associated cardiac anomalies are elegantly depicted on contrast CT [1, 2, 3]. MRI may also be used to diagnose absence of the pulmonary artery branch.       UAPA has a mortality rate of about 7 %. Prognosis is negatively affected by pulmonary hypertension and pulmonary haemorrhage. Surgical revascularisation of maintained peripheral pulmonary vasculature to hilar vessels has been tried successfully in paediatric cases. Embolisation is used to control haemorrhage. Pneumonectomy is reserved for cases of recurrent haemoptysis or recurrent infections [1, 3].",
    "differential_diagnosis": "Agenesis, of, right, pulmonary, artery., Right, pulmonary, hypoplasia., Post, inffective, loss, of, right, lung, volume., Previous, right, lung, surgery.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011675/000001.jpg?itok=yNvz-J2s",
            "caption": "Reduced right lung volume is seen with decreased right lung markings and ipsilateral tracheal/mediastinal shift. The right pulmonary artery is not visualised. Apparent widening of the right paratracheal stripe is also seen."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011675/000005.jpg?itok=KXyjcS2V",
            "caption": "The right lung volume appears reduced. Nodular thickening of the right lung fissures is seen. Nodularity is also seen along the anterolateral pleural surface in right hemithorax."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011675/000007.jpg?itok=SNUg0wAQ",
            "caption": "Nodularity seen along tight pleural surface and fissure. Subpleural emphysematous changes in right mid/lower lobe."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011675/000006.jpg?itok=f8TBJQmi",
            "caption": "No definite mediastinal/lung parenchymal abnormality is noted in right paratracheal region. Mediastinal shift is seen to the right side with the SVC and azygos vein likely producing the right paratracheal opacity on chest radiograph."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011675/000010.jpg?itok=K71Qc4Za",
            "caption": "The right pulmonary artery is not visualised. Main pulmonary trunk and left pulmonary artery appear unremarkable. Right internal mammary artery (arrow) appears enlarged in size. Prominent vascular collaterals seen in the mediastinum surrounding the carina."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011675/000008.jpg?itok=IHwL3UE3",
            "caption": "Vascular collaterals are seen along the anterior and anterolateral chest wall/pleura (arrows)."
          },
          {
            "number": "Figure 3d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011675/000009.jpg?itok=NWYVBqak",
            "caption": "Vascular collaterals are seen along the anterior and anterolateral chest wall/pleura (arrows)."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Vascular"
    ],
    "imaging_technique": [
      "CT",
      "CT-High Resolution"
    ],
    "link": "https://www.eurorad.org/case/11675",
    "time": "28.11.2017"
  },
  "11678": {
    "case_id": 11678,
    "title": "Incidental finding of pulmonary sequestration",
    "section": "Chest imaging",
    "age": "45",
    "gender": "male",
    "diagnosis": "Pulmonary sequestration",
    "history": "A 45-year-old man presented with shortness of breath and chest pain. A CT Pulmonary Angiogram (CT PA) was ordered for investigation of a pulmonary embolus.",
    "image_finding": "The CT PA showed a hypodense area in the posterobasal segment of the left lower lobe. This area appears to mimic a bullous lesion in emphysema, however, with vessels extending from it (Fig. 1).An abnormal arterial branch originating from the descending thoracic aorta was also evident (Fig. 2). The venous drainage was not appreciable in any of the images. It was not possible to differentiate whether the lesion was intralobar or extralobar.",
    "discussion": "Pulmonary sequestration is a segment of non-functioning lung parenchyma which has no connection to the tracheobronchial tree and receives its blood supply from an aberrant systemic artery. Thus, there is no ventilation /perfusion in the sequestrated segment [1, 3]. Traditionally, pulmonary sequestrations are divided into intralobar sequestrations (ILS) and extralobar sequestrations (ELS). The two types of sequestrations are similar in their relationship to the bronchial tree and arterial supply but differ in their venous drainage system [2, 4]. Pulmonary sequestrations are rare, accounting for approximately 0.15-6.4% of all congenital pulmonary malformations [1, 2, 5].ILS account for approximately 75-85% of all sequestrations and are characterized by development within the visceral pleura, an aberrant systemic artery (usually a branch of the aorta) and venous drainage by the pulmonary veins but can occur through the azygous / hemiazygous vein, portal vein or IVC [3, 5]. ILS usually present in older age with recurrent infections. Infections can occur due to anomalous connections with bronchi, lung parenchyma or the GIT, which can allow bacteria to enter the sequestration [1, 2, 4].ELS account for approximately 15-25% of all sequestrations and are characterized by a separate pleural segment without any lung parenchyma, a small aberrant systemic artery and drainage through the systemic veins or directly in the right atrium [2, 5, 6]. ELS usually present in the neonatal period and can be supradiaphragmatic (90%) or infra-diaphragmatic (10%) [5, 6].On prenatal diagnosis, pulmonary sequestrations are diagnosed on ultrasound as echo dense homogeneous masses. MRI is the best tool in diagnosis of sequestrations and for differential diagnosis amongst other entities, such as congenital diaphragmatic hernia and congenital pulmonary airway malformations [5].Postnatal diagnosis of pulmonary sequestrations is initially shown on chest radiographs and clarified best by contrast enhanced helical CT. MRI is particularly helpful in delineating complex lesions and congenital diaphragmatic hernias. Ultrasound may also be very useful in accurate and prompt diagnosis during the neonatal period [6, 7].Surgical treatment is conventionally divided into symptomatic and asymptomatic patients. Treatment is considered only for those who are symptomatic such as neonates with ARDS or can be elective for older patients with recurrent infections [8].Video-assisted thoracoscopic surgery (VATS) can be used to resect pulmonary sequestrations as long as accurate delineation of the aberrant blood supply can be achieved [8]. 3D CT and MRI are often used prior to surgery to map out the lesion and its blood supply [7, 8].",
    "differential_diagnosis": "Pulmonary, sequestration, Congenital, lobar, emphysema, Congenital, pulmonary, airway, malformation, Bronchogenic, cyst, Pulmonary, arteriovenous, malformation",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011678/000001.jpg?itok=QCt9izy5",
            "caption": "Sequestration in left lower lobe (red arrow). The sequestration shows emphysematous change. There is minor dependent atelectasis bibasally, otherwise lungs are clear."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011678/000002.jpg?itok=gadP4Ufz",
            "caption": "Systemic arterial supply of the sequestrated segment (red arrow). \nVisualised part of the upper abdomen are within normal limits."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011678/000003.jpg?itok=jHk6QpsU",
            "caption": "Close up of the systemic artery supplying the sequestrated segment (red arrow)"
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011678/000004.jpg?itok=lTkntqIN",
            "caption": "Sequestrated segment in the mediastinal window (red arrow). The sequestration is only visualized by the anomalous arterial supply. The venous drainage was not appreciable. The visualized parts of the abdomen are within normal limits."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011678/000005.jpg?itok=PpTy00Gn",
            "caption": "Sequestration better visualised in the Lung window (red arrow). There is mild bibasal atelectasis. \n\nThere was no evidence of pulmonary artery filling defects in the study."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT-Angiography"
    ],
    "link": "https://www.eurorad.org/case/11678",
    "time": "19.05.2014"
  },
  "11689": {
    "case_id": 11689,
    "title": "Dysphagia lusori",
    "section": "Chest imaging",
    "age": "80",
    "gender": "male",
    "diagnosis": "Dysphagia lusoria",
    "history": "An 80-year-old man with known history of systemic hypertension and old cerebrovascular accident presented with a 6-month history of intermittent dysphagia with infrequent nausea and vomiting without a known cause and was transferred to our department for radiological assessment.",
    "image_finding": "Contrast-enhanced CT of the thorax reveals an apparent right subclavian artery with a retroesophageal course and extrinsic compression on the posterior oesophageal wall. The artery shows signs of atherosclerosis (Fig. 1, 2).",
    "discussion": "Dysphagia lusoria is the term used to describe the swallowing difficulties resulting from oesophageal compression by an aberrant right subclavian artery (arteria lusoria).The first case of a symptomatic aberrant right subclavian artery was described by Hunauld in 1735 [1].Aberrant right subclavian artery (ARSA) is the most common congenital abnormality of the aortic arch, which occurs in 0.5% to 1.7% of the population [2].The congenital abnormality of the right subclavian artery can be explained by the involution of the 4th vascular arch with the right dorsal aorta. The 7th intersegmental artery remains attached to the descending aorta, and the latter becomes the right subclavian artery [3]. The artery crosses between the oesophagus and the vertebral column to reach the right arm in 80% of cases. In 15% of individuals, it runs between the oesophagus and the trachea and passes anterior to both in about 5% of cases [4].About two thirds of cases with this congenital anomaly experience no symptoms. In symptomatic adults, complications such as dysphagia, chest pain, intermittent dyspnoea, chronic cough, aortitis and ruptured associated aneurysm have been reported [5].Dysphagia is reported in 90% of the symptomatic patients and is commonly found in older patients, which is explained by increased rigidity of the oesophageal wall, elongation of the aorta and arterial atherosclerosis [5]. In children, respiratory symptoms such as stridor and recurrent chest infections due to compression of trachea are reported more frequent than dysphagia, mainly due to their soft trachea comparing with adults [6].The diagnosis of dysphagia lusoria is difficult as the clinical presentations are mostly nonspecific and endoscopic examinations can be negative in more than 50% of the patients [5]. The morbidity and mortality rates are higher if there is an associated dilatation in the proximal ARSA \u201cdiverticulum of Kommerell\u201d [7].Barium study may show posterior indentation on the oesophagus. Enlarged superior mediastinum can be the only radiological finding on chest radiography. Angio-CT and MRI of the thorax are the best diagnostic modalities for ARSA, but angiogram may be required for preoperative assessment [8].Management of dysphagia lusoria depends on the severity of the symptoms. Surgical resection and ligation of the aberrant blood vessel with or without endovascular prosthesis may be required in severe dysphagia with weight loss. Symptomatic treatment and dietary modification play an important role in management of mild to moderate dysphagia (like in our patient) [5].",
    "differential_diagnosis": "Dysphagia, lusoria, Zencker, diverticulae, Oesophageal, tumours, Dysphagia, lusoria",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011689/000001.jpg?itok=6i4kiXtX",
            "caption": "An apparent right subclavian artery with a retroesophageal position and extrinsic compression on the posterior oesophageal wall.\nThe artery shows signs of atherosclerosis."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011689/000002.jpg?itok=5UiqG_PB",
            "caption": "The image shows marked posterior compression on the proximal oesophagus."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Arteries / Aorta"
    ],
    "imaging_technique": [
      "CT-Angiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/11689",
    "time": "30.04.2014"
  },
  "11710": {
    "case_id": 11710,
    "title": "Diffuse form of fibrosing mediastinitis causing stenosis of multiple mediastinal vessels",
    "section": "Chest imaging",
    "age": "50",
    "gender": "male",
    "diagnosis": "Fibrosing mediastinitis",
    "history": "A 50-year-old male patient presented with a 4-month history of dyspnoea on exertion associated with occasional fever, wheezing and cough with minimal expectoration. On examination breath sounds were decreased on right side with stony dull note. A few prominent veins were seen in the neck.",
    "image_finding": "Chest radiograph showed right pleural effusion with widening of the mediastinum (Fig. 1). CT chest showed an ill-defined minimally enhancing soft tissue with calcifications (Fig. 2), encasing multiple mediastinal vascular structures. The soft tissue was encasing and severely narrowing the calibre of superior vena cava with enlarged azygous vein (Fig. 3), and a few collaterals in the upper chest and neck. All the branches of the aortic arch were encased with mild narrowing of left common carotid and left subclavian arteries (Fig. 4). Main and right pulmonary artery were encased with associated narrowing (Fig. 5). Extending inferiorly there was extrinsic compression of left atrium with narrowing of bilateral inferior pulmonary veins (Fig. 5). Right main bronchus was encased by the lesion, but there was no stenosis. There was moderate right pleural effusion. Under CT guidance, multiple biopsy samples were obtained from the mediastinal lesion, which showed dense hyalinised fibrous tissue. There was no evidence of malignancy.",
    "discussion": "Fibrosing mediastinitis is a rare benign disorder characterized by slowly progressive proliferation of dense fibrous tissue within the mediastinum, enveloping mediastinal structures [1]. It is also known by synonyms like sclerosing mediastinitis, mediastinal fibrosis, chronic mediastinal fibrosis or cryptogenic mediastinal fibrosis [2].The disease often presents in young patients with clinical symptoms due to compression of mediastinal structures or in about 40% of cases incidentally [1, 3]. It presents in two forms- focal granulomatous form and diffuse nongranulomatous form [5]. Focal granulomatous form is considered to be due to proliferation of fibrous tissue secondary to granulomatous infections such as histoplasmosis, tuberculosis, aspergillosis, blastomycosis, mucormycosis and cryptococcosis [5]. The aetiological factors for diffuse nongranulomatous form are autoimmune conditions, treatment with methysergide, radiotherapy, retroperitoneal fibrosis, Beh\u00e7et's disease and primary sclerosing cholangitis [5].Histopathology shows aggregates of lymphocytes and plasma cells within a hyalinised \ufb01brous connective tissue [3].Chest radiographs may show non-specific widening of the mediastinum [1].Computed tomography (CT) is the best modality for evaluation of these patients. On CT also, two distinct forms of mediastinal involvement are described. The more common, localized mediastinal disease predominantly affecting the right paratracheal and subcarinal regions, associated with stippled calcification and the less common, diffusely infiltrating type, affecting multiple mediastinal compartments [1]. Patients with localized form typically have evidence of prior granulomatous infection, while the latter have not, but have other associated conditions like retroperitoneal fibrosis [1]. There is frequent involvement of the mediastinal vascular and tracheobronchial structures by the lesion, with more than 90% of patients showing obstructive/ compressive changes in the major vessels or airways [6]. Superior vena cava obstruction is the most common manifestation [3]. Obstruction of the pulmonary veins, presenting as parenchymal abnormalities such as ground glass opacities and involvement of pulmonary arteries and veins can result in infarcts [1]. CT can demonstrate the level and extent of stenosis of these vessels.CT is also useful in determining severity and extent of airway or oesophageal narrowing if they are involved [1].On T2 W MRI images fibrosing mediastinitis characteristically shows areas of low signal intensity due to fibrous tissue and calcification [1].There is no proven effective medical therapy for fibrosing mediastinitis. Corticosteroids and tamoxifen have been tried [4]. Palliative treatment such as grafts for SVC obstruction, dilatation of bronchial and oesophageal strictures can be of some help [2]. In cases of localized disease, surgical resection of affected tissues may be curative [1].It is important to recognize this rare entity and differentiate it from other infiltrative disorders of mediastinum like lymphoma and metastatic carcinoma.",
    "differential_diagnosis": "Fibrosing, mediastinitis, Lymphoma, Metastatic, lymphadenopathy",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011710/000001.jpg?itok=jk2zJdqE",
            "caption": "Chest Radiograph PA view showing widening of the mediastinal shadow and right pleural effusion."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011710/000002.jpg?itok=LxsbdzGC",
            "caption": "NECT axial image showing multiple nodular calcifications within the soft tissue encasing the mediastinal vessels"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011710/000003.jpg?itok=kSQB1nhx",
            "caption": "(a) Volume rendered coronal image showing the soft tissue compressing the SVC (white arrowheads). (b) Axial CECT image shows severely narrowed SVC (black arrow). (c) CECT axial image showing dilated azygous vein (black arrow)."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011710/000004.jpg?itok=ZqubcIN2",
            "caption": "(a) & (b) CECT axial and sagittal sections showing encasement of all three branches of aortic arch, with narrowing of left common carotid and left subclavian arteries (black arrowheads)"
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011710/000005.jpg?itok=FZ_23t2v",
            "caption": "Fig. 5 (a) & (b). CECT coronal & axial sections showing encasement and diffuse narrowing of the right pulmonary artery (black arrowheads). (c) Axial CECT section showing narrowing of bilateral inferior pulmonary veins (black arrows)"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Mediastinum"
    ],
    "imaging_technique": [
      "Digital radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/11710",
    "time": "30.05.2014"
  },
  "11754": {
    "case_id": 11754,
    "title": "An unusual complication of an esthetic treatment",
    "section": "Chest imaging",
    "age": "31",
    "gender": "male",
    "diagnosis": "Silicone embolism syndrome.",
    "history": "Acute onset of chest pain, fever, cough and dyspnoea appeared 2 days after silicone injection in the mammary glands in an HIV+ transsexual male, resolved after steroid, antibiotic and ventilation therapy for a presumptive diagnosis of infective pneumonia. All serologic analysis, blood and urine culture and BAL were negative.",
    "image_finding": "Chest X-ray showed increased density in the mammary glands due to subcutaneous silicone injection  and a diffuse interstitial thickening with ground glass opacities. Chest computed tomography (CT) revealed diffuse, bilateral peripheral interstitial air-space opacities, more evident in the apical regions.  The imaging findings raised concern for opportunistic infection.",
    "discussion": "Silicone embolism syndrome was \ufb01rst described in the 1970s as an acute complication following subcutaneous injection of silicone in the mammary glands, buttocks or hips for cosmetic augmentation [1].The exact mechanism of pulmonary pathology is unknown [2], although it seems to be related to access of silicone in the bloodstream and embolisation in the lungs due to the high pressure needed for high dose administration, local massage,  or accidental injection into the venous circulation [3; 4; 5]. The pathologic changes reported in the literature range from presence of intravascular emboli with minimal inflammation to an acute pneumonitis,  extensive oedema and haemorrhage with diffuse alveolar damage [3; 5; 6].This wide spectrum of presentations suggests that besides the embolic phenomenon,  there is interplay between the amount of silicone, the number of exposures and possibly host immunity [4]. Patients usually report symptom onset within the \ufb01rst few hours after the treatment, usually 72 hours at maximum [7].The presenting symptoms are dyspnoea, cough, fever, chest pain and haemoptysis, usually suggesting a diagnosis of acute pneumonia [2; 3]. These symptoms can be associated with tissue necrosis, foreign body giant cell reactions, and inflamation in the site of the injection [7].The typical radiological findings are of bilateral, patchy, predominatly peripheral interstitial disease, associated with areas of consolidation and/or ground-glass opacities, which are sometimes wedge-shaped, suggesting an embolic origin [4; 7; 2].The diagnosis can be con\ufb01rmed by \ufb01nding embolic vacuoles on a lung biopsy specimen [4]. Treatment is supportive, consisting mainly of supplemental oxygen and steroid therapy and survival is likely [7; 8]. However the usefulness of steroids is still debated, since these drugs are often administered in the setting of unexplained acute respiratory failure and there are only few untreated patients with whom to compare outcomes [2; 4]. There is another subgroup of patients which present mainly with neurological symptoms with a more severe prognosis [7; 8; 9]. The main role of the imaging is to exclude, when possible, other causes of acute lung disease, mainly infective in nature, and to document the response to treatments. In conclusion, silicone embolism syndrome should be considered in the differential diagnosis of young women or trans-sexuals presenting with otherwise unexplained hypoxic acute respiratory failure, hemoptysis and or pulmonary haemorrhage [3 ; 4].",
    "differential_diagnosis": "Silicone, embolism, syndrome., Acute, infectious, pneumonia, Cryptogenetic, organizing, pneumonia, Pulmonary, thromboembolism, Fat, embolism",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011754/000001.jpg?itok=UOACNtGI",
            "caption": "Chest X-Ray, PA view, showing multiple bilateral nodular opacities in the lower lobes and diffuse interstitial thickening"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011754/000002.jpg?itok=Wi2cCw2U",
            "caption": "Chest X-Ray, lateral view"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011754/000003.jpg?itok=yOk6c9Jw",
            "caption": "Chest CT shows diffuse, bilateral peripheral interstitial air-space and groud glass opacities, predominantly in the apical region."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011754/000004.jpg?itok=8herKZSX",
            "caption": "Chest CT with soft tissue window: the nodular opacities seen in the X-ray are due to the pseudonodular masses in the mammary glands."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011754/000005.jpg?itok=lTYPL4pA",
            "caption": "Coronal view"
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011754/000006.jpg?itok=GZIVvK0v",
            "caption": "Coronal view"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011754/000007.jpg?itok=dHFPbv5-",
            "caption": "Chest CT after 11 days of treatment shows complete radiological resolution."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011754/000008.jpg?itok=46J2a9SM",
            "caption": "Coronal view"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/11754",
    "time": "04.05.2014"
  },
  "11766": {
    "case_id": 11766,
    "title": "Adenocarcinoma in an intralobar pulmonary sequestration infiltrating the diaphragm",
    "section": "Chest imaging",
    "age": "46",
    "gender": "female",
    "diagnosis": "Adenocarcinoma in an intralobar pulmonary sequestration infiltrating the diaphragm",
    "history": "A 46-year-old female non-smoker presented with intermittent fever for the past 2 months and night sweat, without cough or any other symptoms.",
    "image_finding": "The chest X-ray showed an opacity in the right lower lobe with a rounded mass. The CT detected a well-defined, inhomogeneous, 4 x 3, 8 cm lesion mainly in an intradiaphragmatic location, without pathological lymph nodes. This lesion showed arterial vascular supply originating from the abdominal aorta, with deformation of the liver surface, without infiltrating the liver. This raised the radiological suspicion of a tumour within an intralobar pulmonary sequestration infiltrating the diaphragm, with abscess as differential diagnosis. Due to the clinical presentation and uncertainty a PET-CT was performed, showing an abscess formation. An angiography was subsequently performed for better characterization of the blood supply. In the same session preoperative embolization of the feeding artery originating from the abdominal aorta close to the coeliac trunk was done. The pathology result, after wedge resection of the lower pulmonary lobe and diaphragm, confirmed the intralobar sequestration associated with both adenocarcinoma and abscess.",
    "discussion": "Pulmonary sequestration is a rare condition [1, 2], accounting for 0.15% to 6.4% [3] of congenital pulmonary malformations. Intralobar pulmonary sequestration is more frequent [1, 3], however, it is usually detected in the early years of life [3, 4, 5, 6]. Frequently it is asymptomatic, but commonly associated with infection or pneumonia [3, 7, 8], as in our adult patient presenting with symptoms of infection. The association with lung cancer, especially adenocarcinoma, is rare; just a few cases having been reported [8, 9, 10, 11, 12, 13]. An association with both, cancer and infection, is even less frequently detected [8, 12]. The particular aspect of infiltration of the diaphragm is also an uncommon aspect of lung sequestration. Classically, the pulmonary sequestration is defined as \"a congenital mass of aberrant pulmonary tissue that has no normal connection with the bronchial tree or with the pulmonary arteries\" [14], reported as intralobar and extralobar sequestration. The chest radiograph can be used as a first diagnostic tool. However, for diagnosis in the adult population, CT is needed for identification, localization and characterization of the pulmonary sequestration and in most cases enables the identification of the aberrant arterial supply [1, 3, 10, 14]. The CT [1, 3, 10, 14] together with angiography [14] supports the diagnosis. Angiography clearly demonstrates the vascular supply and together with CT helps to plan the surgical approach as part of the therapy. The pathology confirms the diagnosis, as in our case. The possibility of pulmonary sequestration - associated or not with other pathologies - should be kept in the differential diagnosis list even in the adult population when evaluating mass-like opacities of the diaphragmatic lung regions.",
    "differential_diagnosis": "Adenocarcinoma, in, an, intralobar, pulmonary, sequestration, infiltrating, the, diaphragm, Pneumonia, Abscess, Bronchiectasis, Tumour, Hernia",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011766/000002.jpg?itok=2PnziS4J",
            "caption": "a, b, c: Contrast-enhanced axial CT demonstrates an inhomogeneous, 4 x 3.8 cm lesion in the right lower lobe infiltrating the diaphragm. A tumour within an intralobar pulmonary sequestration infiltrating the diaphragm was suspected."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011766/000004.jpg?itok=ill2l226",
            "caption": "a, b, c: Angiography confirms the CT findings  showing the lesion with independent arterial supply from the aorta, close to the coeliac trunk. A preoperative embolization of the feeding artery was performed."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011766/000005.jpg?itok=700F4Cmi",
            "caption": "a, b: Frontal and lateral chest radiograph showed an opacity in the right lower lobe with a rounded mass measuring 3 cm and an infrahilar consolidation. Partial eventration of the right hemidiaphragm could also be suspected."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011766/000006.jpg?itok=6ZJZvlnE",
            "caption": "a, b, c, d, e, f: Contrast-enhanced CT angiogram shows the lesion causing deformation of the liver surface, without infiltrating it (blue arrow). The systemic arterial supply from the aorta is also depicted (red arrow)."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Thorax",
      "Arteries / Aorta"
    ],
    "imaging_technique": [
      "CT",
      "Conventional radiography",
      "Catheter arteriography"
    ],
    "link": "https://www.eurorad.org/case/11766",
    "time": "04.07.2014"
  },
  "11793": {
    "case_id": 11793,
    "title": "Incidental upper thoracic oesophageal pulsion diverticul",
    "section": "Chest imaging",
    "age": "42",
    "gender": "male",
    "diagnosis": "Oesophageal diverticulum",
    "history": "A 42-year-old gentleman presented with recurrent lower respiratory tract infections. He had a background of sarcoidosis and marked congenital kyphoscoliosis with associated chest wall deformity and previous Harrington rod fixation.",
    "image_finding": "A chest X-ray (CXR) confirmed the kyphoscoliosis, chest wall deformity and Harrington rod fixation. There was right lower zone (RLZ) air space opacification and loss of volume. In the right upper zone (RUZ), adjacent to the mediastinal contour and obliterating the para-tracheal stripe, there was a soft tissue density lesion with calcification in the inferior margin (Fig. 1).Within the RUZ there was a 7 x 5.5 cm cavity containing an air/debris level with an associated pleural reaction. Multiple pockets of gas were seen within the soft tissue component with ovoid calcified elements in the more dependent aspect (Fig. 2).A repeat volume acquired CT with 100 ml dilute water-soluble oral contrast showed the \"cavity\" filled with contrast. There was no evidence of aspiration of oral contrast on the study (Fig. 3 & 4). Volume loss and cylindrical bronchiectasis was also noted in the apical segment of the RLL (Fig. 4).",
    "discussion": "BackgroundDr. Abraham Ludlow first described an oesophageal diverticulum in 1764 [1]. Overall, they are uncommon and generally affect middle-aged or elderly people. Pulsion diverticula are outpouchings of oesophageal mucosa through weak points of the muscle wall caused by high intraluminal pressures, a result of oesophageal motility disorders [2, 3]. During the act of swallowing, the muscles of the pharynx contract and pressure in the pharynx increases. If the cricopharyngeus muscle does not open at the appropriate time, pressure builds up immediately above it and the pharyngeal mucosa may herniate through a potential area of weakness in the posterior wall of the pharynx at \u2018Killian\u2019s dehiscence\u2019, between the cricopharyngeus and thyropharyngeus muscles [2, 3]. Traction diverticula are rare and occur as a result of perioesophageal inflammation pulling on the oesophageal wall. Oesophageal diverticula are most commonly classified by anatomical position: pharyngoesophageal (Zenker's diverticula), mid-thoracic and epiphrenic [4]. Clinical PerspectiveSymptoms are often non-specific but may include dysphagia, regurgitation and pain [2]. Complications are rare but may include aspiration pneumonia, rupture and cancer. Imaging PerspectiveImaging plays a vital role in the diagnosis of oesophageal diverticula. Fluoroscopic oral contrast swallows are the main diagnostic tool, although patients may alternatively undergo oesophagoscopy [2]. Oesophageal manometry may be used in patients found to have diverticula to further assess for dysmotility, as this may influence treatment options.In the case described above, CT with oral contrast was performed rather than the more commonly used fluoroscopic swallow due to diagnostic uncertainty and the patient\u2019s spinal deformity. The CT confirmed a large cervical oesophageal diverticulum, which contained food debris and tablets. It is likely that, as a result of the diverticulum, the patient developed pulmonary aspiration given the presentation of recurrent episodes of lower respiratory tract infections and the CT findings of right lower lobe volume loss and bronchiectasis.OutcomeAsymptomatic and minimally symptomatic oesophageal diverticula often do not require treatment [3, 4]. Surgery is reserved for patients with complications or symptoms causing disruption of their life. Treatment for co-existing oesophageal motility disorders should also be considered [2]. Historically an open diverticulectomy with a cricopharyngeal myotomy was performed, however, transoral endoscopic division of the separating wall between the pouch and the oesophagus with myotomy is now the procedure of choice [2]. The patient subsequently elected to have no therapeutic intervention and remains under follow up.",
    "differential_diagnosis": "Oesophageal, diverticulum, CAVITATING, LUNG, LESION, Carcinoma, TB, Abscess, SUPERIOR, MEDIASTINAL, MASS, Thymic, mass, Teratoma, Aneurysm, Lympadenopathy",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011793/000002.jpg?itok=Dlq77OFY",
            "caption": "CXR demonstrating Kyphoscoliosis, chest wall deformity and Harrington rod. RLZ opacification and loss of volume. RUZ adjacent to mediastinum, obliterating the para-tracheal stripe, there is a 6 cm soft-tissue density lesion with calcific densities."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011793/000003.png?itok=9y-V4Vty",
            "caption": "Axial CT with lung and soft tissue windows. 7 x 5.5 cm cavity containing an air:debris level with an associated pleural reaction. Multiple pockets of gas were seen within the soft tissue component."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011793/000005.png?itok=02UzEULC",
            "caption": "Axial CT with oral contrast which fills the RUZ mass confirming the presence of oesophageal diverticulum. Free passage of contrast seen into the stomach."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011793/000006.png?itok=LiSQnkWK",
            "caption": "Coronal CT showing oral contrast in oesophageal diverticulum. Lung windows demonstrate RLL bronchiectasis."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Mediastinum",
      "Lung",
      "Oesophagus"
    ],
    "imaging_technique": [
      "CT",
      "Conventional radiography"
    ],
    "link": "https://www.eurorad.org/case/11793",
    "time": "24.06.2014"
  },
  "11801": {
    "case_id": 11801,
    "title": "Lipoid pneumonia (ECR 2014 Case of the Day)",
    "section": "Chest imaging",
    "age": "76",
    "gender": "male",
    "diagnosis": "Lipoid pneumonia (chronic exogenous lipoid pneumonia)",
    "history": "A 76-year-old man was referred to our hospital for fever, cough, and pain in the right side of the chest. He had a history of laryngeal carcinoma and laryngectomy with residual facial nerve paralysis, dysphagia and dysphonia.",
    "image_finding": "Chest radiograph performed on admission (Fig. 1) shows multiple airspace consolidations with mass-like appearance within the right lung. The patient received antibiotic treatment with favourable clinical response. Chest radiograph performed before discharge (Fig. 2) demonstrated minimal improvement of the right basal consolidation, the rest of the lesions remaining unchanged.Based on these findings, a contrast-enhanced thoracic CT was performed (Fig. 3). It shows a mass-like consolidation with spiculated margins in the posterior segment of the right upper lobe (RUL), and smaller consolidations with similar characteristics and peribronchovascular distribution in the right middle (RML) and right lower (RLL) lobes. Mild architectural distortion within the posterior segment of the RUL and the RML is also seen. Small airways disease with tree-in-bud pattern is also present in the RLL. Areas of very low-attenuation \u2013 fat attenuation within the consolidations are depicted on the mediastinal window. Middle oesophagus dilatation is also seen.",
    "discussion": "Lipoid pneumonia is an infrequent disorder, with an estimated incidence of 1-2.5% [1]. It results from accumulation of lipids in the alveoli, and depending on the source of the lipids, there are two types: exogenous \u2013 inhalation or aspiration of animal fat, mineral or vegetable oil \u2013 and endogenous \u2013secondary to bronchial obstruction, chronic pulmonary infection, alveolar proteinosis, or diseases that led to abnormal fat deposition such as Niemann-Pick or Gaucher [1, 2]. Exogenous lipoid pneumonia was first described in 1925 [1]. It is usually related to chronic use of oil-based laxatives and nasal drops [1], and it has also been described on fire-eaters, and patients with history of long-term use of lubricants and decongestants such as Vaseline, Vicks Vapor-Rub and lip gloss [1].Clinical presentation can be acute or chronic. Acute presentation is uncommon and patients present with cough, dyspnoea and low-grade fever [1, 2]. If chronic, patients are usually asymptomatic [1, 3], but they may suffer chronic cough and dyspnoea [1, 3]. Predisposing factors to aspiration \u2013 such as elderly or young age, or neuromuscular or oesophageal disorders \u2013 are frequent [4]. Thorough investigation is important to achieve the appropriate diagnosis because predisposing factors and history of oil exposure are often missed.In the proper clinical context, imaging findings can be diagnostic. In acute setting, findings appear within the first 30 minutes and present as ground-glass opacities or consolidations on CT. They usually are segmental or lobar in distribution, and affect the RML and lower lobes [1]. Chronic disease shows irregular mass-like lesions with characteristic fat attenuation [4]. They can be single or multiple with peri-bronchovascular distribution and lower lobe predominance. Interlobular septal thickening, crazy \u201cpaving\u201d pattern, and fibrotic changes can also be seen [4]. The presence of fat is an important diagnostic feature of chronic exogenous lipoid pneumonia. In the acute setting, fat attenuation material within the consolidations can also be seen, but inflammatory changes usually occult its presence [1]. Hamartomas are other fat-containing lesions of the chest. They are the most frequent benign pulmonary neoplasm [4] and, besides the presence of fat, popcorn calcifications are characteristic. The diagnosis is often determined from the clinical and imaging features, and long-term stability [4], and biopsy is required in atypical cases [1]. Discontinuation of the causative agent is the main treatment [3]. Antibiotics, corticoids and bronchoalveolar lavage can also be used [2]. Surgery is reserved for atypical cases.",
    "differential_diagnosis": "Lipoid, pneumonia, (chronic, exogenous, lipoid, pneumonia), Primary, pulmonary, lymphoma, Lepidic, predominant, adenocarcinoma, (former, bronchioalveolar, carcinoma), Sarcoidosis, Lipoid, pneumonia, Chronic, eosinophilic, pneumonia",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011801/000001.jpg?itok=SBgwZroL",
            "caption": "Chest radiograph performed on admission shows multiple airspace consolidations with mass-like appearance within the right lung."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011801/000002.jpg?itok=nxqUTCFq",
            "caption": "Chest radiograph performed before discharge demonstrates minimal improvement of the right basal consolidation, the rest of the lesions remaining unchanged."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011801/000003.jpg?itok=3n9lp4Bj",
            "caption": "Contrast-enhanced CT shows mass-like consolidations within the right lung with internal areas of fat attenuation (depicted on the mediastinal window, right)."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "Conventional radiography"
    ],
    "link": "https://www.eurorad.org/case/11801",
    "time": "29.04.2014"
  },
  "11804": {
    "case_id": 11804,
    "title": "Combined pulmonary fibrosis with emphysema syndrome",
    "section": "Chest imaging",
    "age": "58",
    "gender": "male",
    "diagnosis": "Combined pulmonary fibrosis and emphysema syndrome",
    "history": "A 58-year-old man presented with exertional dyspnoea. He was a former smoker (40 packs-years), had no professional exposure, no clinical signs of connective tissue disease and quit smoking 4 years ago. On physical examination he showed diffuse ronchi, velcro-like crackles on the lung bases, clubber fingers and cyanosis.",
    "image_finding": "Chest X-ray demonstrated lower lobe reticular markings and upper lobe hyperlucency. High Resolution Computed Tomography (HRCT) was performed and showed predominantly upper lobe paraseptal bullae, small areas of low attenuation with ill-defined margins and without visible walls and lower lobe intra- and interlobular septal thickening, ground-glass opacities, traction bronchiectasis, architectural distortion and honeycombing.The patient was also hypoxemic and underwent other instrumental investigations, namely spirometry [forced expiratory volume in one second (FEV1): 66%, forced vital capacity (FVC): 63%, FEV1/FVC: 84%, total lung capacity (TLC): 61%, transfer capacity of carbon monoxide (DLCO): 31%]; six-minute walking test (6MWT) in O2-6lt/min with decrease in arterial oxygen saturation (SpO2) from 97% to 79% (after 240mt O2-therapy was prescribed); bronchoalveolar lavage: 11% neutrophils, 1% eosinophils,  3% lymphocytes, 85% macrophages.",
    "discussion": "The consensus definition of CPFE has been challenged; although initially considered to represent an incidental coexistence of two separate entities, CPFE has been recently proposed as a distinct syndrome. Its diagnosis is mainly based on HRCT findings and clinically is characterized by relatively preserved spirometric values and disproportionate impairment of gas exchange [1].Its prevalence has been estimated between 5% and 10% of cases of interstitial lung diseases. It mainly affects men generally over 65 years of age, smokers or ex-smokers, so cigarette smoking is the main aetiologic factor.Some mechanisms involved in the pathogenesis of CPFE have been reported: 1) increases in oxidative stress; 2) a mutation in the surfactant protein C gene in a young non-smoking female patient; 3) potential roles for TNF-a, IL-1/b, neutrophil elastase and metalloproteinases producing both emphysema and pulmonary fibrosis in animal models.Some authors reported cases of CPFE in the absence of smoking or in the context of connective tissue diseases. The main symptoms are: exertional dyspnoea, cough, wheezing, perioral cyanosis and asthenia. Physical examination reveals bibasilar inspiratory crackles and finger clubbing. The patients are at high risk for developing complications such as lung cancer, acute lung injury and pulmonary hypertension which has a dismal prognosis for their survival [1-3]. Chest X-ray can show reticular markings and upper lobe hyperlucency in both lung bases and subpleural regions but is neither sensitive nor specific in diagnosing CPFE. HRCT is the most appropriate investigation with these findings: 1) emphysema, defined as demarcated areas of low attenuation bordered by a very thin (<1mm) wall or without visible wall and/or subpleural bullae (>1 cm) predominantly in the upper lobes; 2) diffuse parenchymal disease with fibrosis defined as reticular opacities, honeycombing, traction bronchiectasis and/or bronchiolectasis predominantly in the lower lobes. Such findings correlate with histopathology: UIP is the most common pattern, but non-usual interstitial pneumonia, smoking-related ILD or even other unclassifiable fibrotic lung disease have also been observed [2-5].Functional investigations as forced vital capacity, forced expiratory volume in the first second and total lung capacity are within normal ranges or slightly abnormal. Hypoxemia is moderate at rest and worsens during exercise. DLCO, the variable best correlated with the degree of parenchymal destruction, is reduced.Treatment of CPFE is based on systemic corticosteroids, inhaled bronchodilators, immunomodulator drugs and oxygen therapy for hypoxaemia. Specific therapy for PHA has also been considered [1-3, 5].",
    "differential_diagnosis": "Combined, pulmonary, fibrosis, and, emphysema, syndrome, Interstitial, lung, diseases, secondary, to, inherited, or, acquired, abnormalities, Interstitial, lung, diseases, secondary, to, connective, diseases",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011804/000004.jpg?itok=SSg9B5Bf",
            "caption": "Frontal chest X-ray showed bibasal and subpleural fine reticular markings and upper lobe hyperlucency."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011804/000005.jpg?itok=V06PA6T2",
            "caption": "Lateral chest X-ray showed fine reticular markings at the lung bases."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011804/000006.jpg?itok=b9Cg96g2",
            "caption": "A magnified view of the right lung base shows in greater detail the reticular pattern."
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011804/000007.jpg?itok=YnCc8SvQ",
            "caption": "A magnified view of the right upper lobe reveals areas of hyperlucencies and a subpleural bulla."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011804/000008.jpg?itok=RWf_xptT",
            "caption": "Axial CT shows upper lobe centrilobular and paraseptal emphysema; some subpleural cystic airspaces probably reflecting honeycombing are also visible on the right upper lobe."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011804/000009.jpg?itok=EcwW8ENo",
            "caption": "Axial CT shows lower lobe fibrotic changes with intra- and interlobular septal thickening, ground-glass opacities, architectural distortion, traction bronchiectasis and honeycombing."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011804/000010.jpg?itok=DUvPQAJg",
            "caption": "Axial CT shows lower lobe fibrotic changes with intra- and interlobular septal thickening, ground-glass opacities, architectural distortion, traction bronchiectasis and honeycombing."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT-High Resolution"
    ],
    "link": "https://www.eurorad.org/case/11804",
    "time": "10.09.2014"
  },
  "11823": {
    "case_id": 11823,
    "title": "Posterior mediastinal mass presenting with dysphagia and chest pain: Calcified leiomyoma located in distal part of oesophagus",
    "section": "Chest imaging",
    "age": "46",
    "gender": "female",
    "diagnosis": "Oesophageal leiomyoma",
    "history": "A 46-year-old woman presented with retrosternal chest pain and dysphagia aggravating during the past 3 months. Physical examination and basic blood investigation did not reveal any abnormality. She had no previous surgery or any past medical history.",
    "image_finding": "CT of the chest demonstrated a soft tissue lesion located at the posterior mediastinum containing calcifications (Fig. 1). Barium swallow study demonstrated luminal narrowing and endoscopy confirmed luminal narrowing caused by external compression with abnormal oesophageal mucosa (Fig. 2). Mucosal biopsy was not undertaken in order to avoid potential complications as it was considered to be a leiomyoma. The patient underwent surgery and the mass was excised. The histopathological report showed benign smooth muscle tumour and immunohistochemistry showed that the tumour cells were strongly positive for desmin and smooth muscle antigen (SMA) positive, and were negative for CD 34 and c-kit mutations (Fig. 3). The patient had an uneventful postoperative recovery.",
    "discussion": "Benign submucosal tumours can be seen in any part of the gastrointestinal tract and oesophageal submucosal tumours are less common than other gastrointestinal tract tumours [1]. Gastrointestinal leiomyoma is a common type of benign gastrointestinal submucosal tumour [2- 5] and it is also the most common benign oesophageal neoplasm accounting for more than 70% of these tumours. It originates from muscularis mucosa or muscularis propria and dysphagia is the most common symptom of leiomyoma followed by retrosternal pain [6-8]. It may occur in all parts of the oesophagus, but 60% occur in the distal third, 30% in the middle, and 10% in the proximal oesophagus [7, 9]. They often present as a single lesion, less than 5 cm in size in 50% cases [3, 10-11] and frequently cause symptoms, necessitating resection [12]. Leiomyomas grow slowly, and half of the patients are asymptomatic unless the tumour grows intramurally [6]. A retrocardiac mass containing amorphous calcifications is typical for leiomyoma of the oesophagus [13]. Leiomyomas are the most common benign lesions of the oesophagus and are of mesenchymal origin. The symptoms are not specific and the size of tumour correlates with the severity of the symptoms. Dysphagia with concomitant epigastric pain or retrosternal burning are the most common symptoms when the diameter of the lesion exceeds the critical point of 4.5 - 5 cm [2]. Radiologically oesophageal leiomyomas may present as a posterior mediastinal mass on chest radiograph [6-8]. Barium swallow findings consist of a filling defect in the contour of the oesophageal lumen without a mucosal abnormality. On contrast-enhanced CT, leiomyoma shows weak homogeneous contrast enhancement and it is difficult to differentiate them from other oesophageal tumours [14, 15]. On MRI the lesion is isointense to the submucosa on T2W images which helps in differentiating it from other oesophageal masses, which present higher signal intensity on T2 weighted sequences [14]. As leiomyomas are submucosal lesions, conventional endoscopy will not lead to an accurate diagnosis [16]. Endoscopic ultrasound is more useful to differentiate these lesions, showing a homogeneous and hypoechoic lesion with well-defined borders and clear fat plane with the adjacent structures [17]. The treatment of leiomyomas depends on their size, while lesions larger than 5 cm in diameter can be resected with video-assisted thoracoscopic or laparoscopic approach [18].",
    "differential_diagnosis": "Oesophageal, leiomyoma, Oesophageal, leiomyomatosis, Oesophageal, carcinoma, Oesophageal, lymphoma, Oesophageal, GIST, Peptic, stricture, Achalasia",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011823/000004.jpg?itok=t_0dJNIa",
            "caption": "CT of the thorax reveals a mass inseparable from the wall of the oesophagus displacing the lumen. Note the calcifications in the lession (arrow)."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011823/000005.jpg?itok=-LD8lFXL",
            "caption": "The mass is located at the posterior mediastinum containing multiple calcifications (arrows)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011823/000006.jpg?itok=Xs7GhpTh",
            "caption": "Endoscopy: The mass is extending to the lumen (arrow)."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011823/000007.jpg?itok=M99X9MqV",
            "caption": "Barium swallow: There is a filling defect narrowing the lumen."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011823/000008.jpg?itok=7x0dqQWG",
            "caption": "The mass consists of benign smooth muscle cells."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Anatomy",
      "Thorax"
    ],
    "imaging_technique": [
      "Percutaneous",
      "CT",
      "PACS",
      "Fluoroscopy"
    ],
    "link": "https://www.eurorad.org/case/11823",
    "time": "15.09.2014"
  },
  "11839": {
    "case_id": 11839,
    "title": "A rare cause of tracheal obstruction: Ectopic thyroi",
    "section": "Chest imaging",
    "age": "23",
    "gender": "female",
    "diagnosis": "Ectopic intra-tracheal thyroid",
    "history": "A 23-year-old female patient, operated for goitre in 2004, presented with complaints of difficulty in breathing, progressive breathlessness on exertion, cough and noisy breathing for the past 7 months. On clinical examination there were diffuse sibilant rhonchi.",
    "image_finding": "Chest radiography was normal (Fig. 1). Cervical and chest CT were performed and revealed a rounded soft tissue lesion in the posterior wall of the cervical trachea, significantly enhancing after injection of contrast medium (Fig. 2).The lesion protrudes to the tracheal lumen reducing its calibre considerably (Fig. 3), and exceeds the right tracheal wall coming in contact with the jugular and carotid vessels, and the prevertebral muscles.Bronchoscopy depicted a smooth lesion in the trachea, protruding intraluminally just below the right vocal cord (Fig. 4, 5).The patient was treated surgically with complete resection of the tumour and laryngotracheal anastomosis.Pathological examination revealed that the mass corresponded to ectopic thyroid tissue.",
    "discussion": "Ectopic thyroid tissue is a rare developmental anomaly implicating abnormal embryogenesis of the thyroid gland during its passage from the floor of the primitive foregut to its final pre-tracheal position [1, 2].It may be found in suprahyoid or infrahyoid location, along the thyroglossal duct and at the intralaryngotracheal area, with the latter being the rarest [3].A clinical history of total thyroidectomy or goitre should be a reference point as to the aetiology of an intratracheal mass preoperatively [4].Two theories may explain the origin of intratracheal thyroid tissue. First, a fetal anomaly could occur when the thyroid is splitted by the developing trachea and its cartilage rings. Second, thyroid tissue could rise into the tracheal lumen [5, 6].Common clinical symptoms of Ectopic Intratracheal Thyroid (EITT) include progressive dyspnoea, stridor, cough, difficulty swallowing, and haemoptysis [7].Management of EITT is based on correct diagnosis. If a patient presents with upper airway obstruction, he/she should undergo complete exploration (flexible laryngotracheobronchoscopy, indirect laryngoscopy and imaging studies).Computed tomography and magnetic resonance imaging are the examinations of choice for the diagnosis. They help identify the precise site, assess the degree of obstruction and explore the surrounding soft tissue and any other possible location of ectopic thyroid tissue. Malignancy is suspected if there is cervical lymphadenopathy or intratracheal invasion by the tumour [7].Biopsy is required in order to confirm the diagnosis. Biopsy may cause severe bleeding as EITT is very vascular [8].Correct management of EITT depends on the size of lesion, the patient\u2019s age, the existence of local signs, the status of thyroid function, and the histopathological findings [7].Treatment options include surgical excision, thyroid-suppression therapy, and radioiodine ablation.Surgical excision is indicated in cases with a large thyroid gland causing dyspnoea, or for cases of histologically proven malignancy [7].Radioiodine ablation may cause radiation thyroiditis and/or tracheitis, exacerbating airway obstruction [7]. Furthermore, EITT may not take up iodine as effectively as the orthotopic thyroid gland, which may be destroyed by radioiodine ablation treatment [7] rendering radioiodine ablation potentially dangerous. It may be an alternative option for symptomatic elderly patients who refuse or are unsuitable for surgery.Even though EITT remains uncommon, it should be considered as a possible cause of airway obstruction. A high degree of suspicion by physicians is essential in order to explore the possibility of EITT in patients presenting with airway obstruction symptoms, particularly in those who have a history of goitre.",
    "differential_diagnosis": "Ectopic, intra-tracheal, thyroid, Tracheal, papilloma, Invasive, thyroid, carcinoma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011839/000001.jpg?itok=MMtGalRo",
            "caption": "There is no abnormality to explain the symptoms."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011839/000002.jpg?itok=rCIukm6M",
            "caption": "Non-enhanced axial view: rounded soft tissue lesion in the wall of the trachea, protruding intraluminally and invadinge its wall, being in contact with cervical vessels and prevertebral muscles."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011839/000003.jpg?itok=1KPBhzI-",
            "caption": "Contrast-enhanced axial view: the lesion shows significant enhancement."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011839/000004.jpg?itok=DMTXZM0h",
            "caption": "Contrast-enhanced coronal reformat: hyperenhancing rounded soft tissue lesion in the wall of the trachea, protruding intraluminally and invadinge its wall, being in contact with cervical vessels and prevertebral muscles."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011839/000005.jpg?itok=Qq3V89-Y",
            "caption": "Contrast-enhanced sagittal reformat: hyperenhancing rounded soft tissue lesion in the wall of the trachea, protruding intraluminally and invadinge its wall, being in contact with cervical vessels and prevertebral muscles."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011839/000006.jpg?itok=xCX6zkUG",
            "caption": "VR reconstruction of  trachea and bronchial tree show an extreme narrowing of the cervical trachea."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_video/2018-08/0000011839/000007F.png?itok=vMjGKw7W",
            "caption": "CT virtual bronchoscopy - upper view: showing the location of the lesion just below the vocal cords level."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_video/2018-08/0000011839/000008F.png?itok=pDGSAiNN",
            "caption": "Inferior view of CT virtual bronchoscopy, showing better the obstruction of the tracheal lumen."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax",
      "Head and neck"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "Image manipulation / Reconstruction",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/11839",
    "time": "06.07.2014"
  },
  "11841": {
    "case_id": 11841,
    "title": "Pleuropulmonary blastoma in combination with cystic nephrom",
    "section": "Chest imaging",
    "age": "21",
    "gender": "male",
    "diagnosis": "Pleuropulmonary blastoma in combination with cystic nephroma",
    "history": "A previously healthy 21-month-old Caucasian boy presented with a history of vomiting and a left-sided abdominal mass. The antenatal history was unremarkable. He was born in the 39th week of pregnancy by caesarean section. His parents had no medical history and no family history of tumours and other genetic disorders.",
    "image_finding": "Abdominal ultrasound showed two multilocular cystic lesions in the left kidney with multiple anechoic spaces traversed by thin septations. Abdominal MRI demonstrated two multilocular cystic masses in the left kidney, without evidence for liver or lymph node metastasis or invasion in inferior vena cava. Chest radiograph showed a large radiolucent lesion in the left upper and middle hemithorax without definite bronchovascular markings. CT demonstrated one large and a few small cystic air-containing cavities with no fluid levels of the left upper lobe. A few small cystic lesions were also found in the left lower lobe. The right lung was normal and there was mild mediastinal shift to the right side.The patient underwent thoracoscopic excision of the lesion, and nephrectomy of the left kidney. Histopathology revealed an intrapulmonary cystic lesion with pleural adhesions, covered partially with respiratory-like and unclassified epithelium, in addition to cell-rich blastomatous areas beneath the epithelium.",
    "discussion": "Pleuropulmonary blastoma (PPB) is an embryonal tumour of the lung, which only occurs in young children under 6 years of age at diagnosis [1]. PPB is related to family tumour susceptibility syndrome associated with pulmonary cysts, cystic nephroma (CN) and other embryonal neoplasms, including rhabdomyosarcoma and Wilms\u2019 tumour [2]. A review of the International Pleuropulmonary Blastoma Registry (IPPBR) (www.ppbregistry.org) revealed that cystic nephroma (CN) or related tumours were found in 9.2% of 152 registry-reviewed PPB cases [3, 9]. The registry identified 18 patients with PPB associated with 20 renal tumours (15 CN), either in the same patient or a family member. Eleven children had both PPB and renal tumours (7 CN). The data from (IPPBR) indicate that 40% of the cases with PPB may have a genetic predisposition [4]. Recently, PPB has been linked to mutations in the DICER-1 gene. This gene encodes an enzyme that negatively regulates gene expression [5, 8].PPB has been classified into 3 groups based upon the characteristics of the tumour: type 1, purely cystic; type 2, intermediate cystic/solid; and type 3, predominantly solid [6, 10]. Current data support the assertion that type 1 PPB may progress to the more aggressive types 2 or 3 PPB. [1]. Most cases of PPB present as recurrent respiratory infections, respiratory distress and in some cases as recurrent pneumothorax [7]. Radiograph is the first imaging modality for respiratory symptoms. CT is typically used for evaluation of the initial extent of the disease and monitoring after resection and treatment. Appearances of PPB depend on the type. Type 1 appears as air-filled lung cysts associated with multiple septations, type 2 is an air-filled cystic mass with variable soft tissue component and type 3 is a large, heterogeneous, solid mass. PBB Type 1 is indistinguishable from benign lung cysts, based on imaging findings, especially Congenital Pulmonary Airway Malformation (CPAM) type1 and 4 [1, 2]. Therefore many congenital cystic lung lesions are removed surgically because of the risk of recurrent infection and possible underlying neoplasm. Treatment of PPB type 1-3 includes surgical resection +/- chemotherapy. Benefit of local radiation in type 2 and 3 PPB is controversial. Lesions that are not removed should be monitored closely. Five-year survival is 85-90 % in type 1 and 45-60 % in type 2 and 3 [2]. In conclusion PPB type 1 should be considered in the differential diagnosis in children with renal tumours and cystic lung lesions.",
    "differential_diagnosis": "Pleuropulmonary, blastoma, in, combination, with, cystic, nephroma, CPDN, (Cystic, Partially, Differentiated, Nephroblasoma), with, congenital, lobar, emphysema, Pleuropulmonary, blastoma, in, combination, with, cystic, nephroma, Wilms\u2019, tumour, with, pneumothorax, Mesoblastic, nephroma, with, congenital, pulmonary, airway, malformation, (CPAM), Renal, cyst, with, cavitary, necrosis, complicating, pneumonia",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011841/000001.jpg?itok=5umu9mXW",
            "caption": "Large radiolucent lesion in the left upper and middle hemithorax without definite bronchovascular markings."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011841/000002.jpg?itok=pL4a1FRV",
            "caption": "Large radiolucent lesion in the left upper and middle hemithorax without definite bronchovascular markings."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011841/000003.jpg?itok=QNtl093P",
            "caption": "The left upper lobe shows one large and a few small cystic air-containing cavities. Few small cystic lesions were also found in the left lower lobe. Mild mediastinal shift to the right side."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011841/000004.jpg?itok=13y1U4yy",
            "caption": "The left upper lobe shows one large and a few small cystic air-containing cavities. Few small cystic lesions were also found in the left lower lobe. Mild mediastinal shift to the right side."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011841/000005.jpg?itok=54DPdsIZ",
            "caption": "Two multilocular cystic masses in the left kidney, without evidence for liver or lymph node metastasis or invasion in inferior vena cava."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011841/000006.jpg?itok=b4s07rZF",
            "caption": "Two multilocular cystic masses in the left kidney, without evidence for liver or lymph node metastasis or invasion in inferior vena cava."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011841/000007.jpg?itok=r8A_uUOT",
            "caption": "Two multilocular cystic lesions in the left kidney with multiple anechoic spaces traversed by thin septations."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Paediatric",
      "Lung",
      "Abdomen"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT",
      "Ultrasound",
      "MR"
    ],
    "link": "https://www.eurorad.org/case/11841",
    "time": "12.07.2014"
  },
  "11858": {
    "case_id": 11858,
    "title": "Pleural liposarcom",
    "section": "Chest imaging",
    "age": "57",
    "gender": "male",
    "diagnosis": "Well differentiated liposarcoma",
    "history": "A 57-year-old male patient was referred by his primary care physician because of the radiological finding of a thoracic mass, in a chest radiography performed to study his sleep apnoea hypopnoea syndrome. The patient was a smoker who reported seven to eight month long productive cough.",
    "image_finding": "Posteroanterior and lateral chest radiographs showed a well-defined mass in the postero-lateral-superior region of the right hemithorax with a greater craniocaudal diameter than the transverse, forming obtuse angles with the superior wall and acute with the inferior wall and associate with no rib invasion (Fig. 1).CT with intravenous contrast revealed a pleural mass of homogeneous density, predominantly fat (-80 to -100 HU), well defined borders and growth inwards the thoracic cavity, not showing enhancement after the administration of intravenous contrast and diameters of 6.2 x 5 cm, with no evidence of thoracic wall invasion (Fig. 2-3).MRI showed a well-defined pleural-based mass, homogeneously hyperintense in T1 and T2- weighted MR images. A thin hypointense capsule was observed in T2 weighting and some hypointense septa were seen. There was homogeneous suppression of signal intensity on the T1 fat saturation sequence. No enhancement was observed after gadolinium injection (Fig. 4).",
    "discussion": "The most common soft tissue sarcomas in adulthood are liposarcomas, with a peak incidence between 40 and 60 years [1], with the retroperitoneum and thigh being the most frequent locations. However, primary pleural sarcomas are extremely rare malignant tumours [2].Malignant pleural disease has a bad prognosis. 90% of the cases are secondary to metastasis or lymphoma. Only 10% are malignant pleural mesothelioma or other tumours such as liposarcoma [3]. Most of the patients with liposarcoma in the thoracic cavity (85%) have symptoms, while 15% are asymptomatic and are diagnosed through a routine chest radiography [4]. Most common symptoms in these patients are chest pain, cough, dyspnoea and pleural effusion [2]. The main differential diagnosis based on imaging findings is lipoma [5]. In both lipoma and liposarcoma, fat may be found on CT (< 20 HU) and MRI (depending on the sequence used). On T1- weighted sequences fat has high signal intensity that decreases on T2-weighted images. Moreover, fat saturation and STIR sequences can suppress the fat signal and therefore confirm the presence of fat. Contrast may help define the tumour and reveal vascular areas. Lipomas are seen as subcutaneous fat-containing lesions. Some of them may contain connective tissue septa. There are several kinds of liposarcomas, such as well differentiated liposarcomas or atypical lipomas (our case), myxoid liposarcomas, pleomorphic and round-cell liposarcomas and dedifferentiated liposarcomas. Well differentiated liposarcomas or atypical lipomas contain more than 75% of fat. There are three subtypes: lipoma-like, inflammatory and sclerosing well-differentiated. Pathologic examination is necessary to establish a diagnosis. They can recur if there is no complete surgical removal, but they do not metastasize.Myxoid liposarcomas (most common, 50%) have an inhomogeneous and cystic appearance on MRI. Pleomorphic and round-cell liposarcomas also have an inhomogeneus appearance, often containing areas of necrosis.Dedifferentiated liposarcomas possess a high-grade nonlipogenic sarcoma component with a well-differentiated liposarcoma component [6].Diffusion- weighted MRI is a promising tool for differentiating malignant from benign pleural lesions accurately, complementing with dynamic contrast enhanced MRI. The importance of these techniques is the dissemination risk of the biopsy. PET \u2013CT is not tumour-specific and can also be positive in inflammatory lesions [3]. Thus, in our case, histologic examination of the surgically resected specimen confirmed the final diagnosis. Surgical resection, as in our case, is the only treatment option, with chemotherapy and radiotherapy remaining ineffective [4]. Some studies report that adjuvant radiotherapy may benefit patients [2].",
    "differential_diagnosis": "Well, differentiated, liposarcoma, Atypical, lipoma, Fat, lineage, tumour, metastasis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011858/000001.jpg?itok=mm8ylvo8",
            "caption": "Posteroanterior chest radiography shows a mass in the right hemithorax."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011858/000002.jpg?itok=0VcnMCQY",
            "caption": "Lateral chest radiography shows an extrapulmonary mass."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011858/000003.jpg?itok=l7SKGoQ7",
            "caption": "Mediastinal window shows a homogeneus mass without enhancement after  intravenous contrast administration."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011858/000004.jpg?itok=0ug5djCB",
            "caption": "Lung window shows an extrapulmonary and well-defined mass."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011858/000005.jpg?itok=ri8y4vlb",
            "caption": "Coronal CT reconstruction"
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011858/000006.jpg?itok=gTvbxQef",
            "caption": "Sagittal CT reconstruction"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011858/000007.jpg?itok=__pS53oK",
            "caption": "T1-weighted sequence shows a homogeneously hyperintense mass."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011858/000008.jpg?itok=557LYviC",
            "caption": "T2-weighted sequence shows a homogeneously hyperintense mass."
          },
          {
            "number": "Figure 4c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011858/000009.jpg?itok=JnMsWfV1",
            "caption": "T1 fat saturation sequence shows homogeneus suppression of the signal intensity of the mass."
          },
          {
            "number": "Figure 4d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011858/000010.jpg?itok=jN7kVa5z",
            "caption": "Fat saturation contrast-enhanced sequence shows no enhancement post gadolinium."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT",
      "MR"
    ],
    "link": "https://www.eurorad.org/case/11858",
    "time": "09.08.2014"
  },
  "11861": {
    "case_id": 11861,
    "title": "Unusual pattern of spread of primary lung cance",
    "section": "Chest imaging",
    "age": "74",
    "gender": "male",
    "diagnosis": "Primary lung cancer",
    "history": "A 74-year-old man was admitted to our hospital presenting with fever, cough and moderate dyspnoea.",
    "image_finding": "Chest radiograph at admission showed an ill-defined rather round parenchymal consolidation in the right upper lobe interpreted as pneumonia. Ten days later, this had increased in size and within it there were lucencies suggestive of cavitation. A contrast-enhanced CT (CECT) confirmed these findings and showed involvement of the main right pulmonary artery with a large filling defect, suggestive of pulmonary embolism with lung infarction. Due to clinical deterioration another CECT was performed a few days later showing increase of the parenchymal consolidation and internal cavitation. Despite treatment, there was no improvement in vascular obstruction, raising suspicion of a neoplastic origin of the lesion. A subsequent Positron Emission Tomography (PET CT) revealed fluorodeoxyglucose (FDG) uptake in the consolidation of the right upper lobe and within the right pulmonary artery. Transbronchial needle aspiration revealed a small cell tumour, which was considered surgically unresectable. The patient was further treated with chemotherapy.",
    "discussion": "The obstruction of pulmonary arteries with reduction or blockage of blood supply to lung is commonly caused by blood clots, air bubbles or fat particles into the lumen of pulmonary vessels and is known as pulmonary embolism (PE) [1-2].PE can also be caused by growth of a neoplasm inside the vascular lumen such as angiosarcoma, metastatic emboli or primary lung cancer. The vascular invasion by lung carcinoma is frequent microscopically, while a polypoid growth of the cancer into the lumen of pulmonary artery is very rare [3-5].The mechanical obstruction and the pulmonary arterial constriction by humoral or reflex mechanisms causes an increase of the vascular resistance with right ventricular failure that may rapidly progress to cardiac failure and death. The lung infarction occurs rarely, due to the dual pulmonary bloodstream and the oxygenation of the pulmonary tissues via ventilation [6].Unlike common PE that can have an acute onset with severe haemodynamic failure, PE related to malignancy has a more insidious onset with nonspecific symptoms such as chest pain, shortness of breath, progressive hypoxia, fever, cough, haemoptysis. Imaging is crucial for diagnosis. Chest radiograph is generally negative, can be useful to rule out other diseases or may reveal an enlarged pulmonary artery (Fleishner sign), regional oligaemia (Westermark's sign) and pleural effusion. A wedge-shaped pleural-based opacity (Hampton's hump) is suggestive of lung infarction.CECT is the best imaging test directly detecting emboli within the vessels.This may appear, on the imaging planes perpendicular to the blood vessel, as a thin rim of contrast around a central filling defect (polo mint's sign) or as a linear filling defect surrounded by contrast material (railway track sign) on the longitudinal images. Other findings are abrupt narrowing or complete obstruction of the pulmonary arteries [7]. Frequently the tumoral obstruction is misdiagnosed as the more common thromboembolism. Differentiating features between the two types may be the following: thromboembolic PE filling defects are usually multiple, whereas in tumour involvement it is a solitary finding.Expansion of pulmonary artery and enhancement of the intraluminal lesion secondary to its vascularization favour malignancy.Part of the parenchymal consolidation was partly due to a post-obstructive necrotic pneumonia, however, the FDG uptake within the tumour also suggested spread of the tumour.Treatment may include surgical resection combined with postoperative chemotherapy or chemotherapy combined with radiotherapy. In any case the treatment is challenging and decision and prognosis greatly depend on possible arterial invasion that is generally an ominous prognostic sign [5-8].",
    "differential_diagnosis": "Primary, lung, cancer, Thromboembolism, Lung, infarction",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011861/000001.jpg?itok=cn3qQJoi",
            "caption": "Chest radiograph \n(frontal) at admission shows an ill-defined rather round consolidation in the right upper lobe."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011861/000002.jpg?itok=s7BfliIX",
            "caption": "Chest radiograph \n(lateral) at admission shows an ill-defined rather round consolidation in the right upper lobe."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011861/000003.jpg?itok=HKVqG4xa",
            "caption": "Chest radiograph (ten days later) shows interval increase in size of the lesion with internal cavitation."
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011861/000004.jpg?itok=4z4C1n_y",
            "caption": "Chest radiograph (ten days later) shows interval increase in size of the lesion with internal cavitation."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011861/000013.jpg?itok=IHPmAq0x",
            "caption": "CECT (axial view on lung windowing) shows extensive consolidation of the right upper lobe with internal cavities."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011861/000007.png?itok=bxwxLjBt",
            "caption": "Coronal reformat on lung windowing shows massive consolidation of the right upper lobe with internal cavities."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011861/000008.png?itok=N7kZBnKg",
            "caption": "Sagittal reformat on lung windowing shows massive consolidation of the right upper lobe with internal cavities."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011861/000005.png?itok=3Cy0nWmy",
            "caption": "CECT (axial view on mediastinal windowing) shows extensive consolidation of the right upper lobe with internal cavities. The right pulmonary artery is completely filled with thrombus in contiguity with the parenchymal consolidation (red arrow)."
          },
          {
            "number": "Figure 2e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011861/000009.png?itok=bun9cmXH",
            "caption": "Contrast-enhanced coronal reformat  on mediastinal windowing shows extensive consolidation of the right upper lobe with internal cavities. The right pulmonary artery is completely filled with thrombus in contiguity with the parenchymal consolidation."
          },
          {
            "number": "Figure 2f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011861/000022.jpg?itok=BV_W4klA",
            "caption": "Comparison between unenhanced and enhanced CT show a modest enhancement of the filling defect inside right pulmonary artery. (80 vs 40 U.H.)"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011861/000023.png?itok=brrKpmIR",
            "caption": "PET/CT shows fluorodeoxyglucose uptake  in the consolidation of right upper lobe and within the lumen of the right pulmonary artery."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011861/000024.png?itok=5i8dx3GR",
            "caption": "PET/CT shows fluorodeoxyglucose uptake  in the consolidation of right upper lobe and within the lumen of the right pulmonary artery."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011861/000010.png?itok=z2bQZ6vt",
            "caption": "PET/CT shows fluorodeoxyglucose uptake within the lumen of the right pulmonary artery."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011861/000019.jpg?itok=ikuFRIJJ",
            "caption": "CECT (axial view on lung  windowing) shows consolidation of the right upper lobe with internal cavitation."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011861/000017.jpg?itok=YdC3bxhZ",
            "caption": "CECT (axial view on mediastinal windowing) shows involvement of the right pulmonary artery involved by a  massive thrombus. Note also expansion of the right pulmonary artery."
          },
          {
            "number": "Figure 4c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011861/000018.jpg?itok=lgW5K7uI",
            "caption": "Coronal reformat on mediastinal windowing shows consolidation of the right upper lobe with internal cavities and the right pulmonary artery being expanded and completely filled by thrombus."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011861/000025.png?itok=9dDW7d6v",
            "caption": "CECT follow-up (axial) shows: increasing polypoid growth within the lumen of the pulmonary arteries."
          },
          {
            "number": "Figure 5b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011861/000026.png?itok=HSOv9CyU",
            "caption": "CECT follow-up (axial) shows: increasing polypoid growth within the lumen of the pulmonary arteries."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT",
      "PET-CT",
      "PET",
      "Image manipulation / Reconstruction"
    ],
    "link": "https://www.eurorad.org/case/11861",
    "time": "19.10.2014"
  },
  "11897": {
    "case_id": 11897,
    "title": "High-riding superior pericardial recess",
    "section": "Chest imaging",
    "age": "50",
    "gender": "female",
    "diagnosis": "High-riding superior pericardial recess",
    "history": "A 50-year-old woman underwent a CT examination of the chest after thoracic trauma.",
    "image_finding": "The CT shows a hypodense lesion in the right paratracheal area along the course of the ascending aorta (Fig. 1, 2, 3).",
    "discussion": "The high-riding superior pericardial recess was first described by Choi [1]. It represents an extension of the superior aortic recess above the level of the aortic arch into the right paratracheal region between the brachiocephalic vessels and the trachea, contiguous with the superior pericardial recess and without any definable wall.There is usually no fat plane between the fluid and the aorta.It does not exert any mass effect on adjacent structures.With thin-section MDCT, the prevalence reaches 6.6% [2]. This fluid-containing lesion has a round, oval, triangle, half-moon or irregular-shaped configuration on the axial images.The fluid can easily migrate to other pericardial recesses within some minutes [3].High-riding superior pericardial recess occurs in physiological conditions, without significant pericardial effusion.The differential diagnosis includes low attenuation adenopathy, bronchogenic cyst, pericardial cyst, aortic dissection or thrombus.Clues for the correct diagnosis of high-riding superior pericardial recess are homogenous water density, continuity of the fluid with the adjacent pericardium, the typical location along the aortic arch or at the right paratracheal region, lack of fat plane adjacent to the aorta, lack of definable wall and absence of mass effect.Treatment is not required and it is very important not to confuse this pseudolesion with other mediastinal masses, in order to avoid unnecessary invasive diagnostic procedures, especially in the setting of trauma.",
    "differential_diagnosis": "High-riding, superior, pericardial, recess, Low, attenuation, lymph, node, Mediastinal, cyst, Aortic, dissection, or, thrombus, Mediastinal, haematoma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011897/000001.jpg?itok=d4p8mN6X",
            "caption": "Contrast-enhanced axial CT on mediastinal windows\nshowing a hypodense lesion in the right paratracheal area along the course of the ascending aorta."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011897/000002.jpg?itok=PmOUrFtK",
            "caption": "Contrast-enhanced axial CT on mediastinal windows\nshowing a hypodense lesion in the right paratracheal area along the course of the ascending aorta."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011897/000003.jpg?itok=LxG-AlAm",
            "caption": "Contrast-enhanced axial CT on mediastinal windows\nshowing a hypodense lesion in the right paratracheal area along the course of the ascending aorta."
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011897/000004.jpg?itok=ZN-hp3ug",
            "caption": "Contrast-enhanced axial CT on mediastinal windows\nshowing a hypodense lesion in the right paratracheal area along the course of the ascending aorta."
          },
          {
            "number": "Figure 1e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011897/000005.jpg?itok=WaukIJ33",
            "caption": "Contrast-enhanced axial CT on mediastinal windows\nshowing a hypodense lesion in the right paratracheal area along the course of the ascending aorta."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011897/000006.jpg?itok=CKcXVff7",
            "caption": "Contrast-enhanced coronal CT on mediastinal windows."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011897/000007.jpg?itok=Vp0UmXOz",
            "caption": "Contrast-enhanced coronal CT on mediastinal windows."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011897/000008.jpg?itok=t1KqsaDX",
            "caption": "Contrast-enhanced coronal CT on mediastinal windows."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011897/000009.jpg?itok=dg64hhoO",
            "caption": "Contrast-enhanced sagittal CT on mediastinal windows."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011897/000010.jpg?itok=ARJhZgFc",
            "caption": "Contrast-enhanced sagittal CT on mediastinal windows."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Mediastinum"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/11897",
    "time": "04.07.2014"
  },
  "11919": {
    "case_id": 11919,
    "title": "heim\u2013Chester disease (ECR 2014 Case of the Day)",
    "section": "Chest imaging",
    "age": "44",
    "gender": "female",
    "diagnosis": "Erdheim-Chester disease with involvement of multiple organ systems",
    "history": "A 44-year-old woman with history of progressive and bilateral exophthalmos refractory to conventional therapies referred to our Emergency Department for sudden painless vision loss in the left eye. She complained also of shortness of breath and dry cough. Laboratory blood tests including thyroid function were within normal limits.",
    "image_finding": "Head CT showed bilateral homogeneous retrobulbar soft tissue (Fig.1a). A left-sided 3-wall orbital decompression was performed to reduce optic nerve compression (Fig.1b), bone/soft tissue specimens were sent for histological examination. Brain MRI confirmed intraconal tissue surrounding optic nerves hypointense on T2WI, with homogeneous enhancement on contrast-enhanced T1WI (Fig.2a,b). Chest radiograph revealed diffuse interstitial involvement, fissural thickening and enlarged cardiac image (Fig.3). High-resolution chest CT showed smooth interlobular septal thickening, pleural and pericardial effusion (Fig.4a,b). Soft tissue infiltrating right atrium wall and surrounding right coronary artery was observed at CT mediastinal window (Fig.4c). On cardiac MRI tissue showed hypointensity on T2WI and delayed enhancement on contrast-enhanced T1WI (Fig.5a,b). Diffuse retroperitoneal soft tissue was evident around aorta, renal arteries, kidneys and ureters (Fig.6a,b). Digital pyelography showing right pelvicaliectasis due to obstruction of proximal ureter was performed for nephrostomy placement (Fig.7). Radiograph of distal femurs demonstrated symmetric cortical sclerosis of meta-diaphyseal regions (Fig.8).",
    "discussion": "Erdheim\u2013Chester disease (ECD) is a rare systemic non-Langerhans cell histiocytosis of unknown origin, characterized by infiltration of tissues by foamy CD68+/CD1a- histiocytes surrounded by fibrosis [1]. The most common sites of involvement are the skeleton, CNS, cardiovascular system, lungs, retroperitoneum, skin; although cases of thyroid, testes and lymph nodes infiltration have also been reported [1, 2]. Diagnosis of ECD is particularly challenging since multiorgan involvement determines heterogeneous clinical manifestations with variable prognosis, ranging from asymptomatic bony lesions to multisystemic life-threatening disease [3]. Bone involvement is almost constant. Radiography and scintigraphy show pathognomonic features: respectively bilateral symmetric osteosclerosis and increased uptake of technetium-99 of meta-diaphysis of long bones [1, 4]. Extraosseous involvement is present in about half of patients [1, 3, 5]. Hypothalamic-pituitary infiltration leads to diabetes insipidus while retroorbital infiltration to bilateral painless exophthalmos. Diabetes insipidus, bilateral exophthalmos and bone pain compose the ECD diagnostic triad [1, 4]. CNS involvement can have proteiform manifestations with infiltrative, meningeal pattern or both [6, 7]. Retroperitoneal infiltration is relatively frequent. The \"hairy kidney\" appearance on CT due to bilateral infiltration of perirenal and posterior pararenal space is highly suggestive [8]. Infiltration of renal arteries can lead to hypertension [8]. Cardiovascular involvement typically manifests as pericardial effusion, right atrial wall thickening and circumferential periaortic tissue infiltration (\"coated aorta\"), extended even to aortic collaterals, including coronary arteries [8, 9]. In case of pulmonary ECD histiocytic infiltration follows a perilymphatic distribution, usually accompanied by fibrosis. High-resolution chest CT shows smooth symmetric interlobular and fissural thickening, multifocal areas of ground-glass attenuation, centrilobular micronodules, thin-walled cysts, pleural effusion [5, 8]. Involvement can be diffuse or predominant in upper or lower lobes resembling cardiogenic pulmonary oedema. Normal calibre of pulmonary veins may help in differential diagnosis. Because symptoms of ECD are often unspecific, the number of differential diagnosis is large. Lymphoma, multifocal fibrosclerosis, Langerhans cell histiocytosis and sarcoidosis should be considered due to their possible systemic involvement. Presence of pathognomonic radiological findings of ECD, in particular evidence of a diffuse systemic perivascular and perilymphatic involvement, can direct diagnosis. However histopathological confirmation is crucial for diagnosis. In our patient histological analysis of specimens showed a chronic inflammatory infiltrate rich in CD68+ histiocytes in the orbital bone and retroorbital soft tissue (Fig.9). To date there is no standard treatment for ECD. Interferon-\u03b1 provides the best management strategy, with stabilization of the disease in most cases even though prognosis remains poor [1, 10].",
    "differential_diagnosis": "Erdheim-Chester, disease, with, involvement, of, multiple, organ, systems, Langerhans, cell, histiocytosis, Multifocal, fibrosclerosis, Lymphoma, Sarcoidosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011919/000001.jpg?itok=ZwZ2iDUP",
            "caption": "Preoperative unenhanced head CT (1a) showing bilateral homogeneous retrobulbar tissue. Postoperative unenhanced head CT after surgical orbital decompression (1b). Please note the absence of the lateral and medial orbital wall (yellow arrows)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011919/000002.jpg?itok=dm6xfOq1",
            "caption": "Brain MRI showing bilateral intraconal homogeneous retrobulbar tissue surrounding optic nerves, hypointense on T2WI (2a), with mild homogeneous enhancement on contrast-enhanced T1WI (2b)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011919/000003.jpg?itok=4gvF4r32",
            "caption": "Chest radiograph showing diffuse reticular interstitial involvement, fissural thickening and enlarged cardiac image."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011919/000004.jpg?itok=GlWZmsma",
            "caption": "Axial images at lung window setting (4a, b) showing interlobular thickening, fissural thickening, pleuropericardial effusion. Axial images at mediastinal window setting (4c) showing tissue infiltrating right atrium and surrounding right coronary artery (yellow arrow)."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011919/000005.jpg?itok=hlqDSuLS",
            "caption": "Cardiac-gated T2WI showing pericardial effusion and low-signal tissue surrounding circumferentially right coronary artery (yellow arrow) and infiltrating right atrial wall (5a). Late-enhancement cardiac MR showing strong enhancement of the tissue and thickened pericardium (5b)."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011919/000006.jpg?itok=Rb2y9i-U",
            "caption": "Enhanced abdominal CT showing bilateral perirenal infiltration extending into the renal sinus of kidneys. Please note also circumferential periaortic infiltration."
          }
        ]
      },
      {
        "number": "Figure 7",
        "subfigures": [
          {
            "number": "Figure 7",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011919/000007.jpg?itok=uOpXEnkL",
            "caption": "Percutaneous pyelography showing marked dilatation of the right renal collecting system due to the stenosis of the upper portion of ureter (yellow arrow)."
          }
        ]
      },
      {
        "number": "Figure 8",
        "subfigures": [
          {
            "number": "Figure 8",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011919/000008.jpg?itok=ghph-fyi",
            "caption": "Radiograph of distal femurs showing bilateral and symmetric heterogeneous osteosclerosis of diaphyseal and metaphyseal regions."
          }
        ]
      },
      {
        "number": "Figure 9",
        "subfigures": [
          {
            "number": "Figure 9",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011919/000009.jpg?itok=bPes4hlV",
            "caption": "Etmoidal mucosa showing a chronic inflammatory infiltrate rich in macrophages sometimes with foamy cytoplasm. (Haematoxylin and Eosin; original magnification x100) (9a). Macrophages exhibiting cytoplasmatic immunoreactivity for CD68 (9B), PGM-1 (9C) (Haematoxylin counterstaining; original magnification x100)."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Head and neck",
      "Thorax",
      "Cardiac",
      "Kidney",
      "Bones",
      "Education",
      "Abdomen"
    ],
    "imaging_technique": [
      "MR",
      "Conventional radiography",
      "Percutaneous",
      "Experimental",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/11919",
    "time": "10.06.2014"
  },
  "11930": {
    "case_id": 11930,
    "title": "False positive PET/CT of pleural lesion decades after pleurodesis",
    "section": "Chest imaging",
    "age": "51",
    "gender": "male",
    "diagnosis": "Pleurodesis nodule.",
    "history": "A 51 year old gentleman presented with cough for four months and weight loss but no shortness of breath,  fever, history of travel or previous tuberculosis. He was a heavy smoker and worked with asbestos in the past. He had right pneumothorax and pleurodesis in the 1970s but no other medical problems.",
    "image_finding": "The patient underwent a chest radiograph which showed peripheral right middle zone opacity (Figure 1) and hence CT thorax was performed, which showed 2 cm x 1.7 cm right middle lobe peripheral pleural based lesion with a central area of high attenuation (Figures 2, 3, 4, 5 and 6). There were also emphysematous changes.The case was discussed in the lung cancer MDT and it was decided that the patient should undergo FDG-PET. PET showed this lesion to be hypermetabolic (Figures 4 and 5) and there were a few other pleural based lesions which were hypermetabolic as well. Later, the results were discussed again in an MDT meeting and it was decided to perform CT guided biopsy for a histological diagnosis, as it was difficult to rule out malignancy and mesothelioma at that point.The CT guided biopsy demonstrated no evidence of malignancy and the changes seen were consistent with foreign body type giant cell reaction, probably related to previous pleurodesis.",
    "discussion": "Background:Pleurodesis is performed to prevent recurrence of pneumothorax or recurrent pleural effusion. It can be performed chemically or mechanically.Fluorodeoxyglucose (FDG)-positron emission tomography (PET) is being used more and more to differentiate benign from malignant focal lesions and it has been shown to be more efficacious than conventional chest computed tomography (CT). However, FDG is not a cancer-specific agent and false positive findings in benign diseases have been reported. Infectious diseases (mycobacterial, fungal, bacterial infection), sarcoidosis, radiation pneumonitis and post-operative surgical conditions have shown intense uptake on PET [1]. Clinical perspective:In our patient, there was a long term history of cough associated with weight loss and there were also strong risk factors for lung malignancy including heavy smoking and working with asbestos. The FDG-PET was suspicious for malignancy and mesothelioma. A cohort study following patients from 14 to 40 years after pleurodesis for pneumothorax did not show evidence of mesothelioma or increased incidence of lung cancer [2, 3]. Another study demonstrated that more than two decades post-pleurodesis, a large percentage of patients have pleural thickening, demonstrated on plain chest x-ray and this may lead to mild restrictive impairment which might explain some of the chest symptoms, such as long-standing cough with good long term outlook [4]. Fanggiday et al, demonstrated a case with FDG-avid pulmonary nodules, mimicking lung cancer. After histopathological examination they appeared to be the result of persistent inflammation due to talcage pleurodesis, which had occurred 48 years before[5].Imaging Perspective:The FDG-PET demonstrated an area of high uptake at the suspicious lesion, which made the diagnosis of cancer more probable, but was not confirmed on histology. Outcome:In the era of FDG-PET, a diagnostic dilemma is emerging, as it appears that many of the changes may manifest as chronic inflammatory lesions with increased metabolic activity [2]. PET/CT offers the opportunity to accurately localize the areas of increased FDG uptake within the regions of pleural thickening caused by pleurodesis. However, the dilemma of misleading FDG accumulation cannot be solved by this imaging modality and hence histological evaluation is needed.Teaching point:Metabolic imaging with FDG-PET has a definitve role in the evaluation and management of malignancy. However, false positive or negative PET images are frequently encountered. Proper interpretation and accurate characterization of an abnormality is accomplished with increased awareness of possible false positive and negative conditions [1].",
    "differential_diagnosis": "Pleurodesis, nodule., Mesothelioma., Chronic, pleuritis.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011930/000001.jpg?itok=JFJFMOaK",
            "caption": "Chest Radiograph Showing right mid zone nodule."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011930/000002.jpg?itok=1dX2xsyu",
            "caption": "Subpleural nodule on right side in CT of the chest"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011930/000003.jpg?itok=CBCKTMP5",
            "caption": "Right upper lobe subpleural nodule in contrast enhanced CT of the chest."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011930/000004.jpg?itok=-oiCjBHF",
            "caption": "Coronal PET showing hypermetabolic lesion"
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011930/000005.jpg?itok=C5w_A1dB",
            "caption": "Axial PET CT showing hypermetabolic lesion"
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011930/000006.jpg?itok=qqBVfZR8",
            "caption": "Coronal reformat of the CT chest on lung windows."
          }
        ]
      },
      {
        "number": "Figure 7",
        "subfigures": [
          {
            "number": "Figure 7",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011930/000007.jpg?itok=VFV86Rlf",
            "caption": "Coronal reformat of CT chest on mediastinal window"
          }
        ]
      },
      {
        "number": "Figure 8",
        "subfigures": [
          {
            "number": "Figure 8",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011930/000008.jpg?itok=FuSM20u2",
            "caption": "Sagittal reformat of CT of the chest on mediastinal window"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "CT",
      "PET-CT"
    ],
    "link": "https://www.eurorad.org/case/11930",
    "time": "23.07.2014"
  },
  "11945": {
    "case_id": 11945,
    "title": "Central venous catheter fracture with fragment embolism",
    "section": "Chest imaging",
    "age": "51",
    "gender": "male",
    "diagnosis": "Spontaneous central venous catheter fracture with fragment embolism",
    "history": "A 51-year-old asymptomatic man with colon carcinoma undergoing chemotherapy presented with malfunction of a central venous catheter (CVC), that had been properly positioned. There was no local swelling or any evidence of fluid leakage.",
    "image_finding": "Thoracic CT (Figure 1 and 2) showed a fractured CVC in the right subclavian vein (tip is flagged with an arrow). The distal fragment was located in the descending branch of the left pulmonary artery. Chest radiograph after CVC removal (Figure 3) showed the migrated fragment (arrow).",
    "discussion": "The placement of CVC can lead to early complications (such as incorrect position, improper anchoring of the reservoir, infection, vascular perforation, hemothorax, pneumothorax, hemorrhagic pericardial effusion) and late complications (for example drug leakage, mechanical malfunction, thrombosis, migration of the catheter, fragment embolism) (1, 2).Migration of the tip of CVC is not an uncommon event and the mechanism is not clear - increased intrathoracic pressure, changing the body position or physical movements can be potential causes (1, 2).The most common symptoms associated with catheter migration include chest wallswelling at the injection port chamber and pain in the shoulder. Other suggestivefeatures include withdrawal occlusion, resistance to injection of fluid, sudden onset ofcough or chest pain and palpitations. However, migration to the pulmonary artery or its branches is frequently asymptomatic since there are few sensory endings in the vascular endothelium (1, 2). Monitoring with chest radiography helps in early detection. CVC removal and replacement are usually required (1, 2). In this case, the proximal part of CVC was removed and it was decided not to remove the distal fragment after weighing the risks and benefits, opting for imaging follow-up.",
    "differential_diagnosis": "Spontaneous, central, venous, catheter, fracture, with, fragment, embolism, Migration, of, other, medical, device, Foreign, body",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011945/000002.jpg?itok=a_lCFgB_",
            "caption": "Chest radiograph after CVC removal shows the migrated fragment (arrow)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011945/000004.jpg?itok=CyVHqIiR",
            "caption": "Axial CT also shows the migrated fragment in the descending branch of the left pulmonary artery."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011945/000009.jpg?itok=nHmBUVTp",
            "caption": "Axial CT (bone window)."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011945/000010.jpg?itok=24nke200",
            "caption": "Axial CT (bone window)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011945/000005.jpg?itok=dgdY0YEI",
            "caption": "Thoracic CT shows a fractured CVC in the right subclavian vein, whose tip is flagged with an arrow. The distal fragment is located in the descending branch of left pulmonary artery (b and c)."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011945/000006.jpg?itok=V0SO45Nr",
            "caption": "The distal fragment is located in the descending branch of left pulmonary artery."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011945/000008.jpg?itok=RP1l4i2y",
            "caption": "The distal fragment is located in the descending branch of left pulmonary artery."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Cardiovascular system",
      "Abdomen"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/11945",
    "time": "09.07.2014"
  },
  "11963": {
    "case_id": 11963,
    "title": "Rare findings in pulmonary amyloidosis",
    "section": "Chest imaging",
    "age": "55",
    "gender": "female",
    "diagnosis": "Localized pulmonary amyloidosis",
    "history": "A case of a 55-year-old female patient is presented, who did not have a history of cigarette smoking nor professional exposure to chemicals, and did not complain of respiratory symptoms. A chest X-ray, performed for a car accident, showed abnormal findings, so a chest CT was subsequently carried out.",
    "image_finding": "Chest CT revealed some large nodular opacites with amorphous calcifications and multiple well-defined cystic lesions in both lungs, moreover, a subsegmental collapse of the middle lobe was detected (Fig. 1). Tracheobronchial tree presented multifocal and irregular wall thickenings, some with calcifications (Fig. 2). Some lymph nodes in mediastinum were found with short axis up to 10 mm (Fig. 1). No pleural abnormalities were detected.Bronchoscopy confirmed multifocal and irregular yellowish wall thickening in tracheobronchial tree. Mucosal biopsy was done at tracheal wall and Congo-red staining revealed amyloid deposit of greenish birefringence under polarized light microscopy. Pulmonary function testing of the patient revealed mild obstructive syndrome and mild reduction in CO diffusing capacity. The findings were consistent with airways and lung amyloidosis.",
    "discussion": "Amyloidosis is a rare disease characterized by extracellular deposition of various proteins in \u03b2\u2013pleated sheets, disrupting organ function. Two forms of amyloidosis are commonly described, systemic and localized.Systemic amyloidosis can be primary, with monoclonal immunoglobulins in serum or urine immunoelectrophoresis, can be secondary to several diseases (i.e. chronic infections, Crohn\u2019s disease, Sjrogren syndrome, etc.) or it can be familial [1]. Localized amyloidosis is defined as amyloid deposition isolated to an organ or district without systemic deposition [1, 2].Amyloid in the respiratory tract has been classified by authors at The Mayo Clinic as associated with systemic amyloidosis or localized pulmonary disease [3]. In systemic amyloidosis, thoracic involvement may commonly show diffuse interstitial or nodular lung disease, adenopathy and pleural disease. In localized amyloidosis, three types of respiratory injuries are described: tracheobronchial, nodular and interstitial involvement [3, 4, 5]. We underline some rare findings in our case, in particular the patient described herein presented nodular pulmonary amyloidosis in association with tracheobronchial involvement. In light of these data, we emphasize that tracheobronchial amyloidosis is exceptionally described associated with lung involvement [3, 4, 6]. To the best of our knowledge, to date, only few and sporadic cases are reported in English literature describing lung and tracheobronchial lesions in the same patient [3, 7].Secondly, it is interesting to notice that localized pulmonary involvement in amyloidosis without systemic amyloidosis is very rare, more precisely the localized form occurs in approximately 10-20% of patients with amyloidosis [1, 2]. In our case, after detecting amyloid deposits on tracheobronchial tree, a diagnosis of localized form of amyloidosis was reached on the basis of an abdominal fat biopsy excluding systemic amyloid deposits.Rarely mediastinal enlarged lymph nodes are present in localized pulmonary disease, while pleural effusions is well documented in patients with systemic amyloid disease often related to congestive heart disease or nephrotic syndome [3, 4]. We did not notice hilar/mediastinal adenopathy nor pleural abnormalities.Finally, cystic lung disease (as in lymphoid interstitial pneumonia) or pulmonary nodular amyloidosis has been occasionally reported in association with Sjogren syndrome, together with the combination of pulmonary cysts and nodules [8, 9]. In this regard, our patient had a long history of sicca syndrome, positive Shirmer test, and SSA SSB positive autoantibodies, data consistent with Sj\u00f6gren syndrome. On the basis of the clinical presentation, quite nonspecific, we recommended surveillance with periodic pulmonary function tests and chest radiographs.",
    "differential_diagnosis": "Localized, pulmonary, amyloidosis, Lung, tumour, Lung, infection, Relapsing, polychondritis, Tracheabronchopathia, osteochondroplastica",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011963/000001.jpg?itok=h5PA7nzM",
            "caption": "Lung window: some calcified nodular opacities and cysts are shown bilaterally."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011963/000002.jpg?itok=Q2Bkx5sT",
            "caption": "Lung window: subsegmental atelectasis is evident in middle lobe."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011963/000003.jpg?itok=_gZR2pYv",
            "caption": "Lung window: multiple rounded and elliptical cysts ranging from 5 to 55 mm in diameter, with a mild lower zone predominance; cysts are characterized by a thin (up to 3 mm) or no visible wall."
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011963/000004.jpg?itok=eCFFuG37",
            "caption": "Mediastinal window: some mediastinal lymph nodes are shown."
          },
          {
            "number": "Figure 1e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011963/000005.jpg?itok=WygkXy7-",
            "caption": "Mediastinal window: subcarinal calcified lymph node."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011963/000006.jpg?itok=NGSSKSrt",
            "caption": "Lung window: multiple areas of tracheobronchial wall thickening are shown."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/11963",
    "time": "02.08.2014"
  },
  "11977": {
    "case_id": 11977,
    "title": "Harbouring a parasite and bacteria simultaneously: Pulmonary hydatido-tuberculosis",
    "section": "Chest imaging",
    "age": "25",
    "gender": "male",
    "diagnosis": "Spontaneously ruptured pulmonary hydatid cyst with concomitant tuberculosis.",
    "history": "A 25-year-old farmer from India, on anti-tuberculosis treatment for 2 months presented with acute onset dyspnoea, chest pain and acute onset copious whitish sputum stained with blood. Rhonchi were auscultated in right apex and bronchial breath sounds in left lower zone. Sputum analysis was positive for acid-fast bacilli.",
    "image_finding": "Chest X-ray and Scanogram of thorax demonstrated a well-defined cavity in the left lower zone with membrane-like structures within. Right apical segment delineated multiple cavities. Few fine fibrotic lines were noted in both the lung fields, predominantly in right hemithorax. Right upper zone appeared collapsed with ipsilateral tracheal traction and right middle and lower zone were collapsed with elevation of the diaphragm.HRCT thorax, axial, sagittal and coronal reformatted images clearly depicted a well-defined spherical cavity in the basal segment of the left lower lobe, with collapsed membranes within. Cavitatory and fibrotic changes noted on chest X-ray were confirmed.",
    "discussion": "A. Tuberculosis in the tropics is rampant, and so is echinococcosis. And co-existence of both, although rare in Western countries, is more frequent in endemic areas. [1] Unhygienic rearing of animals is an important predisposing factor. Incidence of human echinococcosis is closely related to the prevalence of the disease in domestic animals. E. granulosis causes cystic echinococcosis and is endemic in the Mediterranean, Middle East, and Latin America. E. multilocularis causes alveolar echinococcosis and is endemic in Alaska, central Europe, Turkey and China. Humans become exposed to eggs of tapeworm after close contact with dogs. Typically larvae that pass through the liver are trapped in pulmonary arterial capillaries and develop into hydatid cysts. [2]Cystic echinococcosis most commonly affects liver followed by lung. Pulmonary hydatid disease affects the right lung in 60% cases, mostly in the lower lobes. [3]B. Symptomatology of both diseases is essentially the same - mild cough with or without expectoration, chest pain and haemoptysis. Differentiating one from the other clinically is far-fetched. Rupture is often accompanied by expectoration of copious amount of salty expectoration. Symptomatic hydatid disease of lung follows rupture of the cyst. [3]Serological diagnosis for either of the two diseases may not be confirmatory [4]. Due to a wide spectrum of presentation, false negative serological tests are common.C. Radiological features are conclusive with CT leading the investigation protocol. [4]Diagnosis of intact hydatid cyst is usually based on a suspicion resulting from an unexpected finding on routine chest radiographs in a patient from an endemic area. Radiographically, it appears as a homogeneous spherical opacity with definite edges. Calcification is rare. Even the availability of a basic chest X-ray in the periphery would point the clinician towards a presumptive diagnosis and referral of these patients to the nearest tertiary equipped centre.Cyst rupture is the commonest complication of pulmonary hydatidosis. The characteristic \u201cserpent sign\u201d can be noted due to collapsed membranes within the cyst.Fluoroscopy and CT demonstrate \u201cwater lily sign\u201d due to membranes seen floating in the cyst's fluid. Air lining between the pericyst and endocyst is appreciated on CT as \u201ccumbo sign\u201d.D. Surgical enucleation or pericystectomy is the treatment of choice. It is imperative to continue medical treatment post-operatively. [4]E. Teaching points:\u2022 Unhygienic rearing of animals in tropics is a common predisposing factor (Occupational history).\u2022 False negative serology maybe seen.\u2022 CT is the imaging modality of choice.\u2022 Serpent sign is classical for ruptured hydatid cyst.",
    "differential_diagnosis": "Spontaneously, ruptured, pulmonary, hydatid, cyst, with, concomitant, tuberculosis., Fungal, colonisation, of, tuberculous, cavities, Tuberculous, lung, abscess",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011977/000001.jpg?itok=VSCa_IZ-",
            "caption": "Multiple cavities in right apex. Fibrotic changes and atelectasis of right hemithorax with resultant ipsilateral pulling of trachea (green arrow) and diaphragm (orange arrow). Well-defined cavity with collapsed membranes in left lower zone (yellow arrow)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011977/000002.jpg?itok=i80GF5pd",
            "caption": "Scanogram showing cavities in right apex. Fibrotic changes and atelectasis of right hemithorax with ipsilateral pulling of trachea (green arrow) and diaphragm (orange arrow). Well-defined cavity with collapsed membranes in left lower zone (yellow arrow)."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011977/000003.jpg?itok=G4mqOOi5",
            "caption": "HRCT thorax, axial plane. Collapsed membranes within the cavity of basal segment of left lower lobe are clearly depicted (arrow), suggestive of classical \\\"serpent sign\u201d."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011977/000004.jpg?itok=OYgICmgE",
            "caption": "HRCT thorax, sagittal reformatted image. Collapsed membranes within the cavity of basal segment of left lower lobe are clearly depicted (arrow) suggestive of classical \\\"serpent sign\u201d."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011977/000005.jpg?itok=59WNogvJ",
            "caption": "HRCT thorax, axial section demonstrates multiple tuberculous cavities in apical and anterior segment of right upper lobe."
          },
          {
            "number": "Figure 2e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011977/000006.jpg?itok=b3cvAWxH",
            "caption": "HRCT thorax, coronal reformatted image confirms the cavitatory and fibrotic findings of X-ray. Collapsed membranes within the cavity of basal segment of left lower lobe are clearly depicted suggestive of classical \\\"serpent sign\u201d."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011977/000007.jpg?itok=I7YklA27",
            "caption": "Diagrammatic Illustration of classical radiological manifestations of pulmonary hydatid cyst."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "Image manipulation / Reconstruction",
      "Digital radiography",
      "CT-High Resolution"
    ],
    "link": "https://www.eurorad.org/case/11977",
    "time": "13.08.2014"
  },
  "11988": {
    "case_id": 11988,
    "title": "Pulmonary amyloidosis",
    "section": "Chest imaging",
    "age": "72",
    "gender": "female",
    "diagnosis": "Localized pulmonary amyloidosis - nodular form",
    "history": "A 72-year-old woman underwent chest X-ray in the preoperative setting of a total knee replacement (Fig. 1). For this patient there were no significant data regarding her medical history.",
    "image_finding": "As a coincidental finding, multiple pulmonary nodules were seen on the preoperative chest X-ray. A subsequent CT of the chest, performed after administration of intravenous contrast, confirmed the presence of multiple nodules in both lungs with a predominantly peripheral distribution (Fig. 2). Some of these nodules were cavitated. There was no perilymphatic or centrilobular distribution pattern. There were no signs of interstitial disease and there were no associated lymphadenopathies. In order to rule out malignancy she underwent a FDG-PET examination (Fig. 2) demonstrating FDG-uptake in these nodules (SUVmax 6.1). Because malignancy could not be excluded, a wedge resection of the right lower lobe was performed for histological sampling purposes. Staining with Congo red under crossed polarization light demonstrates a yellow-green birefringence confirming the diagnosis of amyloidosis (Fig. 3). The affinity of amyloid for Congo red did not alter after incubation with potassium permanganate, specifying this type as a non-AA type.",
    "discussion": "Amyloidosis represents a heterogeneous group of disorders characterized by overexpression of specific subunit proteins with an extracellular accumulation [1]. There are two forms of amyloidosis, the systemic and the organ-limited form. Besides the form in which amyloidosis can occur, different categories of amyloidosis are known in a classification system based on the different subunit proteins [2]:-\tAL: Primary or immunoglobulin light-chain disease-\tAA: Secondary or amyloid protein disease-\tATTR: Hereditary or mutant transthyretin disease-\tA\u03b22M: Dialysis-associated or \u03b22-microglobulin diseasePulmonary involvement is most commonly found in the primary form (AL) of amyloidosis in which it can be a part of a widespread process involving many organs or in which it may be localized in the lung parenchyma [1]. Regardless of the form, three distribution patterns of lung involvement are described: tracheobronchial, nodular parenchymal and diffuse alveolar septal distribution [3]. In the tracheobronchial distribution pattern, submucosal depositions of amyloid are found mainly in the trachea and main bronchi, most frequently located in the subglottic region. This form can be nodular or diffuse with narrowing of the lumen. Radiologic signs include nodular and irregular narrowing of airway lumen, airway wall thickening and calcified amyloid deposits [2]. The presence of nodular parenchymal involvement is most frequently found in the localized form of the disease [2, 4]. These nodules tend to be located at the periphery of the lung and are most often multifocal, well-defined and lobulated. They are variable in size ranging from 0.6 to 9 cm [2]. Large nodules may, as in our case, cavitate. Diffuse parenchymal involvement is suspected when fine reticular or reticulonodular opacities are found. They may even be accompanied with alveolar infiltrates [2]. Cyst formation is rare and has been reported in associating with Sj\u00f6gren syndrome accompanied with pulmonary nodules, parenchymal opacities and/or bronchiectasis [4]. Other rare manifestations of pulmonary amyloidosis are lymph node involvement [5] and pleural effusion (mostly due to cardiac amyloidosis)[2]. A chest X-ray normally yields sufficient information about the extent of the pulmonary involvement. A (high-resolution) CT is more sensitive in detecting tracheobronchial involvement and subtle parenchymal lesions. FDG-PET imaging has been used to exclude malignancy in cases of pulmonary nodules in which it has a higher specificity than CT imaging [6]. However, false positive results can occur due to infections, inflammatory disorders and, as in our case, amyloidosis [7]. This makes histologic sampling necessary in establishing a definite diagnosis.",
    "differential_diagnosis": "Localized, pulmonary, amyloidosis, -, nodular, form, Cavitated, lung, metastases, Granulomatous, disease, Rheumatoid, nodules, Septic, pulmonary, embolism",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011988/000002.jpg?itok=gA5ouJ64",
            "caption": "Chest CT images showing multiple peripherally distributed nodules. Some are cavitated. Comparative PET shows FDG-uptake in these nodules. Since there are no pathognomonic radiographic features of pulmonary amyloidosis, a wedge resection was performed."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011988/000003.jpg?itok=iF0hbaeY",
            "caption": "Preoperative chest X-ray (AP and lateral view) showing multiple nodular opacities distributed throughout both lungs."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000011988/000004.jpg?itok=XFnAoz99",
            "caption": "H&E staining (A) shows an amorphous component (arrow) within the normal alveolar morphology. Congo red staining (B) under crossed polarization light (C) demonstrates a yellow-green birefringence. No effect of potassium permanganate (C-D)."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Thoracic wall",
      "Thorax"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT",
      "PET-CT"
    ],
    "link": "https://www.eurorad.org/case/11988",
    "time": "08.10.2014"
  },
  "12032": {
    "case_id": 12032,
    "title": "Askin tumour in a patient with a history of lymphoma in complete remission since 2012",
    "section": "Chest imaging",
    "age": "55",
    "gender": "male",
    "diagnosis": "Askin tumour",
    "history": "A 55-year-old man, diagnosed with stage IA Hodgkin lymphoma in 2000, treated with chemo and radiotherapy, in complete remission since October 2012, presented in the emergency department of our hospital with a clinical history of 1 month with persistent right coastal pain.",
    "image_finding": "PA and lateral chest X-ray showed an extra-pulmonary well-defined, homogeneous lesion with fluid density located in the superior and posterior region of the right hemithorax, without evidence of bone involvement (Fig. 1).Subsequently, a contrast-enhanced chest CT was performed and showed a 72x68x10 mm (APxTxCC) solid, well-defined and heterogeneous\u2014probably with necrotic areas\u2014soft tissue mass in the right upper chest wall, infiltrating the extra-pulmonary fat adjacent to the 4th-5th right intercostal spaces, abutting the major pulmonary fissure (Fig. 2, 3).Two well-defined multilobulated nodules of 9 and 10 mm, in the RUL and LUL, respectively, were also found (Fig. 4).The radiological diagnosis was right extra-pulmonary mass probably secondary to lymphomatous recurrence or metastasis. CT-guided biopsy was performed and the histologic findings were consistent with an extra-skeletal Ewing sarcoma (Fig. 5).",
    "discussion": "Background Askin's tumour (AT) is a type of extra-skeletal Ewing sarcoma of the thoracic region first described by Askin et al in 1979. It grows in the soft tissues of the chest wall or rib cage [1-7] and has, as bone Ewing sarcoma, a neuroectodermal origin. Both of them share the t (11, 22) (q24, q12) chromosomal translocation. [1, 2, 3]Occasionally, it was described in association with Hodgkin lymphoma radiotherapy, because it has been observed that radiotherapy increases the risk of developing solid tumours. The highest risk is in the irradiated region [6, 8].It is more common in children and young adults, although it can occur in any age range. [1, 2, 4-6, 9]Clinical perspective Askin tumour usually presents with an insidious clinical history of chest wall pain, dyspnoea, cough, and can also be associated with weight loss, Horner syndrome, lymphadenopathy and haemoptysis. [1, 3-6, 9]Imaging perspective Chest radiography is usually the first imaging test to be performed and usually shows an extra-pulmonary mass with or without rib destruction (25-63% of cases), malignant pleural effusion and signs of mediastinal and local invasion. Calcifications are rare. Mediastinal lymphadenopathy, hiliar, and pneumothorax are other associated findings. [1, 3, 5]CT usually reveals a large mass of heterogeneous density\u2014due to the presence of areas of cystic degeneration, necrosis or haemorrhage\u2014, which is often associated with rib destruction and pleural effusion. It can have both intra-and extra-thoracic component with extension to the diaphragm, pleura, pericardium, vertebrae and spinal cord [1, 2, 5, 6, 9, 10]. Imaging findings are nonspecific for Askin tumour. The most important role of the CT is to confirm the presence of a mass in the chest wall and estimate its extent [3, 5, 6]. It is also useful to assess treatment response, local recurrence and distant metastases. Likewise, imaging tests have an important role to guide biopsies and to determine whether tumour resection was complete. [6]. The final diagnosis requires biopsy of the lesion and cytological and immunohistochemical study. [4-6]Outcome and take home message Treatment consists of neoadjuvant chemotherapy, surgery and radiotherapy. [1, 3, 7, 9, 10]Askin's tumour is a high-grade malignancy neoplasm with a poor prognosis that should be considered in the differential diagnosis of the diseases of the chest wall. [4-7, 9, 10] Differentiation from lymphoma is crucial because it requires surgical treatment. [6]",
    "differential_diagnosis": "Askin, tumour, Lymphoma, recurrence, Rhabdomyosarcoma, Neuroblastoma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012032/000001.jpg?itok=fAPMbuvb",
            "caption": "PA and lateral view of chest X-ray shows a homogeneous extrapulmonary mass, dependent of the pleura or the soft tissue in the posterolateral upper hemithorax."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012032/000002.jpg?itok=2j-nU3ia",
            "caption": "Lateral view of chest."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012032/000003.jpg?itok=_cmP4xaS",
            "caption": "Thoracic contrast enhanced CT reveals a solid, heterogeneous density, extrapulmonary mass that invades the 4th and 5th right intercostals spaces."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012032/000004.jpg?itok=DF5X9AKF",
            "caption": "Axial images of thoracic contrast enhanced CT show pulmonary nodules in the anterior segments of the right (1 a) and left upper lobes (1 b), probably neoplastic in nature."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012032/000005.jpg?itok=a9JT9Y4r",
            "caption": "Nodule in the left upper lobe."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012032/000006.jpg?itok=qchl2m2n",
            "caption": "CT-guided biopsy was performed."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012032/000007.jpg?itok=pIsc__O8",
            "caption": "VR reconstruction image shows the mass in the right upper hemithorax"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thoracic wall"
    ],
    "imaging_technique": [
      "Image manipulation / Reconstruction",
      "CT-High Resolution"
    ],
    "link": "https://www.eurorad.org/case/12032",
    "time": "30.08.2014"
  },
  "12035": {
    "case_id": 12035,
    "title": "Multiple pulmonary aneurysms in Behcet disease",
    "section": "Chest imaging",
    "age": "50",
    "gender": "male",
    "diagnosis": "Pulmonary aneurysms with thrombosis in Beh\u00e7et disease",
    "history": "A 50-year-old man presented in the emergency department with a 5-month history of fever, weight loss (10 kg), dyspnoea and haemoptysis. The physical examination revealed a concomitant oral ulcer.",
    "image_finding": "Contrast-enhanced chest CT revealed bilateral pulmonary aneurysms which were partially thrombosed (Fig. 1-3).",
    "discussion": "Beh\u00e7et's disease (BD) is a systemic vasculitis of unknown origin, first described in 1937.The venous system is affected most, however, several cases of arterial aneurysms were reported in the literature [1-3].The reported prevalence of pulmonary manifestations ranges from 1 to 7.7% [1].Multisystem involvement is frequent and patients can have ophtalmological, neurological, vascular and dermatological manifestations [4].CT-angiography is an excellent technique of diagnosis. It is a non-invasive technique and allows the exploration of pulmonary arteries highlighting the aneurysmal dilatation and the thrombi in the lumen of these arterial aneurysms. MRI and MRA offer the obvious advantage of multiplanar capability without the need for contrast injection [5].Pulmonary arterial aneurysms are the leading cause of death in patients with Beh\u00e7et's disease, however, pulmonary arterial aneurysms may completely resolve under immunosuppressive therapy [3]. The treatment is based on corticosteroids and endovascular treatment with coils [2].Early detection of pulmonary artery aneurysm in the case of Beh\u00e7et disease can save the patient's life [4].",
    "differential_diagnosis": "Pulmonary, aneurysms, with, thrombosis, in, Beh\u00e7et, disease, Mycotic, pseudoaneurysm, Traumatic, pseudoaneurysm, Tumoural, pseudoaneurysm",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012035/000001.jpg?itok=SNl4cvPu",
            "caption": "Contrast-enhanced CT on mediastinal windowing shows multiple bilateral pulmonary  artery aneurysms partially thrombosed."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012035/000003.jpg?itok=oZ6BX-Je",
            "caption": "Partial thrombosis of bilateral pulmonary artery aneurysms are noted on coronal reformat."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012035/000004.jpg?itok=y3RC00RP",
            "caption": "Thoracic topogram showing bilateral enlarged hila."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Mediastinum",
      "Thorax"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/12035",
    "time": "08.09.2014"
  },
  "12088": {
    "case_id": 12088,
    "title": "Productive cough revealing a rare case of bronchiectasis",
    "section": "Chest imaging",
    "age": "12",
    "gender": "female",
    "diagnosis": "Kartagener syndrome",
    "history": "A 12-year-old female patient presented with fever, productive recurrent cough and yellow sputum.The physical examination showed heart sounds on the right side.Biochemical profile revealed leukocytosis 12000GB/mm3.",
    "image_finding": "The patient had a chest X-ray demonstrating a situs inversus totalis (dextrocardia, right-sided aortic arch, right-sided stomach bubble and suspected left-sided liver). Chest radiograph showed signs of bronchiectasis most marked at the bases associated with tram lining.The chest CT confirmed the situs inevrsus totalis and extensive bronchiectasis.",
    "discussion": "Kartagener syndrome is characterized by the triad of bronchiectasis (lower lobe predominant); sinusitis and situs inversus [1]. Kartagener syndrome belongs to a group of disorders classified as primary ciliary dyskinesias (PCD). It is considered as a rare autosomal recessive disorder which affects the dynein arms in cilia lining the respiratory epithelium and fallopian tubes and within the flagella of sperm [2].Patients present with chronic lower respiratory tract infections, but also sinusitis and otitis media; this infection is caused by the abnormal ciliary function which reduce mucus clearance and this in turn acts as a substrate for the growth of bacteria. The syndrome is associated with infertility due to defective sperm motility [3].The \u201cgold-standard\u201d diagnostic test for PCD has been electron microscopic ultrastructural analysis of respiratory cilia obtained by nasal scrape or bronchial brush biopsy [4].Bronchiectasis is a common finding both on plain radiography and Computed Tomography (especially high resolution CT) associated with situs inversus totalis and sinusitis [1, 2, 3].The main differential diagnosis includes other aetiologies of bronchiectasis depending on the infant age, in the neonatal period including transient tachypnea of the newborn (TTNB), neonatal pneumonia and meconium aspiration, as well as surfactant protein deficiency 128 and interstitial lung disease [4].In our case the Kartagener syndrome was not suspected in the early years of the patient's life; however, the chronic infection of the bronchial tree and the imaging findings were pathognomonic of the syndrome.Early and accurate diagnosis is necessary in order to reduce the incidence of infections and slow the progression of the disease.Physiotherapy is the treatment of choice to clear inspissated mucus. Aggressive measures to prevent respiratory infections and treatment of superinfection are thought to slow disease progression. Patients may require lung or lung/heart transplantation even after treating the recurrent infections [5].The radiologist may suggest the Kartagener syndrome based on a chest radiograph or CT showing the association of situs inversus totalis and bronchiectasis.Early diagnosis can significantly contribute to delaying the disease progression and the onset of respiratory failure.",
    "differential_diagnosis": "Kartagener, syndrome, Cystic, fibrosis, Post-infectious, bronchiectiasis, Other, aetiologies, of, bronchoectasis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012088/000001.jpg?itok=oDiwFiOt",
            "caption": "Chest radiograph demonstrates a situs inversus totalis with dextrocardia and right-sided aortic arch.\nNote the right basal bronchiectasis and the blunting of the right costophrenic angle."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012088/000002.jpg?itok=zs30rC--",
            "caption": "Axial chest CT shows cylindrical bronchial dilatation with mucoid impactions. Note the right lower lobe complete atelectasis."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/12088",
    "time": "01.12.2014"
  },
  "12127": {
    "case_id": 12127,
    "title": "Pulmonary epithelioid haemangioendothelioma - pardon me doctor, but what is that rare mass on my lung?",
    "section": "Chest imaging",
    "age": "64",
    "gender": "female",
    "diagnosis": "Pulmonary epithelioid haemangioendothelioma of the left lower lobe with mediastinal involvement and adrenal metastasis",
    "history": "A 64-year-old female patient presented to our emergency department with progressive cough, asthenia and thoracic pain. On work-up, the WBC count was normal, but the patient had anaemia. Regarding her background, she had a history of hypertension, thyroid nodules, gastritis and was obese.",
    "image_finding": "The patient was admitted for further studies and underwent chest radiography (Fig. 1 a, b) and thoracic CT, which revealed a 7 cm mass in the left lower lobe, extending from the left hilum to the pleura, invading the mediastinum, compressing the pulmonary vessels and bronchi, as well as the left atrium (Fig. 3 a, b, c). This soft tissue mass had no calcifications and demonstrated heterogeneous enhancement. Regarding the remainder of the lung parenchyma, there were also patchy left lower lobe consolidations, all of which had resolved on follow-up examination (Fig. 2). In the upper abdominal scan, there was a 3 cm mass in the left adrenal gland, compatible with metastasis (Fig. 3 e). The patient underwent fiberoptic bronchoscopy with lavage, which was negative for malignant cells. Therefore she subsequently underwent surgical biopsy.",
    "discussion": "We report a rare case of a 64-year old female patient with pulmonary epithelioid haemangioendothelioma (PEH) demonstrating dramatic therapeutic response. PEH is a rare neoplasm which originates from the vascular endothelium of large veins [1, 2]. This tumour was initially considered a variant of bronchogenic carcinoma, but is now recognized as a separate entity, namely the pulmonary counterpart of epithelioid haemangioendothelioma, with low to intermediate grade malignancy. There are scarce reports in the literature and its pathogenesis is unclear. Most cases have been reported in female patients with an age presentation ranging from 12-60 years [2]. Clinically, most patients present with dry cough, dyspnoea, pleuritic pain and rarely haemoptysis, although some may remain completely asymptomatic. On imaging, the typical pattern is characterized by multiple perivascular nodules with well or ill-defined borders, ranging from 3 mm to 3 cm, some of which can have calcification [3]. Atypical patterns include the presence of a large solitary mass, mimicking a bronchogenic carcinoma. Pleural effusion and metastases are rarely seen [1]. Diagnosis is established with immunohistochemical analysis, with positivity for vascular markers such as factor VIII, CD31, CD34 and von Willebrand's antigen [1, 2]. In terms of prognosis and considering the scarce literature reports, it seems to be variable, with a 5-year survival rate estimated at about 60% [1]. There are some indicators of poor prognosis, such as large masses (>3cm), pleural effusion and distant metastases on presentation [2]. Treatment is yet to be standardized, with surgical resection considered in case of solitary nodules or unilateral multiple nodules. Some authors suggest that an increased 18-FDG uptake by the nodules raises suspicion of a malignant lesion and should be regarded as a surgical indication [3]. Chemotherapy is considered the treatment of choice for unresectable or metastatic disease and the results are variable. Our patient underwent a 6-month regimen with etoposide and carboplatin, demonstrating marked regression in lesion size. Other therapeutic options include IFN, anti-oestrogens and progesterone, all of which lead to slight regression in lesion size [2].",
    "differential_diagnosis": "Pulmonary, epithelioid, haemangioendothelioma, of, the, left, lower, lobe, with, mediastinal, involvement, and, adrenal, metastasis, Bronchogenic, carcinoma, Lymphoma, Langerhans, cell, histiocytosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012127/000001.jpg?itok=4f_7c2KD",
            "caption": "Posteroanterior view. There is an irregular opacity at the left perihilar area and left lower lobe, silhouetting the cardiac contour, causing slight upward deviation of the left hilum."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012127/000019.png?itok=Abbo0DVH",
            "caption": "Lateral View. There is an irregular mass in the lower lobe, extending upwards towards the left hilum."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012127/000008.jpg?itok=tZXF9XPw",
            "caption": "Lung Window, axial plane: There is obliteration of the left lower lobar bronchus and inferior segmental lingular bronchus."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012127/000009.jpg?itok=i79pEwmn",
            "caption": "Lung window, axial plane: There is obliteration of the left lower lobar bronchus and inferior segmental lingular bronchus."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012127/000010.jpg?itok=tlsUk2c4",
            "caption": "Lung Window, axial plane: there are subsegmental areas of atelectasis and consolidation in the left lower lobe peripherally."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012127/000011.jpg?itok=aOLqtAcg",
            "caption": "Mediastinal window, axial plane: The soft tissue mass extends into the mediastinum, encasing the left hilar structures and posteriorly abutting the aorta, about 45% of its circumference."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012127/000012.jpg?itok=gG1bz2SK",
            "caption": "Mediastinal window, axial plane: The soft tissue mass is also in contact with the left atrium and ventricle."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012127/000013.jpg?itok=V_0xpNTj",
            "caption": "MPR, coronal view."
          },
          {
            "number": "Figure 3d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012127/000014.jpg?itok=oLFtNqmS",
            "caption": "Mediastinal window, axial plane, contrast-enhanced delayed phase: This is a late phase acquisition, depicting the heterogeneous enhancement of this soft tissue mass."
          },
          {
            "number": "Figure 3e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012127/000015.jpg?itok=3VK3kCUj",
            "caption": "Mediastinal window, axial plane, upper abdomen: There is a 3 cm mass in the left adrenal gland, suggestive of metastatic involvement."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012127/000016.jpg?itok=dUFuiEWi",
            "caption": "Contrast-enhanced chest CT, mediastinal window: There is marked reduction in size of the soft tissue mass. The left hilar structures are clearly seen, although there is still some degree of bronchial calibre stenosis."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012127/000017.jpg?itok=Lne9CEou",
            "caption": "Contrast-enhanced chest CT, mediastinal window."
          },
          {
            "number": "Figure 4c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012127/000018.jpg?itok=V0bVTEmJ",
            "caption": "Contrast-enhanced chest CT - Upper abdomen: follow-up examination shows complete resolution of the 3 cm nodule in the left adrenal gland, indicating response to the implemented treatment."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Thorax"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/12127",
    "time": "18.10.2014"
  },
  "12145": {
    "case_id": 12145,
    "title": "Primary cervico-mediastinal liposarcom",
    "section": "Chest imaging",
    "age": "54",
    "gender": "male",
    "diagnosis": "Cervico-mediastinal well-differentiated liposarcoma",
    "history": "A 54-year-old man with no significant previous clinical history was referred for evaluation of a painless slow growing right latero-cervical mass.",
    "image_finding": "Neck ultrasound revealed a bulky heterogeneous cervico-mediastinal lesion composed by an upper hypoechoic solid component and a lower hyperechoic mass. Chest radiography demonstrated enlargement of the anterosuperior mediastinum with lobulated borders. Contrast-enhanced MRI showed the presence of cervicomediastinal mass composed by an upper component (7 cm) with soft tissue signal intensity and contrast enhancement and lower adipose component (15 cm) with thickened and enhancing septa. The preoperative CT examination that confirmed the presence of a homogeneous low density mediastinal mass with compression of the innominate and the azygos veins with internal mammary ectatic venous collateral pathways and displacement of the epiaortic arterial vessels, thoracic aorta, trachea and oesophagus.An ultrasound-guided biopsy was performed and a well-differentiated sarcoma was diagnosed.At surgery, a large encapsulated mass was removed and the pathological diagnosis was a well-differentiated liposarcoma with inflammatory, sclerosing and lipoma-like components. The patient is now undergoing an adjuvant radiation treatment.",
    "discussion": "A. BackgroundPrimary mediastinal liposarcomas are extremely rare thoracic neoplasms and are classified in four histological types: well-differentiated, myxoid, pleomorphic and dedifferentiated. Well-differentiated liposarcoma is the most common subtype and has the best prognosis [1, 2].B. Clinical PerspectiveMediastinal liposarcoma usually occurs in middle-aged patients and presents with unspecific symptoms such as dyspnoea, cough, chest discomfort or superior vena cava obstruction. At least 15% of patients are asymptomatic. While liposarcoma is the most common retroperitoneal fatty lesion, it is extremely rare in the mediastinum. The more frequent mediastinal fat-containing lesions are germ cell neoplasms, thymolipomas, lipomas, lipomatosis and lipoblastoma [1, 2]. MRI imaging could be useful in the differential diagnosis of a mediastinal fat-containing lesion, in order to distinguish mediastinal liposarcoma from the other more common and less aggressive fatty lesions of the chest. CT is useful in determining the relationship with the other mediastinal components and could help the clinician in the surgical planning.C. Imaging PerspectiveThe usual imaging findings of mediastinal liposarcoma are widening of the mediastinum at chest radiography, sometimes with deviation of the trachea, and a heterogeneous fatty mass with variable enhancing solid component at CT and MRI [1, 2]. Some MR imaging findings are more specifically associated with well-differentiated liposarcoma, such as thickened or nodular septa, associated non-fatty tissue, foci of high T2-signal intensity and contrast enhancement [3]. These imaging features along with the growth rate and the mass effect on the surrounding structure should raise the suspicion of malignancy and help differentiating them from lipomas, the more frequent fatty benign counterpart. D. OutcomeWell-differentiated liposarcomas usually do not metastasize, however, they have high rate of local recurrence (40%) and potential for late dedifferentiation into higher-grade sarcomas [1, 2]. The recommended treatment is surgical excision sometimes with adjuvant radiotherapy to reduce the risk of local recurrence.E. Take Home Message, Teaching PointsEven if mediastinal liposarcoma is a rare neoplasia, it should be taken into consideration in the evaluation of a fatty mediastinal mass. While MRI is useful in solving the differential diagnosis, CT is helpful in the surgery planning.",
    "differential_diagnosis": "Cervico-mediastinal, well-differentiated, liposarcoma, Lipoma, or, lipomatosis, Thymoma, or, thymic, carcinoma, Thyroid, neoplasia, Teratoma, Thymolipoma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012145/000001.jpg?itok=na4YP0-y",
            "caption": "Axial T2-weighted sequence: upper component of the cervico-mediastinal lesion with soft tissue \u2013 signal intensity."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012145/000002.jpg?itok=WiTAinJG",
            "caption": "Axial T2-weighted sequence: both components of the cervico-mediastinal lesion are noted."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012145/000003.jpg?itok=hq5BxtYW",
            "caption": "Axial T2-weighted sequence: lower adipose component of the cervico-mediastinal lesion is noted."
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012145/000004.jpg?itok=tp-2iW6f",
            "caption": "Coronal T1-weighted contrast-enhanced fat-sat sequence: few thickened and enhancing septa in the lower adipose component of the lesion."
          },
          {
            "number": "Figure 1e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012145/000005.jpg?itok=p8vCsXFa",
            "caption": "Sagittal T1-weighted contrast-enhanced fat-sat sequence: cervico-mediastinal mass composed by an upper component with contrast enhancement and lower adipose component with a few thickened and enhancing septa."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012145/000006.jpg?itok=UdTr_TgO",
            "caption": "Axial contrast-enhanced CT:\nhomogeneous low-density cervico-mediastinal mass with displacement of trachea and oesophagus."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012145/000007.jpg?itok=7rpa_qyD",
            "caption": "Axial contrast-enhanced CT: homogeneous low-density cervico-mediastinal mass with compression of the innominated vein and displacement of the supraaortic arterial vessels."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012145/000008.jpg?itok=_cuuQRkb",
            "caption": "Coronal MPR of contrast-enhanced CT."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012145/000009.jpg?itok=9HId7vJ8",
            "caption": "Sagittal MPR of contrast-enhanced CT."
          },
          {
            "number": "Figure 2e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012145/000010.jpg?itok=m5hipsVU",
            "caption": "Axial contrast-enhanced CT: homogeneous low-density cervico-mediastinal mass with compression of the anonym and the azygos veins with ectatic venous collateral pathways."
          },
          {
            "number": "Figure 2f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012145/000013.jpg?itok=M4SvGNas",
            "caption": "Axial contrast-enhanced CT: liver enhancement from ectatic venous (internal mammary vein) collateral pathways."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012145/000015.png?itok=G9JmSG1a",
            "caption": "Neck US hyperechoic component of the cervicomediastinal lesion."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012145/000014.png?itok=lPqY9fO8",
            "caption": "Neck US: hyperechoic component of the cervicomediastinal lesion."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012145/000017.png?itok=TllC2LiC",
            "caption": "Chest radiography: enlargement of the anterior superior mediastinum with lobulated borders."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012145/000018.png?itok=f19-qJW0",
            "caption": "Chest radiography (lateral view)."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Mediastinum",
      "Liver"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "MR",
      "CT",
      "Ultrasound"
    ],
    "link": "https://www.eurorad.org/case/12145",
    "time": "12.11.2014"
  },
  "12183": {
    "case_id": 12183,
    "title": "Right lung atelectasis secondary to endobronchial invasion",
    "section": "Chest imaging",
    "age": "79",
    "gender": "female",
    "diagnosis": "Right main bronchus metastatic invasion",
    "history": "Patient, with known history of metastatic melanoma, with cerebral, paratracheal and right hilar metastasis, presents cough, expectorations and dyspnoea increasing with effort.",
    "image_finding": "The posteroanterior chest radiograph shows right atelectasis (Fig. 1a-b) with mediastinal shift to the right and pleural effusion. Previous chest radiographs and enhanced chest CT showed upper mediastinal enlargement related to the melanoma\u2019s paratracheal metastasis (Fig. 2a-e). Occlusion of the upper right lobar bronchus by metastatic extrinsic compression or endobronchial invasion was suspected. Enhanced chest CT confirmed the progression of the necrotic mediastinal and right hilar mass with distal tracheal and right bronchus tumoral invasion (Fig. 3a-c) leading to complete right lung atelectasis. Invasion of the superior vena cava without complete occlusion was noted (Fig. 3d-e). The mass encased upper lobar branches of right pulmonary artery (Fig. 3d). The stricture was treated by a Y tracheobronchial metal prosthesis. A second non-enhanced chest CT was performed few days later, since the patient developed inspiratory stridor and dyspnoea, which showed sub-occlusive filling of right and left sleeves of the stent (Fig. 4a-b), probably due to mucoid impaction.",
    "discussion": "Atelectasis is collapse of lung tissue, seen on chest radiograph as an opacity with direct and indirect signs, like mainly displacement of fissures, crowding of vessels, diaphragmatic elevation, mediastinal shift and compensatory overinflation. Four mechanisms may be involved such as resorption, relaxation, adhesive and cicatricial atelectasis. The obstructive atelectasis is caused by airway obstruction and resorption of alveolar gas. It occurs more rapidly if patients receive pure oxygen or in presence of endobronchial lesions acting as a one-way valve [1]. The typical clinical presentation of central airway stenosis is stridor and inspiratory bradypnoea, but atypical presentations are frequent.In our case, the stenotic right main bronchus is invaded by a metastatic lesion, which is a frequent cause of airways stenosis. In general, those tumours are inoperable because they are classified as advanced stage [2]. There are many indications for airways stenting, like persistence of secondary or primary malignant tracheobronchial obstruction despite endobronchial dilatation, post-intubation or post-tracheotomy subglottic stenosis in spite of treatment [3]. Our patient was treated with a Y tracheobronchial metal prosthesis because of her late stage. The stent varies in size and the main types are made of silicone, metal or both. Silicone stents are the most frequently used but have the disadvantage to migrate more commonly than the other types, requiring repeated bronchoscopy. Metal stents migrate less frequently but have high risk of perforating due to their expansible force and to block secondary to tumoral or granulation tissue growth [3], usually treated with corticosteroids. Self-expanding metal stents are used when there is an airway stricture which cannot be dilated prior to stent insertion. In our case, the stent was blocked probably secondary to mucoid impaction.Chest radiograph is initially used to diagnose atelectasis [4]. High resolution enhanced chest CT helps in identifying the atelectatic lobe, the cause of atelectasis and to exclude other complications, such as vascular invasion. Bronchoscopy is indicated in patients with an airway stent to ensure appropriate stent positioning and stent patency in case they develop unusual respiratory symptoms. Serious complications such as local inflammation with obstruction of the stent, migration of the stent or airway perforation are rare but must be supported quickly [3]. If the patient is haemodynamically stable and there is enough time, then enhanced high resolution chest CT is required.",
    "differential_diagnosis": "Right, main, bronchus, metastatic, invasion, Neoplasia, Mucus, plug, Post, surgical/interventional, complication",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012183/000001.jpg?itok=Og4QmTBS",
            "caption": "PA chest X-ray."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012183/000010.png?itok=auLFShHJ",
            "caption": "PA chest X-ray shows right atelectasis with mediastinal shift to the right (red arrow)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012183/000003.jpg?itok=kBI4-up9",
            "caption": "Previous PA chest X-ray"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012183/000017.png?itok=lsN5YXoz",
            "caption": "Enlargement of the right paramediastinal band related to the paratracheal metastasis (red arrow)."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012183/000005.png?itok=ROrYDseA",
            "caption": "Contrast-enhanced chest CT-coronal reformat on mediastinal windowing."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012183/000006.jpg?itok=2XDq6qHe",
            "caption": "Upper mediastinal metastasis with para-tracheal band enlargment (red arrow)."
          },
          {
            "number": "Figure 2e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012183/000018.png?itok=GOYuO4cs",
            "caption": "Contrast-enhanced chest CT-coronal reformat on pulmonary windowing with para-tracheal band enlargment (red arrow)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012183/000007.png?itok=pBD_01Vb",
            "caption": "High resolution contrast-enhanced chest CT-axial reformat on mediastinal windowing."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012183/000008.png?itok=LfHVmgs-",
            "caption": "The necrotic mediastinal metastases invade distal trachea and right bronchus (white arrow), with total right pulmonary atelectasis."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012183/000014.png?itok=lrtl_5Tq",
            "caption": "High resolution contrast-enhanced chest CT-coronal reformat on mediastinal windowing with distal trachea and right bronchus tumoral invasion (white arrow)."
          },
          {
            "number": "Figure 3d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012183/000012.png?itok=5ye0GQhf",
            "caption": "High resolution contrast-enhanced chest CT-axial reformat on mediastinal windowing showing invasion of the superior vena cava (red arrow) and occlusion of upper lobar branches of right pulmonary artery (white arrow)."
          },
          {
            "number": "Figure 3e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012183/000013.png?itok=2VA5mc0s",
            "caption": "High resolution contrast-enhanced chest CT-coronal reformat on mediastinal windowing with invasion of the superior vena cava (red arrow)."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012183/000015.png?itok=ugQ-xiyi",
            "caption": "High resolution non-enhanced chest CT-axial reformat on mediastinal windowing, with sub-occlusive filling of right and left sleeves of the stent."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012183/000016.png?itok=9Q4oxbYZ",
            "caption": "Sub-occlusive filling of right and left sleeves of the stent (red arrows), probably on mucoid impactions."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Thorax",
      "Vascular"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT-High Resolution"
    ],
    "link": "https://www.eurorad.org/case/12183",
    "time": "06.12.2014"
  },
  "12255": {
    "case_id": 12255,
    "title": "Congenital atresia of the left pulmonary veins and single right meandering vein",
    "section": "Chest imaging",
    "age": "19",
    "gender": "female",
    "diagnosis": "Congenital atresia of the left pulmonary veins and single right meandering vein.",
    "history": "A 19-year-old woman was diagnosed with bronchial asthma. A chest radiography was undertaken and showed volume loss in left hemithorax with small ipsilateral pulmonary artery and a tubular opacity in the right perihilar area. Chest CT angiography was performed to complete the study.",
    "image_finding": "Chest radiography shows volume loss in left hemithorax with reduced size of the left main pulmonary artery and a serpentine tubular structure in the right medial lobe in a juxta-hilar location suggesting an abnormality in the course of the right pulmonary veins (Fig 1a, b).Angio CT examination reveals congenital atresia of the left pulmonary veins (Fig. 2), with left lung hypoplasia and a small left pulmonary artery (Fig. 3). There is also development of systemic collateral arterial circulation with prominent bronchial and intercostal arteries. Smooth thickened interlobular septa are observed, reflecting pulmonary venous hypertension secondary to the atresia of the left pulmonary veins (Fig. 4). In the right lung, a single right inferior pulmonary vein entering in the left atrium is observed. This single vein is markedly dilated describing a tortuous way (\"meandering vein\u201d), collecting all of the pulmonary vein drainage of the right lung (Fig. 5).",
    "discussion": "Imaging studies confirm a congenital atresia of the left pulmonary veins and the presence of a single meandering vein in the right lung. A) The congenital atresia of the pulmonary veins is a rare congenital anomaly and probably results from a deficiency in the incorporation of the common pulmonary vein into the left atrium. It can occur in either of the two lungs, without predominance of right or left side. This condition is usually diagnosed in childhood and most frequent symptoms include recurrent pulmonary infection, mild dyspnoea, or haemoptysis [1] due to hypertrophy of bronchial arteries. In approximately 50% of patients it is associated with other congenital heart defects or anomalous pulmonary venous return [2]. Multidetector CT is the preferred imaging technique and confirms the suspected diagnosis made in the chest X-ray. The CT findings include: small ipsilateral hemithorax with a small ipsilateral pulmonary artery and absence of any draining ipsilateral pulmonary vein into the left atrium, the left atrial wall being completely smooth, with no evidence of even a rudimentary pulmonary vein [2, 3]. Mediastinal abnormal soft tissue can also be observed representing the pulmonary-to-systemic venous collateral circulation [4]. Pulmonary artery hypoplasia explains the systemic-to-pulmonary collateral arteries observed across the bronchial and intercostal arteries. Interlobular septal thickening, peribronchovascular thickening and ground-glass opacities reflect pulmonary venous hypertension and swollen lymphatic vessels.This case shows the main components of this entity: pulmonary hypoplasia with a small hemithorax associated with ipsilateral mediastinal shift, small ipsilateral pulmonary artery, development of arterial supply through systemic branches, absence of pulmonary venous connection to the left atrium [4] and parenchymal abnormalities such as interlobular septal thickening and peribronchovascular thickening. B) On the other hand, the right lung shows a single pulmonary vein with a meandering course. An anomalous unilateral single pulmonary vein is a single vein that drains only to the left atrium after collecting all pulmonary veins [5]. This failure can also be associated with ipsilateral lung hypoplasia and it should be distinguished from the hypogenetic lung (scimitar syndrome). However, the anomalous vein has a normal drainage in the left atrium [6], so that no bypass occurs. The other entity that should be differentiated is anomalous unilateral single pulmonary arteriovenous malformation. A vein with meandering course does not require treatment, because it is not a vascular shunt. However, the scimitar syndrome and arteriovenous malformation syndrome may require surgery or embolization to correct the shunt.",
    "differential_diagnosis": "Congenital, atresia, of, the, left, pulmonary, veins, and, single, right, meandering, vein., Left, lung, findings:, a), Congenital, atresia, of, the, left, pulmonary, veins, b), Pulmonary, hypoplasia, secondary, to, unilateral, absence, of, the, pulmonary, artery, c), Sywer-James-MacLeod, syndrome, Right, lung, findings:, a), Scimitar, syndrome., b), Single, right, meandering, vein., c), Unilateral, single, pulmonary, arteriovenous, malformation",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012255/000001.jpg?itok=c6VN_yxZ",
            "caption": "A serpentine tubular structure is noted in the medial lobe. In the left lung, loss of lung volume and hypoplasia of the main pulmonary artery are seen."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012255/000002.jpg?itok=Kz4V4FVQ",
            "caption": "A serpentine tubular structure is noted in the medial lobe. In the left lung, loss of lung volume and hypoplasia of the main pulmonary artery are seen."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012255/000003.jpg?itok=RbZRIvjd",
            "caption": "CECT (axial view) shows congenital atresia of the left pulmonary veins."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012255/000004.jpg?itok=Cj75frCP",
            "caption": "CECT (axial view) Left lung hypoplasia and a small left pulmonary artery are noted."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012255/000005.jpg?itok=4TKzs_no",
            "caption": "Smooth thickened interlobular septa are observed."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012255/000006.jpg?itok=LRPQ9AX-",
            "caption": "CECT (MIP reconstruction, oblique view) shows unilateral single pulmonary vein with a meandering course."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Pulmonary vessels"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/12255",
    "time": "15.11.2014"
  },
  "12266": {
    "case_id": 12266,
    "title": "Thymolipoma \u2013 A rare incidental thoracic finding",
    "section": "Chest imaging",
    "age": "78",
    "gender": "male",
    "diagnosis": "Thymolipoma",
    "history": "The patient was referred to further investigate an abnormal radiographic finding. There were no respiratory symptoms and only mild heartburn, interpreted as gastroesophageal reflux and treated with Omeprazole.The patient had normal blood pressure and no fever. Diminished respiratory sounds in the right base were found on auscultation.",
    "image_finding": "Posteroanterior chest radiograph revealed as an incidental finding a well-defined dense area in the lower third of the right hemithorax, silhouetting the right heart border and the right diaphragm (Fig. 1). The findings suggested a mass or combined medial and lower right lobe collapse. No other pulmonary infiltrates were noted. There were no signs of pleural effusion with both costophrenic angles preserved.Contrast enhanced CT of the thorax revealed a large well-defined heterogeneous mass with predominance of fat attenuation values mingled with focal areas of soft tissue density, which extended from the anterior mediastinum to the level of the right diaphragm, displacing the lung superiorly, consistent with thymolipoma (Fig. 2-4). In reformatted oblique MIP a vessel rising from the anterior mediastinum and extending into the mass was seen (Fig. 5).The patient underwent surgical excision of the mass with histological confirmation of a thymolipoma.",
    "discussion": "Thymolipomas are rare benign thymic lesions, accounting for 2-9% of all thymic tumours [1]. There is no recognized sex predilection and reported age ranges between 3-56 years [2].These tumours usually demonstrate slow growth and can reach huge dimensions. Most are asymptomatic. Symptoms, when present, are due to mass effect and compression and include pain, cough or dyspnoea [3]. They can be associated with some autoimmune diseases as myasthenia gravis, systemic lupus erythematosus or Graves disease [4].Frequently an incidental finding in chest radiographs, it presents as a mass that usually drapes over adjacent structures and can simulate cardiomegaly, pericardial masses, atelectasis or pleural effusion. When small, thymolipomas can be limited to the anterior mediastinum.CT findings include a large well-defined mass reflecting the encapsulation of this tumour. The tumour is composed predominantly (50-85%) of fat-attenuated tissue, representing the mature adipose component and focal and linear areas of soft-tissue representing thymic tissue and fibrous septations. Sometimes, as in this case, the thymic origin of the vessels can be demonstrated. No invasive features are seen. The differential diagnosis includes fat-containing lesions such as: teratomas, lipomas and liposarcoma, mediastinal lipomatosis and diaphragmatic hernias [5, 6].Although the imaging characteristics can be quite specific, malignancy cannot always be excluded based on imaging [7] and therefore surgical resection is undertaken, usually by thoracotomy. Recurrence has not been documented.",
    "differential_diagnosis": "Thymolipoma, Lipoma/Liposarcoma, Teratoma, Mediastinal, lipomatosis, Diaphragmatic, hernia",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012266/000001.jpg?itok=QiVsl0wR",
            "caption": "Mass-like opacity in the right lower lung zone silhouetting the right heart border and right diaphragm."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012266/000002.jpg?itok=OGfchce1",
            "caption": "Large heterogeneous supra-diaphragmatic predominantly fat-containing well-defined mass with scattered foci of soft-tissue."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012266/000003.jpg?itok=qg-xRFae",
            "caption": "Well-defined mass extending from the anterior mediastinum to the level of the right diaphragm. No evidence of invasion is seen."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012266/000004.jpg?itok=aTdviu2M",
            "caption": "The mass displaces the lung superiorly and posteriorly. Right lung base subsegmental atelectasis is seen. No signs of invasion."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012266/000005.jpg?itok=b7Q20Qww",
            "caption": "The thymic origin of the vessel that vascularizes the mass can be identified (arrow)."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "CT",
      "Conventional radiography"
    ],
    "link": "https://www.eurorad.org/case/12266",
    "time": "01.12.2014"
  },
  "12282": {
    "case_id": 12282,
    "title": "Invasive thymoma - invading the superior vena cava and right atrium",
    "section": "Chest imaging",
    "age": "57",
    "gender": "male",
    "diagnosis": "Grade III invasive thymoma",
    "history": "A 57-year-old man came with puffiness of the face and upper limbs, cough with minimal expectoration and progressive shortness of breath with dull chest pain for the past 2-3 months with weight loss and anorexia. The patient was a chronic smoker. Routine investigations were normal, so a contrast-enhanced chest CT was advised.",
    "image_finding": "A contrast-enhanced CT thorax revealed an abnormal well-defined lobulated, hypodense, mildly enhancing soft tissue lesion with multiple calcifications within the prevascular space of the anterior mediastinum. There was no evidence of necrosis, cystic areas or variable attenuation ruling out mediastinal germ cell tumours. In the retrosternal area, the lesion was abutting the posterior aspect of the sternum. Multiple collaterals were noted in the right axilla, around the scapula and also in the anterior chest wall (Fig. 2). The lesion was encasing the superior vena cava and the origin of the right brachiocephalic trunk (Fig. 3, 4). It was invading the pericardium and was extending into the right atrium forming an intraatrial polypoidal lesion projecting into the lumen - a very classical finding of invasive thymoma (Fig. 5, 6, 7]. A CT-guided biopsy was performed and histology confirmed the diagnosis of thymoma (Fig. 8).",
    "discussion": "Thymic epithelial tumours are mostly located in the anterior mediastinum, although cases in the neck and posterior mediastinum have been reported.Age of onset is usually 40-60 years. No sex predilection is noted.Clinically, they can present with chest pain, cough, venous obstruction, dysphagia or stridor. Associated conditions are myasthenia gravis, pure red cell aplasia, hypogammaglobulinaemia, systemic lupus erythematosus (SLE), rheumatoid arthritis, etc. Thymic tumours are classified into non-invasive thymoma and invasive thymoma and carcinoma (Fig. 1). According to Masoka's classification, our patient had Stage III thymoma and WHO classification C. Macroscopically thymic tumours are of variable shape, with thymoma being typically rounded with a bosselated outer surface and lack of histologic evidence of malignancy [1].CT imaging: One of the important\u2014though challenging\u2014roles of CT is to determine local tumour invasiveness. This is crucial, as tumour invasiveness has been shown to strongly correlate with prognosis and dictate the therapeutic approach.Thorough MRI vascular involvement can be investigated without the use of intravenous contrast agents, however, the disadvantage of a lengthy procedure and poor investigation of the lung parenchyma outweighs its rationale in comparison to computed tomography. Thus, if the aetiology of the anterior mediastinal mass is not known, a complete investigation of it by MRI is not optimal and CECT is preferred as it covers the evaluation of the lung parenchyma [2]. Studies assessing the evaluation of thymoma with FDG-PET modality are small, but the data is not promising. Although FDG uptake was found to be much higher in thymic cancer than thymoma, the amount of uptake, or as it is termed standardized uptake value (SUV), overlaps between low-grade and high-grade thymomas.Treatment depends on the stage as well as the presence of myasthenia gravis, which mandates earlier surgical excision. For thymoma, local excision usually suffices and complete excision results in cure. For invasive thymoma, surgery may still be contemplated if complete excision is thought possible. If not, then down-staging with preoperative chemotherapy may be employed. Radiotherapy is not usually employed for stage I thymoma, but has a role in both post-surgical management of resected invasive thymoma or for inoperable invasive tumours, including thymic carcinoma. Our patient was advised chemotherapy to downsize the tumour, after which tumour resection was performed with cardiopulmonary bypass.",
    "differential_diagnosis": "Grade, III, invasive, thymoma, Thymic, carcinoma/, invasive, thymoma, invading, the, superior, vena, cava, and, the, right, atrium, Mediastinal, germ, cell, tumour, Thyroid, carcinomas, extending, into, the, mediastinum, Lymphoma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012282/000001.jpg?itok=vQtKKG_H",
            "caption": "WHO classification of thymoma"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012282/000007.gif?itok=foTRLWdo",
            "caption": "Masoka staging of thymoma that governs the disease prognosis."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012282/000002.jpg?itok=sio8p3ta",
            "caption": "The lesion in the anterior mediastinum is seen to invade the superior vena cava and extend into the right atrium.\nThe superior vena cava is compressed and shows no enhancement."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012282/000003.jpg?itok=sOMwBQ5c",
            "caption": "Multiple collaterals were noted in the right axilla and around the scapula and also the anterior chest wall."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012282/000004.jpg?itok=wbLBtMmF",
            "caption": "The lesion was seen invading the superior vena cava and the root of origin of the right brachio-cephalic trunk."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012282/000005.jpg?itok=LBmx-ylS",
            "caption": "The lesion was seen to invade the pericardium and extend into the right atrium forming an intraatrial polypoidal lesion projecting intraluminally."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012282/000006.jpg?itok=BL69rV6A",
            "caption": "Right atrial extension of the lesion is a classic finding in thymoma."
          }
        ]
      },
      {
        "number": "Figure 7",
        "subfigures": [
          {
            "number": "Figure 7",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012282/000008.jpg?itok=Fcfv0nwF",
            "caption": "On sagittal reformat the invasion of the superior vena cava and intraatrial extension is noted abutting and encasing the arch of aorta."
          }
        ]
      },
      {
        "number": "Figure 8",
        "subfigures": [
          {
            "number": "Figure 8",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012282/000009.jpg?itok=OWvGZv0r",
            "caption": "Histology revealing a large number of lymphocytes with absent atypia amongst the normal thymic cortical tissue."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Veins / Vena cava",
      "Mediastinum",
      "Management"
    ],
    "imaging_technique": [
      "CT",
      "CT-High Resolution"
    ],
    "link": "https://www.eurorad.org/case/12282",
    "time": "09.05.2015"
  },
  "12305": {
    "case_id": 12305,
    "title": "Acute ascending thoracic aortic rupture due to penetrating atherosclerotic ulce",
    "section": "Chest imaging",
    "age": "68",
    "gender": "female",
    "diagnosis": "Ascending Thoracic Aorta Penetrating Ulcer",
    "history": "A 68-year-old female went to the emergency department because of dizziness, with no dyspnoea or thoracic pain. She was hypotensive, with diminished peripheral pulses. After beginning fluid replacement, she became cyanotic and developed severe sinusal bradycardia first and asystole minutes later. The patient recovered quickly after continuous chest compression.",
    "image_finding": "A chest radiograph and computed tomography (CT) were requested in order to exclude acute pulmonary thromboembolism and acute aortic disease. The chest radiograph showed widened mediastinum and cardiac silhouette (figure 1). Contrast-enhanced CT scan showed no filling defects in the pulmonary arteries and main branches, excluding acute pulmonary thromboembolism. However, pericardial effusion with near 70 Hounsfield Units (HU) was found, as well as stranding of the mediastinal fat, predominantly at the level of aortic-pulmonary window and Barety space (figure 2, 3). Evaluation of the thoracic aorta revealed a 9 mm outpouching of the ascending thoracic aorta, suggesting an atherosclerotic penetrating ulcer and an intramural hematoma (figure 4, 5). Due to the presence of haemorrhagic pericardial effusion and probable hemomediastinum, acute aortic rupture was presumed. The diagnosis was surgically proven.",
    "discussion": "A penetrating atherosclerotic ulcer (PAU) is an ulcerating atherosclerotic lesion that penetrates the elastic lamina and is associated with hematoma formation. It is more commonly found in the middle or distal third of the thoracic aorta. In the ascending aorta, PAU is uncommon because rapid flow from the left ventricle provides protection against atherosclerosis(1-4).While confined to the intimal layer, an atherosclerotic ulcer tends to be asymptomatic. These ulcers may progress to deep lesions that penetrate the elastic lamina and extend to the media, usually associated to hematoma formation. Hematoma typically develops within the media of the aortic wall and may present as a \u201cdouble-barreled\u201d or a \u201cthrombosed\u201d aortic dissection, the first demonstrating a communication between the true and false lumen, and the second one (more prevalent) showing no opacification of the false lumen. A saccular aneurysm is often found as a consequence of stretching of the weakened aortic wall. Both dissection and aneurysm may rupture (1-3,5-7).PAU is typically a condition of elderly hypertensive men and remains silent until rupture occurs. Clinical rupture presentation is unspecific, usually with acute chest, retrosternal or interscapular pain. No clinical distinction is possible between PAU, aortic dissection, and aortic rupture (2-6,8). These entities may therefore be distinguished through imaging analysis, essentially using computed tomography (CT) and magnetic resonance imaging (MRI) (1,9). Angiography is no longer considered a first-line choice for diagnosis purposes. Transesophageal echocardiography may be also used but is operator dependent and is not accessible in all centers (1,10).CT with angiographic study is usually the first choice, due to short acquisition times and possibility of multiplanar reconstruction. CT identifies a focal outpouching of the arterial internal contour, typically with adjacent parietal hematoma. Intimal calcifications may be found interiorly to the hematoma. Aortic wall thickening and enhancement may be also found (1-3,5). MRI has some advantages when compared to CT: lack of ionizing radiation and possibility of getting multiplanar imaging without using contrast material. Moreover, MRI is apparently superior to CT in differentiating acute intramural hematoma from non-acute conditions like stable atherosclerotic plaques and chronic intraluminal thrombus (1).However, CT has important advantages in the emergency setting. It is a more accessible and faster technique, also allowing differential diagnosis with other acute thoracic conditions.The most widespread treatment for PAU is medical therapy. Surgery is performed in patients who have hemodynamic instability, persistent pain, aortic rupture, distal embolization, or rapid enlargement of the aortic diameter (4,11).",
    "differential_diagnosis": "Ascending, Thoracic, Aorta, Penetrating, Ulcer, Acute, aortic, rupture, Penetrating, atherosclerotic, ulcer, Aortic, dissection, Acute, pulmonary, thromboembolism, Cardiac, tamponade, Acute, heart, failure, Acute, coronary, syndrome",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012305/000001.jpg?itok=YO66qDPN",
            "caption": "Widened mediastinum and enlargement of the cardiac silhouette."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012305/000002.jpg?itok=FVEYvEt2",
            "caption": "Hyperattenuating pericardial effusion with near 70 HU (ROI, region of interest)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012305/000003.jpg?itok=aheriTbu",
            "caption": "Hyperattenuating intramural hematoma in the ascending thoracic aorta (74 HU, ROI). Pericardial hemorrhagic effusion (blue arrow) and stranding of the mediastinal fat planes (red arrow) are also seen."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012305/000004.jpg?itok=zBq0MZRc",
            "caption": "Penetrating ulcer in the asscending thoracic aorta (blue arrow) with surrounding intramural hematoma, seen as a peripheral hyperattenuating crescent (black arrow)."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012305/000005.jpg?itok=VldLcaKu",
            "caption": "Penetrant ulcer in the ascending thoracic aorta."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Emergency"
    ],
    "imaging_technique": [
      "CT-Angiography"
    ],
    "link": "https://www.eurorad.org/case/12305",
    "time": "19.12.2014"
  },
  "12312": {
    "case_id": 12312,
    "title": "Sternal foramen",
    "section": "Chest imaging",
    "age": "78",
    "gender": "male",
    "diagnosis": "Sternal foramen",
    "history": "A 78-year-old man with clinical history of pulmonary nodules came for a follow-up chest CT examination.",
    "image_finding": "Analysis of the axial images with coronal and sagittal reformation (Fig. 1 a-c) shows a defect on the body of the sternum at the level of the insertion of the 4th and 5th costal arches. This bone defect has 22 mm on the largest axis and is filled with fat density tissue (Fig. 1 d) that is contiguous with epicardial fat. The defect is surrounded by well-corticalized sternum.Figure 2 shows a volume rendering of the sternum where the bone defect is evident.Apart from pulmonary nodules no other significant alteration was noticed.",
    "discussion": "The normal sternum is a bone composed by three segments: the manubrium, body and xyphoid process. Sternum development starts with the fuse at midline of two mesodermic plates that give rise to six centres of ossification. The ossification and fusing of bone segments starts at the most cranial centre, the manubrium, and progress caudally [1]. A defect of ossification or fusing on the lower third of the body of the sternum can lead to a so called sternal foramen [1, 2]. This anatomical variation has a prevalence of around 6% in some autopsy and CT series [3, 4]. Association of this defect to displacement of the heart, midline abnormalities and accessory fissures on the left lung have been reported [5].This defect might be confused with a bullet hole or even with a bone lesion [4, 6].Complications of otherwise safe procedures such as acupuncture or bone marrow aspiration have been reported in individuals with this variant [6]. One example in the literature is a fatal heart tamponade after the insertion of an acupuncture needle over the lower third of the body of the sternum which, due to the presence of a strenal foramen, pierced the right ventricle [7]. Acknowledging the existence of sternal foramen is of key importance to the radiologist so as not to mistake this anatomical variant for a bone lesion. It is also fundamental to the clinician to be aware of its existence and to search for it before performing bone marrow aspiration on the lower portion of the body or even acupuncture.",
    "differential_diagnosis": "Sternal, foramen, Normal, variant, Lytic, lesion",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012312/000001.jpg?itok=BLpv6DGm",
            "caption": "Axial"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012312/000002.jpg?itok=N7nKoYg6",
            "caption": "Coronal"
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012312/000003.jpg?itok=SjGshCIt",
            "caption": "Sagittal"
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012312/000005.jpg?itok=LwU0d5iV",
            "caption": "Axial in soft tissue window"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012312/000004.jpg?itok=ypVQdWIN",
            "caption": "3D rendering of the sternum showing the defect."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Bones",
      "Musculoskeletal bone"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/12312",
    "time": "04.02.2015"
  },
  "12313": {
    "case_id": 12313,
    "title": "CT findings in Rhodococcus equi lung infection: a case report and a review of the literature",
    "section": "Chest imaging",
    "age": "42",
    "gender": "male",
    "diagnosis": "Rhodococcus equi pneumonia",
    "history": "We present a case of a 42-year-old man with chest pain, purulent sputum and dyspnoea that persisted for several days. The patient reported a substantial weight loss. HIV test was positive and CD4 T-cell count was 30 cells/\u03bcL. A chest CT was performed.",
    "image_finding": "Non-enhanced chest CT showed two mass-like consolidations with internal cavitations and air-bronchograms in the right upper and lower lobes, respectively (Fig. 1, 2). Apart from multiple variable-sized cavitary lesions, confluent consolidations were also evident bilaterally (Fig. 1). Both consolidations and cavitary lesions presented irregular contours.Other findings included focal or coarse ground glass opacities, predominantly surrounding the cavitated consolidations, and also in apical and basal regions of both lungs (Fig. 1).Neither pleural nor pericardial effusion was evident. Some enlarged mediastinal lymph nodes were detected with short axis from few millimetres to 20 mm, the largest subcarinal (Fig. 1). Sputum cultures yielded pleomorphic, gram-positive coccobacilli that were identified as Rhodococcus equi.",
    "discussion": "Rhodococci are aerobic, Gram-positive, nonmotile, catalase-positive actinomycetes that infect primarily immunocompromised patients [1]. R. equi was identified as the cause of an enzootic pneumonia in foals in 1923 and the first R. equi infection in a human was not reported until 1967 [2, 3]. To date, about 300 cases have been reported in the English literature. Increases in prevalence of human R. equi disease during the past 30 years seem to coincide with the HIV epidemic, advances in transplant medicine and cancer chemotherapy. No specific risk factors have been associated with infection in immunocompetent people. R. equi is thought to be acquired by either inhalation from the soil, inoculation into a wound or mucous membrane, or ingestion and passage through the alimentary tract. However, only one-third of all patients with R. equi infection have a history of exposure to horses or pigs [4, 5, 6]. Patients may present with infection at a single site or at multiple sites, the most frequent extrapulmonary manifestations include gastrointestinal infections, pericarditis, meningitis, and abscesses in the liver, kidney, psoas muscles, and contaminated cutaneous wounds [5]. Donisi et al. described 12 HIV-infected patients with R. equi infection with a mean CD4 count of 47 cells/\u03bcL [7]. In our patient, no previous history of contact with farm animals was certain, no sites of extrapulmonary involvement were detected and his CD4 T-cell count was 30 cells/\u03bcL. Only few reports are dedicated to CT findings of Rhodococcus equi pneumonia. The most common CT findings of R. equi infection consist of multiple and large consolidations with or without cavitations, ground-glass opacities, nodules and a tree-in-bud pattern, and there seems to be a preference towards the superior lobes of both lungs. Pleural effusion, empyema and mediastinal lymphadenopathy may also be present [8, 9, 10]. Infrequently Rhodococcus equi causes pericarditis and pericardial effusion [11]. In our case, the principal findings of Rhodococcus equi pulmonary involvement are represented by bilateral large and small consolidations, predominantly with cavitations, and ground glass opacities. CT plays a crucial role in achieving a prompt diagnosis and helping reducing significant morbidity and mortality by avoiding under-diagnosis of this lung infection.",
    "differential_diagnosis": "Rhodococcus, equi, pneumonia, Pulmorary, tuberculosis, Lung, carcinoma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012313/000001.jpg?itok=fLMQGCqv",
            "caption": "Lung window: bilateral focal areas of ground glass opacity in both upper lobes and a subsegmental area of air-space  consolidation in the right upper lobe."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012313/000002.jpg?itok=7mUQTm-K",
            "caption": "Lung window: multiple cavities, sometimes confluent, with irregular walls are shown bilaterally. A large necrotic consolidation with fluid level is noted in the right lower lobe."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012313/000003.jpg?itok=yUCHhdvp",
            "caption": "Lung window: bilateral small nodular lesions and ground glass opacities. Several small cavities in right basal segments. Subsegmental atelectasis of the middle lobe is evident."
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012313/000004.jpg?itok=l3j5myQ0",
            "caption": "Mediastinal window: mildly enlarged mediastinal lymph nodes are noted."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012313/000005.jpg?itok=yKYSr68b",
            "caption": "Lung window: a large consolidation with small areas of cavitation in the right upper lobe (*), a large cavitated consolidation occupying the right superior lower and posterior upper lobes (**), bandlike collapse of the middle lobe (***)."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/12313",
    "time": "05.02.2015"
  },
  "12321": {
    "case_id": 12321,
    "title": "Mediastinal pancreatic pseudocyst",
    "section": "Chest imaging",
    "age": "50",
    "gender": "male",
    "diagnosis": "Mediastinial pancreatic pseudocyst",
    "history": "A 50-year-old male patient with a known history of recent pancreatitis presented with increasing thoracic discomfort over a time course of 4-5 weeks. No other relevant past medical history was of note. He was then initially evaluated with a chest CT examination followed by a abdominal CT examination which demonstrated the following.",
    "image_finding": "Initial CT chest examination (Fig 1a, b and c) shows a cluster of multiple well-defined thick walled inter-communicating low attenuating collections within the posterior mediastinum many of which appear to contain intervening incomplete septations. These surround and partially compress the oesophagus and extend along the length of the posterior mediastinum with the superior-most aspect extending to the level of the T4 vertebra. There is a loculated thick-walled left pleural effusion with adjacent left basal atelectasis. Concurrently performed CT abdomen (Fig 2a, b and c) demonstrates a large amount of ascites as well as findings compatible with the known pancreatitis. Similar appearing communicating collections (pseudocysts) also noted in the central peri-pancreatic region. The patient's pancreatitis was treated with antibiotics and supportive therapy with good clinical improvement. Repeat CT follow-up CT chest examination (Fig 3) shows near-complete resolution of both the complex mediastinal collections as well as the left pleural effusion.",
    "discussion": "In view of overall CT findings, background clinical context and considering resolution of changes with treatment of pancreatitis, the diagnosis of a resolved mediastinal pancreatic pseudocyst was made.Background: While pancreatic pseudocysts are a common complication of pancreatitis, only rarely do they extend into the mediastinum [1-2]. A pseudocyst represents an encapsulated collection of pancreatic secretions, blood, and necrotic material. A mediastinal pseudocyst almost always initially occurs in the lower part of the posterior mediastinum, having gained access to the chest via the oesophageal or aortic hiatus. It may extend superiorly [4]. Clinical perspective: The clinical presentation can be variable and dependent on the location and size, patients may present with combination of symptoms such a dyspnoea, chest pain, palpitations, or dysphagia. Additional uncommon symptoms can include haemoptysis, acute respiratory compromise or cardiogenic shock [3].Imaging perspective: The presence of a cystic posterior mediastinal mass that develops over a short time (over four weeks under the current Atlanta classification) in a patient with evidence of pancreatitis is likely to be a pseudocyst. A CT examination would allow best appreciation of anatomy and often shows one or more cystic, low-attenuation masses in the posterior mediastinum or adjacent thoracic cavity associated with compression or displacement of the oesophagus or splaying of the diaphragmatic crura. Cyst content can be iso-attenuating or hyper-attenuating relative to water, dependent on the presence of factors such as haemorrhage and / or infection [4]. They almost always tend to be located in the lower part of the posterior mediastinum [5]. An abdominal component is common but is not invariably present. Therefore concurrent abdominal imaging would be of value in evaluation of such cases. In unclear cases an aspiration could be performed although this was not performed in our case due to initial clinical improvement with antibiotic and supportive therapy.Outcome:Management options can be variable and can range from watchful waiting for spontaneous regression to medical therapy to drainage (internally or externally with endoscopic, percutaneous, or open surgical approach techniques) [6]. Spontaneous regression of mediastinal pancreatic pseudocysts is rare but has been occasionally reported [7]. This was also demonstrated in this case.Teaching points: This case highlights the typical CT imaging features of a mediastinal pancreatic pseudocyst and shows a situation where resolution occurred with a conservative non-interventional approach.",
    "differential_diagnosis": "Mediastinial, pancreatic, pseudocyst, Necrotic, mediastinal, lymphadenopathy, Infected, bronchogenic, cyst, Infected, oesophageal, duplicated, cyst",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012321/000001.jpg?itok=u2QR5QSq",
            "caption": "Selected axial CT image shows multiple well-defined thick walled inter-communicating low attenuating collections within the posterior mediastinum surrounding and partially compressing the oesophagus. A complex thick walled left posterior basal effusion also seen."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012321/000002.jpg?itok=Zkxr854G",
            "caption": "Selected coronal CT image further demonstrates the anatomical relationships of the mediastinal collections at well as its cranio-caudal extent."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012321/000003.jpg?itok=VLHLBdDZ",
            "caption": "Selected sagittal CT image further demonstrates anatomical relationships of the mediastinal collections at well as its cranio-caudal extent."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012321/000004.jpg?itok=tZgon9yP",
            "caption": "Axial CT abdominal image showing largely necrotic pancreatic gland with two peri-pancreatic pseudocysts and a large volume of ascites."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012321/000005.jpg?itok=sNP7Ikzr",
            "caption": "Coronal CT abdominal image showing largely necrotic pancreatic gland with two peri-pancreatic pseudocysts and a large volume of ascites."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012321/000006.jpg?itok=5CV0ja4h",
            "caption": "Coronal CT abdominal image showing largely necrotic pancreatic gland with two peri-pancreatic pseudocysts and a large volume of ascites."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012321/000007.jpg?itok=YSsx3iF2",
            "caption": "Follow up CT examination 8 weeks later demonstrates near-complete resolution of the mediastinal cystic lesions as well as the left basal pleural effusion."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax",
      "Abdomen"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/12321",
    "time": "15.01.2018"
  },
  "12322": {
    "case_id": 12322,
    "title": "Missed adenoid cystic carcinoma of the trache",
    "section": "Chest imaging",
    "age": "38",
    "gender": "female",
    "diagnosis": "Adenoid cystic carcinoma of the trachea",
    "history": "A 38 year-old lady was initially diagnosed with bilateral pulmonary emboli. Despite anticoagulation she remained breathless with palpitations. Repeat CTPA showed almost complete resolution of the pulmonary emboli but discovered an incidental tracheal mass. She underwent subsequent rigid bronchoscopy and tracheal resection.",
    "image_finding": "Initial CTPA showed pulmonary emboli in the left and right pulmonary arteries (figure 1). Despite several months of anticoagulation, the patient was still breathless. Repeat CTPA showed almost complete resolution with just minor residual thrombus within the proximal aspect of the right upper lobe branch. However, within the proximal trachea just above the level of the aortic arch there appeared to be a soft tissue ingrowth into the tracheal lumen reducing its calibre (figure 2-4). The mass was extending directly from the left lateral tracheal wall with a maximal dimension of 2.7cm. In retrospect these appearances were missed on the earlier CTPA. The patient was admitted for a tracheal resection with histology confirming a grade 2 adenoid cystic tracheal carcinoma with extra-tracheal spread but no lymph node involvement. After additional chemotherapy and radiotherapy follow up CTPA showed complete resolution of the pulmonary emboli with no residual tracheal tumour.",
    "discussion": "Primary malignant tracheal neoplasms are rare, accounting for less than 0.1% of cancer deaths per year [1]. In adults, the majority are squamous cell carcinomas with only 10% being adenoid cystic carcinomas (ACCs). ACCs classically arise from seromucinous glands including the tracheobronchial tree. More than 50% of patients with ACC have metastases, with pulmonary deposits being the most common and lymphatic spread the least [2].Patients diagnosed with ACC present with symptoms comparable to airway obstruction, such as cough, wheeze, stridor and dyspnoea. Subsequently, many patients are incorrectly treated for asthma or PE before a diagnosis of ACC is made [3]. In our case the lesion was missed on a previous CTPA. Despite PE being the main diagnosis to exclude on CTPA, care should be taken in analyzing the central airways and ensuring optimum imaging technique. Conventional CT protocol is not ideal for diagnosing tracheal tumours as it may miss small lesions. MDCT imaging is considered the gold standard allowing visualization of luminal involvement, structural position of the tumour with precise volume acquisition and multiplanar image display [4]. ACC commonly arises at the distal trachea and laryngeal involvement is extremely rare. They typically present as an intraluminal soft tissue mass with diffuse or circumferential tracheal wall extension on CT. The longitudinal extent of tumour involvement needs to be correctly defined as this affects operability and planning of resection margins; reformatted thin section CT may help here [5].MRI can also be used to delineate tracheal tumour extension into tissue planes and vascular anatomy [6]. X-rays are generally unhelpful but rarely, subtle oligaemia secondary to reflex vasoconstriction may be the only clue to a proximal airway tumour. The main cornerstone of diagnosis is via bronchoscopy.Complete surgical resection provides the best chance of prolonged survival or even complete remission. Post-operative radiotherapy is recommended and is shown to have some effect on local control but does not usually influence survival rate. This case emphasizes potential problems in diagnosing a tracheal tumour as its symptoms overlap with more common airway diseases. To compound the problem further, tracheal lesions are commonly missed by radiologists [7]. As the central airways are a rare place to discover malignancy, they represent a possible blind-spot and so vigilance is needed in scrutinizing them on every CT chest examination. Initially missed tracheal lesions lead to a delay in diagnosing ACC, making potentially resectable lesions complex to treat with fatal outcomes.",
    "differential_diagnosis": "Adenoid, cystic, carcinoma, of, the, trachea, Neoplasm-squamous, cell, carcinoma, (most, common, primary, tracheal, malignancy)/, adenoid, cystic, carcinoma, (second, most, common, tracheal, malignancy), Other, malignancy-squamous, cell, papilloma/, mucoepidermoid, carcinoma/, adenocarcinoma/chondrosarcoma/tracheal, leiyomoma/leiomyosarcoma, Non, neoplastic-, Tuberculosis/, inflammatory, fibro-epithelial, polyp.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012322/000003.jpg?itok=NSi3B3Um",
            "caption": "Axial CTPA image showing large pulmonary emboli in the left and right pulmonary arteries. The main pulmonary artery is also enlarged with hepatic vein contrast reflux and straightening of the interventricular septum-right heart strain"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012322/000004.jpg?itok=FhBgOPBZ",
            "caption": "Axial CTPA image showing a soft tissue ingrowth into the tracheal lumen above the level of the aortic arch. This mass has caused the tracheal lumen to reduce its calibre by about 50 percent."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012322/000006.jpg?itok=WCUoCGN8",
            "caption": "Sagittal CTPA reconstructed image in soft tissue windows demonstrating the tracheal mass. Note that there is almost complete resolution of the previously noted large central pulmonary emboli."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012322/000008.jpg?itok=q6hIUtJ4",
            "caption": "Sagittal CTPA reconstructed image in lung windows, demonstrating the tracheal mass."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012322/000007.jpg?itok=cWSzP8do",
            "caption": "Coronal CTPA reconstructed image in lung windows demonstrating the tracheal mass. It is extending directly from left lateral tracheal wall with a maximal dimension of 2.7cm. No pleural effusion or enlarged hilar lymph nodes seen."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012322/000009.jpg?itok=VObGfrAY",
            "caption": "Coronal CTPA reconstructed image in soft tissue windows demonstrating the tracheal mass."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/12322",
    "time": "24.12.2014"
  },
  "12325": {
    "case_id": 12325,
    "title": "Mycobacterium avium intracellulare-related immune reconstitution inflammatory syndrome (IRIS) in HIV",
    "section": "Chest imaging",
    "age": "46",
    "gender": "male",
    "diagnosis": "Mycobacterium avium intracellulare-related immune reconstitution inflammatory syndrome in HIV",
    "history": "A middle-aged male with newly diagnosed Human Immunodeficiency Virus (HIV) infection (CDC stage C3, 13/mmc CD4+ cells), oropharyngeal candidiasis and Pneumocystis jirovecii pneumonia was initiated on combined antiretroviral treatment (ART), with rapid improvement of CD4+ cell count (50/mmc) and stopped viral replication after one month.",
    "image_finding": "At diagnosis, radiographs (Fig. 1) and body CT (Fig. 2) showed sparse ground-glass attenuation changes in the left lung, without lymphadenopathy. During ART, repeated radiographs (Fig. 3) and CT (Fig. 4) a month later, moderately enlarged, homogeneous mediastinal nodes were seen. The largest measured 2.5-3 cm at the left hilum and subcarinal region. Progressive clinical worsening with unexplained fever occurred. Three months after ART initiation, radiographs (Fig. 5) and CT (Fig. 6) showed further enlargement of mediastinal nodes with central necrotic hypoattenuation, causing right-sided tracheal deviation and a confluent subcarinal mass, plus left-sided lower lobe and lingular consolidations. Mediastinoscopic nodal biopsy revealed chronic granulomatous inflammation without neoplasia. Sputum and bronchial aspirate cultures revealed Mycobacterium avium intracellulare infection. Clinical course, laboratory and imaging findings were interpreted as consistent with immune reconstitution syndrome. Introduction of steroids and antimycobacterial chemotherapy allowed clinical recovery and radiologic (Fig.7) regression of pulmonary infiltrates and tracheal deviation.",
    "discussion": "In most HIV-infected patients, antiretroviral therapy (ART) results in restored immune response, decreased frequency of opportunistic infections, and prolonged survival. However, despite suppressed viral replication and increasing CD4+ cell counts, after ART introduction a subpopulation experiences immune reconstitution syndrome (IRIS) which involves clinical and imaging deterioration due to an exaggerated, dysregulated immune response against a previously subclinical infection (\u201cunmasking\u201d IRIS) or a previously treated pathogen (\u201cparadoxical\u201d IRIS) [1, 2].The overall incidence of IRIS has been estimated at 10-32% of patients. The most common form is by far tuberculosis-associated IRIS in resource-poor developing countries. Although less common, IRIS may occur in patients treated for Mycobacterium avium or other nontuberculous mycobacteria. Alternatively IRIS may result from exacerbation of herpes zoster, cryptococcosis, toxoplasmosis or bacterial pneumonia [1-3].Risk factors for developing IRIS include low (<200 cells/microL) baseline CD4+ count; virological response (decreasing plasma HIV-RNA levels) after ART; increased antigenic burden of an opportunistic infection before ART, particularly disseminated or extrapulmonary mycobacteriosis; early initiation of ART after treatment of opportunistic infections. Most (80-90%) cases occur within 3 months (median of 2 to 8 weeks) from ART introduction, regimen switching or restart [1, 2].Heavily dependent on the underlying infection, clinical manifestations of IRIS include fever, weight loss, lymphadenopathy, hepatosplenomegaly, cough and respiratory impairment, arthritis and cutaneous lesions in descending order of frequency. Diagnosis of IRIS requires temporal relationship between symptoms and initiation of therapy, virological response and immunological restoration (increasing CD4+ count from baseline), symptoms and signs consistent with an inflammatory process and exclusion of differential diagnoses [1-4]. Imaging findings of mycobacterial-related IRIS in HIV include new or worsening intrathoracic lymphadenopathies (commonly with central hypoattenuating necrosis and causing tracheal narrowing), parenchymal infiltrates or widespread pulmonary nodules, enlarged celiac, retrocrural and retroperitoneal nodes, sometimes tiny hepatosplenic or iliopsoas abscesses [3-5]. Clinically, IRIS may range from self-limiting cases to severe morbidity, but mortality is uncommon. Prevention involves early ART initiation before advanced immunosuppression and thorough screening for clinically silent opportunistic infections. Treatment involves temporary ART discontinuation, corticosteroids or nonsteroidal anti-inflammatory drugs, and pathogen-specific therapy [1, 2].Due to the increased life expectancy of HIV patients, IRIS is becoming an increasingly encountered phenomenon, which frequently leads to hospital admission and should be considered in all patients whose condition unexpectedly deteriorates after ART, particularly those with previously treated mycobacterial infections. Diagnosis requires awareness of IRIS and of its imaging features, coupled with clinical correlation [4, 5].",
    "differential_diagnosis": "Mycobacterium, avium, intracellulare-related, immune, reconstitution, inflammatory, syndrome, in, HIV, Antiretroviral, treatment, failure, /, Patient, non-compliance, Failed, treatment, of, opportunistic, infection, Reactivated, tuberculosis, Bacterial, pneumonia, Fungal, infection, Non-Hodgkin, lymphoma, Sarcoidosis, Castleman\u2019s, disease, Drug, interactions, or, toxicity",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012325/000001.jpg?itok=TAd3Vbc8",
            "caption": "At diagnosis of HIV infection with oropharyngeal Candidiasis and Pneumocystis jirovecii pneumonia, chest radiograph did not show abnormal pleuropulmonary and hilo-mediastinal changes."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012325/000002.jpg?itok=5lYWSfuG",
            "caption": "At diagnosis of HIV infection with oropharyngeal Candidiasis and Pneumocystis jirovecii pneumonia, chest radiograph did not show abnormal pleuropulmonary and hilo-mediastinal changes."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012325/000004.jpg?itok=vV1jDfr3",
            "caption": "At diagnosis of HIV infection, body CT showed sparse ground-glass attenuation changes in the left lung (arrowheads) consistent with Pneumocystis jirovecii pneumonia."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012325/000003.jpg?itok=7PiUX7lv",
            "caption": "Body CT showed sparse ground-glass attenuation changes in the left lung (arrowheads) consistent with Pneumocystis jirovecii pneumonia, small-sized mediastinal, upper cervical and retroperitoneal lymph nodes (thin arrows)."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012325/000005.jpg?itok=c44e4knW",
            "caption": "Note small-sized mediastinal, upper cervical and retroperitoneal lymph nodes (thin arrows), with homogeneous attenuation and transverse diameter &lt;11 cm."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012325/000006.jpg?itok=eYjyDU5e",
            "caption": "Note small-sized mediastinal, upper cervical and retroperitoneal lymph nodes (thin arrows), with homogeneous attenuation and transverse diameter &lt;11 cm."
          },
          {
            "number": "Figure 2e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012325/000007.jpg?itok=HCLlJWRX",
            "caption": "Note small-sized mediastinal, upper cervical and retroperitoneal lymph nodes (thin arrows), with homogeneous attenuation and transverse diameter &lt;11 cm."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012325/000008.jpg?itok=2xyCCEhS",
            "caption": "A month later, after initiation of antiretroviral therapy repeated chest radiographs revealed left hilar prominence (arrowheads in A) suggestive of hilar and lower mediastinal lymphadenopathy (+ in B)."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012325/000009.jpg?itok=tqG67R-x",
            "caption": "A month later, after initiation of antiretroviral therapy repeated chest radiographs revealed left hilar prominence (arrowheads in A) suggestive of hilar and lower mediastinal lymphadenopathy (+ in B)."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012325/000010.jpg?itok=Fo_1RJIX",
            "caption": "A month later, after initiation of antiretroviral therapy repeated CT showed moderate enlargement of several mediastinal lymph nodes with preserved homogeneous attenuation (thin arrows)."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012325/000011.jpg?itok=ZGRtMo81",
            "caption": "A month later, after initiation of antiretroviral therapy repeated CT showed moderate enlargement of several mediastinal lymph nodes with preserved homogeneous attenuation (thin arrows)."
          },
          {
            "number": "Figure 4c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012325/000013.jpg?itok=LwFz3n9u",
            "caption": "A month later, after initiation of antiretroviral therapy repeated CT showed moderate enlargement of several mediastinal lymph nodes with preserved homogeneous attenuation (thin arrows)."
          },
          {
            "number": "Figure 4d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012325/000014.jpg?itok=cC53bTup",
            "caption": "Prominent (2-3 cm) left hilar (arrow) and subcarinal lymphnodes (+) were detected, with preserved homogeneous attenuation."
          },
          {
            "number": "Figure 4e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012325/000023.jpg?itok=Z8b0s1sm",
            "caption": "Furthermore, moderate enlargement of the dominant interaortocaval node was seen as the only significant finding in the abdomen."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012325/000016.jpg?itok=A3WMbbDY",
            "caption": "Follow-up chest radiographs showed right-sided tracheal deviation (arrow), persistent left hilar prominence (arrowhead),  lower mediastinal lymphadenopathy (+), and left lung basal infiltrate."
          },
          {
            "number": "Figure 5b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012325/000017.jpg?itok=jlAO8FsS",
            "caption": "Follow-up chest radiographs showed right-sided tracheal deviation (arrow), persistent left hilar prominence (arrowhead),  lower mediastinal lymphadenopathy (+), and left lung basal infiltrate."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012325/000018.jpg?itok=S44dOme3",
            "caption": "Follow-up CT showed further  significant enlargement of most mediastinal lymphnodes (thin arrows) with central hypoattenuation, causing right-sided tracheal (*) deviation."
          },
          {
            "number": "Figure 6b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012325/000019.jpg?itok=PuxNr9dV",
            "caption": "Follow-up CT showed further  significant enlargement of most mediastinal lymphnodes (thin arrows) with central hypoattenuation, causing right-sided tracheal (*) deviation."
          },
          {
            "number": "Figure 6c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012325/000020.jpg?itok=noDlwj_2",
            "caption": "Severely enlarged subcarinal mass, with internal multiloculated hypoattenuated ares consistent with confluent necrotic lymphadenopathy. Develpment of left perihilar, lower lobe and lingular pulmonary consolidations (arrowheads)."
          },
          {
            "number": "Figure 6d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012325/000021.jpg?itok=yMmXCi99",
            "caption": "Severely enlarged subcarinal mass, with internal multiloculated hypoattenuated ares consistent with confluent necrotic lymphadenopathy. Develpment of left perihilar, lower lobe and lingular pulmonary consolidations (arrowheads)."
          },
          {
            "number": "Figure 6e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012325/000022.jpg?itok=yM2Rj9Xs",
            "caption": "Develpment of left perihilar, lower lobe and lingular pulmonary consolidations (arrowheads)."
          }
        ]
      },
      {
        "number": "Figure 7",
        "subfigures": [
          {
            "number": "Figure 7a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012325/000024.jpg?itok=DZJ9zO7K",
            "caption": "After clinical recovery, chest X-rays showed subtotal regression of left lower lobe pulmonary infiltrate and of tracheal deviation, persistent hilar and lower mediastinal adenopathies (+)."
          },
          {
            "number": "Figure 7b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012325/000025.jpg?itok=S4f6Ynug",
            "caption": "After clinical recovery, chest X-rays showed subtotal regression of left lower lobe pulmonary infiltrate and of tracheal deviation, persistent hilar and lower mediastinal adenopathies (+)."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/12325",
    "time": "05.01.2015"
  },
  "12326": {
    "case_id": 12326,
    "title": "Thoracic South American blastomycosis (paracoccidioidomycosis)",
    "section": "Chest imaging",
    "age": "58",
    "gender": "male",
    "diagnosis": "South American blastomycosis (paracoccidioidomycosis)",
    "history": "A 58-year-old man from Santa Catarina (Brazil), who worked as a farmer, presented to the emergency department with symptoms of chronic cough and low-grade fever for over one year.",
    "image_finding": "Chest radiograph shows patchy multifocal opacities and nodules of various sizes in both lungs (Fig. 1). CT shows multiple nodules (Fig. 2 a)\u2014some of which are cavitated (Fig. 2 d)\u2014ground glass opacities (Fig. 2 b, d) and foci of air space consolidation (Figures 2 c, d).",
    "discussion": "Paracoccidioidomycosis is the most frequent endemic systemic mycosis in Latin America [1]. It is caused by the fungus Paracoccidioides brasiliensis.It is more common in men, and those at greatest risk are the ones who come in contact with soil in endemic regions, such as farmers [2]. Infection with P. brasiliensis is acquired in the first two decades of life, by inhalation of the fungus. The evolution to active disease is uncommon in the first years after exposure (acute/juvenile form). It is more common in adults aged 30 and 50 years as reactivation of a latent endogenous focus (chronic/adult form) [3]. The lung is the most commonly affected organ (50-100% of cases) but mucocutaneous lesions are also frequent [4]. The chronic form, which accounts for 90% of cases, is also most commonly associated to pulmonary symptoms/lesions. Pulmonary involvement is rare in the acute form [4].Pulmonary symptoms are nonspecific and variable. Patients with the chronic form may be asymptomatic initially but usually progress to severe chronic cough, intense dyspnoea, chest pain and haemoptysis [4]. Chest radiographic abnormalities are frequently multiple and nonspecific and include linear and reticular opacities, nodules, patchy ill-defined opacities, airspace consolidation and cavitation [4].Though the CT findings are also nonspecific (ground-glass attenuation areas, multiple nodules [3], consolidations, interlobular septal thickening and fibrotic lesions [4]) CT may help assessing the extension of the lesions and the response to therapy. Patterns include those of bronchopneumonia, nodules with or without cavitation and miliary disease.Diagnosis can be confirmed by blood analysis or isolation of the fungus in biologic specimens (e.g. examination of sputum, bronchoalveolar lavage fluid or biopsy of lesions) [4]. In this patient the diagnosis was based on examination of sputum. Treatment involves antifungal medications such as Itraconazol and is essential for avoiding progression of the disease and complications such as pulmonary fibrosis.Awareness of paracoccidioidomycosis' multiple radiologic manifestations, clinical features and epidemiology are essential requirements for an early diagnosis. Paracoccidioidomycosis should always be considered a possibility in patients living in or travelling from endemic areas not responding to conventional antibiotic regimes. The chronic form can occur many years after patients have left an endemic area.",
    "differential_diagnosis": "South, American, blastomycosis, (paracoccidioidomycosis), Histoplasmosis, Coccidioidomycosis, Tuberculosis, Other, blastomycoses",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012326/000003.jpg?itok=qioRdymb",
            "caption": "Despite its technical limitations (presence of Bucky lines) this Radiograph shows patchy multifocal opacities and nodules of various sizes."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012326/000008.jpg?itok=P3jHteSz",
            "caption": "Nodules of variable size are seen. They represent inflammatory exudates filling alveolar spaces."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012326/000009.jpg?itok=QO7ZdDSV",
            "caption": "Ground-glass opacity areas (arrows) are suggestive of active inflammation."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012326/000010.jpg?itok=9lJivpDJ",
            "caption": "Though nonspecific, multiple foci of consolidation are typical of paracoccidiomycosis. Both lungs show air-space consolidation with air bronchograms (arrows)."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012326/000011.jpg?itok=hKBuZDMX",
            "caption": "HRCT features are similar to other pulmonary blastomycosis: multiple foci of air space consolidation (blue arrows), ground glass opacities and nodules (some of which are cavitated - yellow arrow) and tree-in-bud opacities (white arrow)."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Respiratory system",
      "Lung"
    ],
    "imaging_technique": [
      "CT",
      "CT-High Resolution"
    ],
    "link": "https://www.eurorad.org/case/12326",
    "time": "05.02.2015"
  },
  "12349": {
    "case_id": 12349,
    "title": "Hepato-pulmonary hydatidosis",
    "section": "Chest imaging",
    "age": "63",
    "gender": "female",
    "diagnosis": "Hepatic-pulmonary hydatidosis",
    "history": "A 63-year-old woman, non-smoker, with unremarkable history, appeared with two-week symptoms consisting of fever, cough, expectoration, haemoptysis and general malaise. Biochemical analysis showed leukocytosis and eosinophilia, as well as elevation of transaminase.",
    "image_finding": "At the emergency room a chest radiograph showed a right lower lobe well-defined opacity (Fig. 1a). On the lateral view the opacity was limited anteriorly by the major fissure and inferiorly by the diaphragm (Fig. 1b).Computed tomography (CT) revealed a low attenuated (<20UH) well-defined mass, with irregular borders, in the right lower lobe with peripheral enhancement (Fig. 2). On the abdominal CT two well-defined cystic masses were identified. The right lobe cyst was a homogeneous hypoattenuated (<20UH) lesion with a peripheral calcified capsule (Fig. 3a) and the left one had a heterogeneous content, with hyperdense internal membranes (Fig. 3b). Coronal CT reconstruction supported the similar appearance of thoracic and abdominal lesions (Fig. 4).",
    "discussion": "Hydatid disease (HD) is a parasitic zoonosis acquired by humans secondary to the ingestion of food contaminated with Echinococcus granulosus eggs or by direct contact with contaminated dogs [1]. In Europe HD is uncommon and usually seen in immigrants or after traveling to endemic areas [2]. The ingested embryos (oncospheres) pass through the duodenal mucosa to the portal vein where they are captured by the hepatic capillaries; here they may die or grow into hepatic cysts (HCs). Some of the oncospheres may escape from the hepatic capillaries and infect distant organs [2].The most frequently affected organs are the liver and the lungs; the spleen, brain, retroperitoneum, kidneys, heart, muscles and skeleton are involved less commonly. Lungs are the most frequently affected organ in children [3]. The coexistence of hepatic and pulmonary disease occurs only in 6% of patients [2].HD is often asymptomatic, but large lung cysts may develop symptomatology such as irritating cough and haemoptysis; liver cysts can obstruct bile ducts causing jaundice [1]. Radiological signs are important because of the varied symptomatology and Echinococcus serology is positive only in 25% of infected patients on initial stages [1]. Hepatic cysts may have different imaging findings; from simple cysts to solid-appearing pseudotumours. HCs can be solitary or multiple and are located most frequently in the right hepatic lobe. Cysts may show a thick capsule, wavy internal bands or septa representing delaminated endocyst or present daughter cysts. Peripheral focal areas of calcification are present in up to 50% of cases [2]. On MRI the cystic wall is hypointense on T1- and T2-weighted images (WI). The cyst content appears hypointense on T1-WI, with marked hyperintensity on T2-WI; daughter cysts are hypointense or isointense relative to the cyst content on T1- and T2-WI [1, 2]. The walls and the cyst internal septal enhance after intravenous contrast administration.Lung infection occurs by trans-diaphragmatic migration of a hepatic cyst or by haematogenous route. Imaging features include a well-defined solitary cystic lesion, or less frequently multiple lesions, found mainly in the lower lobes. Cyst may change in shape according to the adjacent structures. Computed tomography shows a cystic lesion with hypodense content and a thick capsule that enhances after contrast administration [3]. HD complications include cyst rupture, which occurs in up to 50-90%, and bacterial superinfection. Indicated treatment is Albendazol but larger cysts may require surgical resection in combination with Albendazol [4].",
    "differential_diagnosis": "Hepatic-pulmonary, hydatidosis, Cystic, metastasis, Pyogenic, abscess",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012349/000001.jpg?itok=UE_Sn4nh",
            "caption": "Postero-anterior chest  radiograph shows a homogeneous, well-defined opacity in the right lower lobe (arrow)."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012349/000002.jpg?itok=v4xiyP1p",
            "caption": "Lateral view shows a mass in the right lower lobe, abutting the major fissure anteriorly (arrow) and the diaphragm inferiorly."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012349/000003.jpg?itok=Qz45UU0Z",
            "caption": "Unenhanced CT axial image shows a well-defined hypoattenuated mass (&lt;20UH) in the right lower lobe, with irregular borders (arrow)."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012349/000004.jpg?itok=0krYN7KO",
            "caption": "Contrast-enhanced CT axial image demonstrates a low attenuated (&lt;20UH) heterogeneous mass in the right lower lobe, with peripheral enhancement (arrow)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012349/000005.jpg?itok=nNwzicF9",
            "caption": "Unenhanced CT shows a large well-defined cystic lesion in the right hepatic lobe with peripheral calcified capsule (arrow)."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012349/000006.jpg?itok=OmiGnUuS",
            "caption": "Contrast-enhanced CT, shows a well-defined heterogeneous cystic lesion (arrow) in the left hepatic lobe with hyperdense internal detached membranes."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012349/000007.jpg?itok=kMspn1B7",
            "caption": "Contrast-enhanced coronal reconstruction shows pulmonary (white arrow) and hepatic (black arrow) cystic masses. The liver cyst shows peripheral ring enhancement and unattached internal cyst membranes, at the superior part of the cyst."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax",
      "Abdomen",
      "Lung"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/12349",
    "time": "05.01.2015"
  },
  "12385": {
    "case_id": 12385,
    "title": "Congenital segmental bronchial atresia in a young female patient with confirmatory dual energy CT perfusion imaging",
    "section": "Chest imaging",
    "age": "36",
    "gender": "female",
    "diagnosis": "Left upper lobe segmental bronchial atresia",
    "history": "We present a 36-year-old lady with an insidious onset of shortness of breath and abnormal chest X-ray.",
    "image_finding": "An initial chest X-ray at presentation demonstrated an abnormal opacity in the left upper lobe thought to represent infection (Fig. 1). The opacity persisted on follow-up chest X-ray six weeks later (Fig. 2), prompting further evaluation with CT to characterize the lesion.Contrast-enhanced CT thorax revealed a focal non-enhancing tubular mucocoele with surrounding hyperlucent lung and hyperinflation involving the apico-posterior segment of the left upper lobe (Fig. 3, 4, 5). The remainder of the lung parenchyma was normal. A subsequent multiplanar dual energy CT lung perfusion study demonstrated increased volume of the left hemi-thorax with marked segmental hypoperfusion of the apico-posterior segment of the left upper lobe (Fig. 6).",
    "discussion": "Congenital bronchial atresia (CBA) is a rare condition that occurs when a proximal segmental bronchus is absent, rarely this may occur at a lobar level [1]. The distal bronchial tree is preserved, which leads to under-ventilation and accumulation of mucus in the affected segment [1, 2]. On a chest radiograph, this classically manifests as a focal tubular opacity with a hyperlucent area, which can potentially compress adjacent tissue [2]. Hyperinflation is caused by the unidirectional flow of air from the surrounding lung parenchyma into the affected segment. This is facilitated by tiny inter-alveoli and bronchiolar-alveoli tracts (pores of Kohn and canals of Lambert, respectively) [2, 3]. The absence of a patent bronchus means there is no outflow tract for air or mucus produced by the respiratory epithelium, which leads to the formation of the characteristic bronchocoele/mucocoele. The apicoposterior segment of the left upper lobe is involved most frequently [1]. Of note, CBA and congenital cystic adenomatoid malformation frequently coexist [3]. CT is the most sensitive radiological method for diagnosing CBA. Typical findings include the triad of a mucocoele, surrounding low attenuation hyperinflated lung and hypoperfusion of the affected segment [1, 2]. Dual energy CT is a relatively novel functional imaging technique, which has predominantly been used in the investigation of pulmonary embolism but is also useful in characterising other causes of lobar or segmental hypoperfusion, as in this case [4].CBA is generally a benign condition and usually does not require any treatment [2]. It is often discovered incidentally, is typically asymptomatic, and is more common in men. The mean age of diagnosis is 17 years of age [1]. The differential diagnosis includes other abnormalities with mucus impaction, such as allergic bronchopulmonary aspergillosis, cystic fibrosis, or any lesion that causes bronchial narrowing and thus mucus impaction.Recurrent pulmonary infection is the most common clinical manifestation in symptomatic patients. Bronchoscopy is often required to rule out secondary causes of proximal bronchial obstruction i.e. tumours, foreign bodies or inflammatory strictures [2]. Surgery may be indicated where malignancy cannot be excluded or in the setting of recurrent and severe infection [4]. CBA is suitable for full endoscopic pulmonary resection if surgical intervention is indicated, given the young and otherwise fit demographic group it affects [5].",
    "differential_diagnosis": "Left, upper, lobe, segmental, bronchial, atresia, Other, causes, of, mucoid, impaction:, Allergic, bronchopulmonary, aspergillosis, Endobronchial, neoplasm, Arteriovenous, malformation, Intralobar, sequestration, Congenital, lobar, emphysema, Intrapulmonary, bronchogenic, cyst",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012385/000001.png?itok=Jo6xybUR",
            "caption": "Admission chest X-ray demonstrating a tubular opacity in the left upper lobe. A hyperlucent area is seen surrounding the tubular opacity."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012385/000004.png?itok=3RNlKoVk",
            "caption": "Contrast-enhanced CT demonstrates focal non-enhancing tubular low attenuation mucocoele in the left upper lobe."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012385/000007.png?itok=WqbOHdH8",
            "caption": "Further axial dual energy CT lung perfusion study demonstrates marked segmental hypoperfusion of the apico-posterior segment of the left upper lobe. Normal perfusion demonstrated in the right upper lobe."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012385/000008.png?itok=8d51xPlx",
            "caption": "Follow up chest X-ray 6 weeks later demonstrating persistent left upper lobe tubular opacity (arrow) with surrounding hyperlucent area."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012385/000009.png?itok=y86sMCKp",
            "caption": "Axial contrast-enhanced CT thorax on lung windows shows focal mucocoele (arrow) and surrounding hyperlucent lung in the left upper lobe."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012385/000010.png?itok=dg4-eKqo",
            "caption": "Hyperlucent lung noted surrounding the mucocoele (arrow) affecting the apico-posterior segment of the left upper lobe. The remainder of the lung parenchyma is normal."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax",
      "Abdominal wall",
      "Respiratory system",
      "Lung"
    ],
    "imaging_technique": [
      "CT",
      "Conventional radiography",
      "CT-Quantitative"
    ],
    "link": "https://www.eurorad.org/case/12385",
    "time": "20.04.2015"
  },
  "12392": {
    "case_id": 12392,
    "title": "Diffuse idopathic pulmonary neuroendocrine hyperplasia (DIPNECH)",
    "section": "Chest imaging",
    "age": "60",
    "gender": "female",
    "diagnosis": "Diffuse idopathic pulmonary neuroendocrine hyperplasia (DIPNECH)",
    "history": "A 64-year-old female non-smoker was referred for CXR to investigate a longstanding cough. The CXR identified numerous nodules at that time and an increase in the nodularity and interstitial shadowing was seen on a CXR 5 years later. CT performed 5.5 years later confirmed multiple nodules.",
    "image_finding": "Initial CXR (Fig. 1), showed a few tiny nodules bilaterally and prominent bronchial markings. No follow up.Subsequent CXR 5 years later (Fig. 2), showed an increase in the number of lung nodules and a CT was advised. No follow up.HRCT since the most recent CXR showed small randomly distributed nodules/bronchial wall thickening/mosaic perfusion (Fig. 3, 4), which are the most common findings in this entity [1, 2]. No enlarged lymph nodes were present in the chest. Whole body CT was performed to look for primary malignancy, which confirmed bilateral lung nodules\u2014the largest measuring 8 mm in the left upper lobe\u2014(Fig. 4) and mosaic perfusion (Fig. 4, 5). No thoracic lymphadenopathy.Mammogram was also normal.The patient was referred to the regional centre for open lung biopsy via video-assisted thoracic surgery (VATS) to characterise the bilateral lung nodules and possible primary malignancy. Histology showed diffuse idiopathic pulmonary neuroendocrine hyperplasia (DIPNECH) (Fig. 6, 7).",
    "discussion": "DIPNECH is a diagnosis of exclusion and is increasingly being recognised as a cause for multiple lung nodules, which were histologically confirmed in our case. Chronic cough in a female patient is the usual clinical scenario for DIPNECH [3].It is standard practice to explore the possible primary malignancy in a patient with multiple lung nodules. Review of old imaging is helpful especially in knowing that there has been no past malignancy or any other medical condition that could explain multiple lung nodules.Imaging showing small airway disease and lung nodules, which are present for a long time, should raise the possibility of an alternative diagnosis in a patient with no known malignancy.Further imaging with octreotide/MIBG imaging is possible but probably not an established practice.Histology confirmation is the gold standard. In this case pathology showed neuroendocrine cell hyperplasia within small airways and several carcinoid tumourlets present in a bronchiolocentric distribution and fibrosis. This was confirmed by positivity for neuroendocrine immunohistochemical markers (CD56, synaptophysin and chromogranin) and TTF1.This is an important diagnosis to make as it is a precursor to lung carcinoid tumourlet, but currently there are no established guidelines for follow-up and treatment strategies vary, ranging from medical management with inhalers to lung transplant [4].Take home message from this case is that in cases where multiple lung nodules are not secondaries from a known primary, a review of all old imaging and histology confirmation with biopsy could change things for the patient for the better.",
    "differential_diagnosis": "Diffuse, idopathic, pulmonary, neuroendocrine, hyperplasia, (DIPNECH), Lung, metastases, Hypersensitive, pneumonitis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012392/000005.jpg?itok=84Vy3yze",
            "caption": "Low power microscopy of the 8 mm nodule which shows a typical carcinoid tumour."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012392/000006.jpg?itok=1psM8nc1",
            "caption": "High power microscopy shows a bronchiole completely obliterated by fibrosis (red arrow) by neuroendocrine hyperplasia (blue arrow)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012392/000007.jpg?itok=2ifwWAo8",
            "caption": "High power microscopy showing partial involvement of a bronchiole (blue arrow) by neuroendocrine cell hyperplasia (red arrow)."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012392/000008.jpg?itok=iBZNSzLU",
            "caption": "Axial CT lung window image"
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012392/000009.jpg?itok=dlq1eVHz",
            "caption": "Coronal CT showing apical nodules and mosaic perfusion."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012392/000010.jpg?itok=3qcSGNur",
            "caption": "Initial CXR shows subtle interstitial markings. Also note nodules in right lower and left upper lobes."
          }
        ]
      },
      {
        "number": "Figure 7",
        "subfigures": [
          {
            "number": "Figure 7",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012392/000011.jpg?itok=OvdVZvDt",
            "caption": "Follow-up CXR after 5 years shows increased interstitial markings. Also note nodules in right lower and left upper lobes which are largely unchanged."
          }
        ]
      },
      {
        "number": "Figure 8",
        "subfigures": [
          {
            "number": "Figure 8",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012392/000012.jpg?itok=PbceaZjZ",
            "caption": "Coronal CT showing multiple nodules of similar size bilaterally with interstitial thickening and mosaic perfusion."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT",
      "Digital radiography",
      "RIS"
    ],
    "link": "https://www.eurorad.org/case/12392",
    "time": "09.04.2015"
  },
  "12428": {
    "case_id": 12428,
    "title": "Vanishing lung syndrome",
    "section": "Chest imaging",
    "age": "35",
    "gender": "male",
    "diagnosis": "Vanishing lung syndrome",
    "history": "A 35-year-old male patient presented to the emergency department complaining of acute breathlessness. The patient reported a history of on and off dyspnoea with worsening of symptoms on strenuous activity. There were no other respiratory complaints. The patient had been a smoker for the past ten years.",
    "image_finding": "Chest radiograph showed markedly hyperlucent right lung with few thin septae. An area of lucency was also seen in the left upper lobe (Fig. 1). High resolution Computed Tomography was performed, which revealed several large thin-walled bullae involving almost the whole of the right lung with compressed normal lung parenchyma in the lower lobe. Few smaller subpleural bullae were also seen in the upper lobe of left lung associated with paraseptal and centrilobular emphysema in the adjacent lung parenchyma (Fig. 2, 3). No pneumothorax was seen.",
    "discussion": "Giant bullous emphysema also known as \u201cVanishing lung syndrome\u201d or \u201cType 1 bullous disease\u201d was first described by Burke in 1937 [1]. He described a case of vanishing lungs with multiple giant bullae occupying both the hemithoraces. Later Roberts and his colleagues defined the imaging criteria for vanishing lung syndrome as giant bulla involving at least 1/3rd of one or both lungs and compressing the surrounding normal lung parenchyma on radiographs [2]. The disease is usually bilateral and asymmetrical [3]. Coexisting paraseptal emphysematous changes are also usually seen. Patients are usually young men with a longstanding history of smoking [4]. The disease occurs only rarely in non-smokers. Association with alpha-1 antitrypsin deficiency has been described. The condition usually presents with dyspnoea or chest pain due to increasing size of the bullae but occasionally may be detected in asymptomatic individuals. Few of the cases may present with pneumothorax due to rupture of the bullae. Chest roentgenogram is usually the initial investigation and may reveal asymmetric hyperlucent lungs. HRCT images confirm the diagnosis and provide preoperative assessment of severity and extent of the disease. The most common HRCT findings are multiple large bullae in both lungs. The bullae range from in size from few centimetres to very large dimensions almost filling the entire lung [5]. Occasionally it may be difficult to differentiate between a large bulla and a pneumothorax on HRCT. Double wall sign (air seen on both sides of the bulla wall) may be used to differentiate between the two conditions [6].  Complications include secondary infection of the bullae and rupture of bullae leading to pneumothorax. It is extremely difficult to detect pneumothorax, which develops in patients with this condition. Asymptomatic cases are managed conservatively. In symptomatic patients, bullectomy results in marked improvement of symptoms.",
    "differential_diagnosis": "Vanishing, lung, syndrome, Pneumothorax, Obliterative, bronchiolitis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012428/000009.jpg?itok=AHy_M_Kf",
            "caption": "CT scanogram shows diffusely hyperlucent right lung with a thin septa in the lower lung. No vascular markings are visible. Left lung appears relatively normal."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012428/000003.jpg?itok=hkoUp8rJ",
            "caption": "Axial CT (on lung windowing) shows large bulla in right upper lobe. Note paraseptal and centrilobular emphysematous changes in left upper lobe."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012428/000004.jpg?itok=lHiDf6OW",
            "caption": "Axial CT at a lower level than Fig. 2a shows similiar findings in the right lung and in addition to that large paraseptal bullae are noted in the left upper lobe."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012428/000005.jpg?itok=2M73RSdP",
            "caption": "Axial CT below the level of carina shows few large bullae with thin septae in the right lung with adjacent compressed normal lung parenchyma."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012428/000006.jpg?itok=0KpVd6Hf",
            "caption": "Note that the bullae occupy more than two-thirds of the right lung."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012428/000007.jpg?itok=KX-4s5Na",
            "caption": "Findings similiar to Figure 3a."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012428/000008.jpg?itok=VPJDbi9R",
            "caption": "Few large subpleural bullae are also seen in the left lung."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT-High Resolution"
    ],
    "link": "https://www.eurorad.org/case/12428",
    "time": "16.02.2015"
  },
  "12479": {
    "case_id": 12479,
    "title": "M &amp;amp; M (Mediastinal Mass) \u2013 When rare is really rare!",
    "section": "Chest imaging",
    "age": "65",
    "gender": "male",
    "diagnosis": "Saphenous vein graft aneurysm after coronary artery bypass grafting.",
    "history": "A 65-year-old man presented to the emergency department with dyspnoea and chest pain.The patient had a previous history of coronary artery bypass grafting (CABG) 16 years before, hypertension, hyperlipidaemia under pharmacological control, and 20 pack years of active smoking.General physical examination was unremarkable.",
    "image_finding": "Chest radiograph showed cardiomegaly and a rounded left perihilar mass with loss of silhouette sign with the left heart border. Previous sternotomy is noted (Fig. 1).Computed tomography (CT) of the thorax presented a low-density mass on the left side of middle compartment of the mediastinum measuring 6 x 7 cm (Fig. 2). This lesion extended from the level of the aortic arch to the left atrium (Fig. 3). Post iodinated contrast administration, the lesion showed enhancement of a central zone within a peripheral low-density and non-enhancing area, in keeping with a vascular lesion with parietal thrombus (Fig. 5). Extensive calcification of the native coronary arteries is seen (Fig. 3) with coronary bypass grafts extending from the aorta and the anterior descending coronary artery, right coronary artery (Fig. 3) and left circumflex coronary artery (Fig. 4).The mass compressed the main and left pulmonary arteries (Fig. 5).",
    "discussion": "In the reported case the differential diagnosis of the lesion includes a wide range of entities such as lymphadenopathy aortic arch aneurysm, enlarged pulmonary artery, fore-gut duplications cysts (bronchogenic, oesophageal, neuroenteric), pericardial cysts, and tracheal lesions [1, 2, 3].On contrast-enhanced CT the lesion was shown to be connected directly with an ascending aorta side branch and continuing with the left circumflex coronary artery. Taking in account the history of a previous 16-year CABG, this lesion is consistent with an aneurysm of a saphenous vein graft. Saphenous vein graft aneurysm (SVGA) is an uncommon complication of CABG and can be asymptomatic or manifest as cardiac ischaemic events like chest pain or worsening dyspnoea due to graft thrombosis or distal embolism [4-8].This type of aneurysms can be categorised as true aneurysms and pseudo- or false aneurysms. The major distinction is that true aneurysms occur in 10-20 years after surgery [4, 6, 7] and are usually fusiform, while pseudoaneurysms occur early in the post-operative period, are located near anastomotic sites between the graft and the native artery and are typically saccular in shape [4, 5, 6]. This distinction is important because while true aneurysms will require surgery [4, 8], pseudoaneurysms may be successfully treated with minimally invasive procedures such as covered stent placement or coil embolisation.The aetiology of true and false SVGA is unclear, but risk factors for its development include post-operative infection, tight suture anastomoses, suture dehiscence, trauma to the vessel during harvest, intrinsic weakness in venous walls at branching points or valve attachment, grafting of varicose veins, steroid therapy, as well as the typical atherosclerotic disease risk factors, such as hyperlipidaemia, smoking and hypertension [4, 6, 7, 8].In the reported case, the giant aneurysm has a fusiform shape, comprises the mid-portion of the vessel, and presents approximately sixteen years after CABG in a man with clear risk factors for atherosclerosis. This is the pattern of a true aneurysm of a saphenous vein graft.",
    "differential_diagnosis": "Saphenous, vein, graft, aneurysm, after, coronary, artery, bypass, grafting., 1., Middle, mediastinal, masses, -, Lymphadenopathy, -, Aortic, arch, aneurysm, -, Enlarged, pulmonary, artery, -, Pericardial, cysts, -, Ventricular, pseudoaneurysm, -, Thymoma, 2., Bronchogenic, tumours, 3., Lung, metastasis, 4., Saphenous, vein, graft, aneurysm, after, coronary, artery, bypass, grafting",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012479/000001.jpg?itok=3XdVzHTV",
            "caption": "Frontal radiogram displays cardiomegaly and a large rounded left perihilar mass."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012479/000002.jpg?itok=ItPyqFsI",
            "caption": "CT coronal image shows a 6 x 7 cm low-density rounded mass on the left side of the middle compartment of the mediastinum."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012479/000003.jpg?itok=nW7BndQN",
            "caption": "Axial CT images show the extension of the mediastinal mass from the level of the aortic arch to the level of left atrium. Extensive calcification of the native coronary arteries is also seen."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012479/000004.jpg?itok=tFUTpd9p",
            "caption": "Contrast-enhanced axial CT shows partial filling of the lesion and connection between a vascular branch (graft) arising from the ascending aorta and the left circumflex coronary artery."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012479/000005.jpg?itok=4OnlV3Az",
            "caption": "Contrast-enhanced axial CT reveals contrast surrounded by low-density in keeping with thrombus. The mass is seen abutting the main and left pulmonary artery."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Cardiovascular system"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/12479",
    "time": "20.04.2015"
  },
  "12498": {
    "case_id": 12498,
    "title": "Spontaneous, nontraumatic pneumomediastinum complicated by pneumorrhachis",
    "section": "Chest imaging",
    "age": "18",
    "gender": "male",
    "diagnosis": "Primary spontaneous, nontraumatic pneumomediastinum complicated by pneumorrhachis.",
    "history": "An 18-year-old man with sudden onset of chest pain was admitted for investigation. The examination revealed mild subcutaneous crepitus over the neck. His respiratory effort was normal, the breath sounds were clear and equal bilaterally. He had no past medical or surgical history.",
    "image_finding": "Posteroanterior and lateral chest radiographs demonstrated extraalveolar air associated with presence of pneumomediastinum and subcutaneous emphysema (Fig. 1). CT examination of the thorax and neck showed pneumomediastinum,  subcutaneous emphysema and air in the spinal canal at the cervical, thoracic and lumbar levels (Fig. 2). The pulmonary parenchyma was normal (Fig. 2). Five days later a follow-up CT showed a decrease of the pneumomediastinum, of the subcutaneous emphysema and of the air in the spinal canal (Fig. 3). Conservative management was applied and 10 days later the clinical examination was normal and a chest X-ray showed complete resolution of mediastinal and subcutaneous emphysema (Fig. 4).",
    "discussion": "BackgroundIntraspinal air has been described in the literature under various terms, such as intraspinal pneumocele, spinal pneumatosis, spinal emphysema, aerorachia, pneumosaccus, and especially pneumorrhachis (PR) [1, 2]. According to the localization, intraspinal air has been classified into internal (air in the subdural or subarachnoid space) and external (air in the epidural space). Internal intraspinal air has been frequently associated with major trauma and is believed to be a marker of severe injury [3]. External intraspinal air has been found in association with air in other compartments and cavities of the body particularly with pneumocephalus, pneumothorax, pneumomediastinum, peumopericardium or subcutaneous emphysema [1, 4-5].Clinical and Imaging PerspectiveIn the present case a spontaneous nontraumatic pneumomediastinum was complicated by external intraspinal air. This entity develops when air dissects along the fascial planes from the posterior mediastinum or the retropharyngeal space through the neural foramina into the epidural space, which is not protected by a true fascial envelope. The epidural air most commonly collects in the posterior epidural space that has low resistance due to the loose connective tissue. The rich vascular network prevents air from accumulating in the anterior epidural space [6].OutcomeA review of the previous literature, in cases with spontaneous pneumomediastinum and pneumorrhachis, revealed 49 patients with the present case (37 men and 12 women, age range 4-72 years, median age 18 years). Thirteen of the patients had underlying lung disease such as bronchial asthma, bronchiolitis obliterans and pulmonary bullae [4, 7-9]. Twenty two patients had other underlying aetiologic factors (hyperpnoea, illicit drug inhalation, forceful vomiting, violent coughing and air travel) [5, 6, 7-13] while in 14 cases (including the present case) there was no clinically apparent lung disease or other precipitating factors [3, 8, 13]. Neurologic complaints were reported in one patient, which disappeared after C7 laminectomy [14]. The rest of the patients were neurologically asymptomatic and the air in the spinal canal disappeared in a few days. Teaching PointThe present report indicates that in spontaneous pneumomediastinum the accumulation of air within the spinal canal is a self-limiting and benign condition.",
    "differential_diagnosis": "Primary, spontaneous,, nontraumatic, pneumomediastinum, complicated, by, pneumorrhachis., Traumatic, (usually, after, severe, injury), Iatrogenic, (a, complication, of, surgical, or, anaesthetic, procedures, or, diagnostic, interventions, or, a, complication, of, malignancy, and, its, therapy)",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012498/000002.jpg?itok=80Xss1FE",
            "caption": "Posteroanterior (a) and lateral (b) chest radiographs demonstrating extraalveolar air  to  the mediastinum (straight arrows), subcutaneous neck emphysema (curved arrows) and subcutaneous emphysema in the lateral thoracic wall (arrowheads)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012498/000003.jpg?itok=Z2GXwNwh",
            "caption": "The CT scan of thorax and neck demonstrate a normal lung parenchyma, subcutaneous emphysema in the neck (curved arrows), air in the mediastinum (arrowheads) and in the spinal canal (straight arrows)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012498/000004.jpg?itok=tAo4NS-O",
            "caption": "A follow-up CT examination of the thorax demonstrates decrease of the pneumomediastinum (arrowheads), the subcutaneous emphysema (curved arrows) and the air in the spinal canal (straight arrows)."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012498/000005.jpg?itok=ows3ck-j",
            "caption": "A follow-up posteroanterior chest radiograph showing complete resolution of the subcutaneous emphysema and pneumomediastinum."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Mediastinum"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/12498",
    "time": "12.03.2015"
  },
  "12556": {
    "case_id": 12556,
    "title": "A rare case of systemic arterialization of lung without sequestration",
    "section": "Chest imaging",
    "age": "21",
    "gender": "male",
    "diagnosis": "Systemic arterialization of left lung lower lobe without sequestration",
    "history": "A 21-year-old male patient presented with complaints of frank haemoptysis. He mentioned having similar episodes on several occasions since childhood for which he had not been evaluated.",
    "image_finding": "Chest radiograph showed a retrocardiac tubular opacity. A contrast-enhanced CT of the chest revealed a tortuous dilated anomalous artery about 1 cm in diameter arising from the distal descending thoracic aorta at D8/ D9 level and supplying the left lower lobe. The left lower lobe pulmonary artery and its segmental branches appeared atretic. The anomalous artery had a swan neck-like configuration and ramified into multiple large segmental branches. There was no abnormal communication between the anomalous vessel and the pulmonary artery/vein. The bronchopulmonary segments involved were plethoric. The inferior pulmonary veins were seen draining normally into the left atrium. The bronchial tree appeared normal. Patchy areas of ill-defined ground glass attenuation was noted in the anterior and apical basal segments of the left lower lobe.",
    "discussion": "Anomalous systemic arterial supply to normal lung is the rarest of the congenital anomalies in the \u2018\u2018sequestration spectrum\u201d described by Pryce et al [1]. During embryologic development, the lung is supplied by bronchial and splanchnic vessels from the aorta. Persistence of embryonic connection between the aorta and the pulmonary parenchyma has been hypothesised as the cause of this condition [2]. A normal bronchial tree and pulmonary arteries distinguish this entity from classic pulmonary sequestration.In most cases the abnormal vessel arises from the distal part of the descending thoracic aorta. The anomalous artery can also arise from the coeliac trunk, can supply the upper lobe or the right lung. Simultaneous systemic and pulmonary arterial flow into the same segments has also been described. An atresia of pulmonary artery has also been reported in these cases [3].The most common presenting symptom is haemoptysis. Children may be asymptomatic and the condition may be incidentally detected due to a cardiac murmur.CT angiography is excellent in detecting the anomalous vessel and also providing an overview of the morphology of the bronchial tree and the pulmonary parenchyma, thereby excluding other causes of systemic arterialisation of lung like bronchopulmonary sequestration, congenital pulmonary venolobar syndrome etc. Absence or attenuation of the interlobar artery distal to the origin of the superior segmental artery has also been observed in these cases. Intralobar sequestration also has a systemic arterial supply and a normal pulmonary venous drainage but has no communication with the normal tracheobronchial tree and usually manifests as consolidation or rarely as a cystic lesion or cavitation [4].A feared complication is the development of pulmonary hypertension and cardiac failure due to a left to left shunt between the systemic artery and the pulmonary vein. Treatment options include surgery \u2013 lobectomy or segmentectomy, ligation of the anomalous artery or therapeutic embolisation with coils and glue [3]. Our patient underwent a left lung lower lobectomy. The findings may be subtle on chest X-ray and a high index of suspicion is needed to identify the abnormality and treat at the earliest. To the best of our knowledge very few case reports have been described in the literature. Systemic arterialisation of the lung is one of the rarest causes of haemoptysis and CT angiography plays a valuable role in detecting this condition.",
    "differential_diagnosis": "Systemic, arterialization, of, left, lung, lower, lobe, without, sequestration, Bronchopulmonary, sequestration, Pulmonary, AV, malformation, Chronic, inflammatory, disease, of, lung, with, hypertrophied, bronchial, artery",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012556/000001.png?itok=j8Xvzh3k",
            "caption": "Serial coronal reformatted CT images showing the anomalous vessel arising from the distal descending thoracic aorta and supplying the lower lobe of the left lung."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012556/000002.png?itok=yTMYnsvo",
            "caption": "Serial coronal reformatted CT images showing the anomalous vessel arising from the distal descending thoracic aorta and supplying the lower lobe of the left lung."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012556/000003.png?itok=sC1BSaln",
            "caption": "Serial coronal reformatted CT images showing the anomalous vessel arising from the distal descending thoracic aorta and supplying the lower lobe of the left lung."
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012556/000004.png?itok=fRUiwoMG",
            "caption": "Serial coronal reformatted CT images showing the anomalous vessel arising from the distal descending thoracic aorta and supplying the lower lobe of the left lung."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012556/000005.png?itok=-4W55Ij0",
            "caption": "Coronal reformatted CT image showing the \\'swan neck-like\\' abnormal artery arising from the distal descending thoracic aorta to the lower lobe of the left lung."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012556/000006.png?itok=So6L5F_v",
            "caption": "Serial sagittal CT images showing the anomalous artery from the thoracic aorta."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012556/000007.png?itok=D1wiGTOE",
            "caption": "Serial sagittal CT images showing the anomalous artery from the thoracic aorta."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012556/000008.png?itok=4AHZVpm_",
            "caption": "Serial sagittal CT images showing the anomalous artery from the thoracic aorta."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012556/000009.png?itok=8YxthB5z",
            "caption": "Chest X-ray shows a tubular retrocardiac opacity."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012556/000010.png?itok=TU0f3wfC",
            "caption": "Chest X-ray shows a tubular retrocardiac opacity."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012556/000011.png?itok=B48VRYsO",
            "caption": "Coronal CT lung window shows mild ground glass attenuation in the anterior and apical basal segment of the lower lobe of the left lung."
          },
          {
            "number": "Figure 5b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012556/000012.png?itok=jt_VNbRm",
            "caption": "Coronal CT lung window shows mild ground glass attenuation in the anterior and apical basal segment of the lower lobe of the left lung."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012556/000013.png?itok=gFSdJzam",
            "caption": "Thin volume-rendered images showing the anomalous vessel from the aorta to the lower lobe of the left lung."
          },
          {
            "number": "Figure 6b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012556/000014.png?itok=1hZT7ML7",
            "caption": "Thin volume-rendered images showing the anomalous vessel from the aorta to the lower lobe of the left lung."
          }
        ]
      },
      {
        "number": "Figure 7",
        "subfigures": [
          {
            "number": "Figure 7",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_video/2018-08/0000012556/000015F.png?itok=d1ZKMS4Q",
            "caption": "Volume rendered images showing the anomalous vessel from aorta to the lower lobe of left lung."
          }
        ]
      },
      {
        "number": "Figure 8",
        "subfigures": [
          {
            "number": "Figure 8",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_video/2018-08/0000012556/000016F.png?itok=2p3AQQXO",
            "caption": "Serial axial CT images showing the origin of the anomalous vessel from the aorta to the lower lobe of the left lung."
          }
        ]
      },
      {
        "number": "Figure 9",
        "subfigures": [
          {
            "number": "Figure 9",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012556/000017.png?itok=4CEbQqsG",
            "caption": "Axial CT image showing the origin of the abnormal vessel from the descending thoracic aorta."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT-Angiography",
      "Conventional radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/12556",
    "time": "18.05.2015"
  },
  "12561": {
    "case_id": 12561,
    "title": "Hughes-Stovin syndrome: A very rare clinical disorde",
    "section": "Chest imaging",
    "age": "17",
    "gender": "male",
    "diagnosis": "Hughes-Stovin syndrome",
    "history": "A 17-year-old male patient presented with cough, repetitive haemoptysis, dyspnoea and chest pain for 6 months. There was no history of fever. His CBC result was normal and tuberculosis test was negative.",
    "image_finding": "Contrast-enhanced CT of the chest showed aneurysmal dilatation of left main pulmonary artery with partially thrombosed lumen (Fig. 1, 3). Dilatation of a subsegmental pulmonary artery branch on the right side was also noted (Fig. 2). Images of the upper abdomen revealed non-visualization of the infrarenal part of the IVC associated with multiple collateral vessels in infrahepatic location (Fig. 4).",
    "discussion": "Hughes-Stovin syndrome (HSS) is a very rare clinical disorder with less than 40 cases published in the English literature so far [1]. It is characterized by a combination of systemic venous thrombosis and pulmonary artery aneurysm. Pulmonary artery aneurysms are generally multiple and bilateral in 50% of cases. The majority of patients develop peripheral venous thrombosis; however, intracardiac, dural sinus, inferior and superior vena cava, jugular, iliac and femoral vein thrombosis have also been reported [2]. Aneurysms generally involve pulmonary and bronchial arteries but can also occur anywhere in systemic circulation. HSS has also been reported in cases of left hepatic artery [3] and iliac artery aneurysms [4].HSS usually affects the young adult population (reported cases ranged from 12 to 48 years) with strong predilection for the male gender [5-7]. Patients generally present with non-specific findings suggestive of pulmonary artery aneurysm (haemoptysis, dyspnoea, chest pain and signs of pulmonary hypertension) following a history of peripheral venous thrombosis. Other associated signs include fever and intracranial hypertension. Aetiology of HSS is unknown; however, it is assumed that HSS is a form of vasculitis following a mechanism of pathogenesis similar to that related to Behcet's disease [8].Diagnosis of HSS is made on the basis of clinical symptoms, patient history and imaging (chest radiographs, conventional angiography or computed tomography) for detection and evaluation of the pulmonary artery aneurysms. Traditionally conventional angiography has been regarded as the gold standard for diagnosis of HSS. However, it should be noted that selective pulmonary angiography can be hazardous as it carries the risk of aneurysm rupture [9]. Multi-detector row helical CT angiography now offers more precise visualization of large systemic arteries than conventional angiography. As such, it can be regarded as an emerging and effective standard in the diagnosis of pulmonary artery aneurysms because of its non-invasive nature, ease of performance and increasing availability. Furthermore, Ketchum et al showed that 3D volume rendering analysis can detect morphologically abnormal, tortuous branches of bronchial arteries even before aneurysm formation [10, 11]. Histologic studies show destruction of the arterial wall and perivascular lymphomonocytic infiltration of capillaries and venules [8]. HSS has a poor prognosis and aneurysmal rupture is the leading cause of death. However, early diagnosis and timely intervention is crucial in improving the prognosis. Therefore all young male patients presenting with typical clinical history should be suspected for HSS and carefully evaluated.",
    "differential_diagnosis": "Hughes-Stovin, syndrome, Idiopathic, vasculitic, syndromes, (HSS, and, Behcet\u2019s, disease), Tuberculosis, (Ramussen\u2019s, aneurysm), Syphilitic, aneurysm, Bacterial, and, mycotic, aneurysm, Pulmonary, hypertension",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012561/000001.png?itok=YO_wowcL",
            "caption": "Aneurysmal dilatation of left main pulmonary artery with partially thrombosed lumen (blue arrow)"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012561/000002.png?itok=UQVKcSid",
            "caption": "Dilatation of subsegmental  pulmonary artery branch on the right side (blue arrow)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012561/000003.png?itok=xVigT31g",
            "caption": "Thrombosed lumen of left main pulmonary artery (blue arrow)"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012561/000006.png?itok=OqnFcYuf",
            "caption": "Non-visualization of infrarenal part of the IVC associated with multiple collateral vessels in infrahepatic location."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012561/000007.png?itok=464fDfC2",
            "caption": "Non-visualization of infrarenal part of the IVC associated with multiple collateral vessels in infrahepatic location."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Pulmonary vessels",
      "Veins / Vena cava"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/12561",
    "time": "12.05.2015"
  },
  "12657": {
    "case_id": 12657,
    "title": "Giant goitre",
    "section": "Chest imaging",
    "age": "82",
    "gender": "female",
    "diagnosis": "Multinodular goitre",
    "history": "An 82-year-old woman presented with a history of progressive dyspnoea and dysphagia for several years. She was admitted to the emergency room with atrial fibrillation. Physical examination revealed a diffusely enlarged thyroid with palpable nodules up to several centimetres. The lower edge of the thyroid gland was not palpable.",
    "image_finding": "A posteroanterior chest radiograph showed a giant posterior mediastinal mass causing anterior deviation of the trachea (Fig. 1). Lateral chest radiograph showed posterior displacement of the aorta and anterior deviation of the pulmonary hilum by the mass. Narrowing of the intermediate bronchus was also noted (Fig. 2). A contrast-enhanced chest CT revealed a large heterogeneously enhancing soft tissue mass (20 x12x9 cm) with calcifications extending from the cervical region to the right hemidiaphragm (white arrows in figure 3.2 and 3.4). It caused compression and deviation of the trachea, carina, oesophagus and vascular structures.Surgery was performed via cervical and thoracic approach, and a large mass weighing 780 gr was resected. Pathological results were consistent with a thyroid goitre (Fig. 4).",
    "discussion": "The most common cause of goitre worldwide is iodine deficiency. In fact, it has been estimated that goitres affect as many as 200 million people who have a diet deficient in iodine [1]. A multinodular goitre is simply a thyroid gland that is usually enlarged and contains multiple thyroid nodules. Intrathoracic goitre refers to a goitre where most of its volume is found within the mediastinum. The vast majority of intrathoracic goitres arise from the lower part of one lobe or both lobes of cervical thyroid or isthmus and grow caudally through the thoracic inlet. Intrathoracic goitre generally grows to the position of relatively low resistance. At first, the tumour will grow into the anterior superior mediastinum forming the common retrosternal thyroid goitre.One fourth of intrathoracic goitres are posterior [2]. Posterior intrathoracic goitre exclusively occurs on the right side, since there are thymus, left and right brachiocephalic veins and superior vena cava anteriorly and aortic arch and its three branches in the middle left of the retrosternal space causing resistance in tumour growth locally. Imaging is crucial in revealing the exact location of the intrathoracic goitre and other posterior mediastinal masses [3]. Not only can it be used to help confirm the presence of these masses, but it also helps define the localization and the extent of the lesion, adjacent organ involvement or vascular involvement.The CT findings include anatomic continuity with cervical thyroid, well-defined borders and frequent focal calcifications, cystic areas and relatively high attenuation after the administration of an intravenous contrast material with prolonged enhancement [3, 4]. A lack of continuity between the cervical thyroid and intrathoracic mass does not exclude the diagnosis of a goitre, since the connection may be narrow, fibrous or a vascular pedicle [5]. The differential diagnosis of intrathoracic goitre includes different entities such as lymphadenopathy, branchial cleft cyst, arterial aneurysm, neurogenic tumour, pheochromocytoma, hernias, etc. [3]. When the trachea, oesophagus or vena cava is compressed, surgical resection must be performed. Preventive operation is also feasible for asymptomatic patients in order to avoid future compression [6]. With early intervention, most intrathoracic goitres can be removed through a cervical approach, while tracheomalacia is avoided. Nevertheless, a sternotomy may be preferable in high risk patients, to ensure better visualization, identification of anatomical structures that should be preserved (such as the recurrent laryngeal nerves and the parathyroid glands), better haemostasis and complete enucleated removal [7].",
    "differential_diagnosis": "Multinodular, goitre, Schawannoma, Neurofibroma, Descending, aortic, aneurysm, Hernia, Lymphoma, Neurenteric, cyst, or, oesophageal, duplication, cyst",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012657/000001.jpg?itok=s0A1vRcP",
            "caption": "Enlarged mediastinum secondary to a huge mass (arrows). It significantly occupies the right hemithorax and causes deviation of the trachea (star)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012657/000002.jpg?itok=WYXRFV5d",
            "caption": "The mass obliterates both Raider triangle and retrocardiac space.\nPosterior displacement of the aorta (white arrows) and anterior desviation of the pulmonary hilum.\nNarrowing of the intermediate bronchus (star)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012657/000003.jpg?itok=4HE7kJ83",
            "caption": "A large heterogeneously enhancing soft tissue mass occupies the posterior right mediastinum. It displaces and compresses multiple structures.\n(T: trachea, C: carina, P: pulmonary hilum, Ao: aorta)"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012657/000004.jpg?itok=647At05g",
            "caption": "Nodular hyperplasia, low-power appearance (4x). Multiple hyperplastic non-encapsulated nodules, composed of huge follicles lined by flattened epithelium\n722x541mm (72x72 DPI)."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Mediastinum"
    ],
    "imaging_technique": [
      "Digital radiography",
      "CT",
      "Experimental"
    ],
    "link": "https://www.eurorad.org/case/12657",
    "time": "12.05.2015"
  },
  "12700": {
    "case_id": 12700,
    "title": "Right lung aplasi",
    "section": "Chest imaging",
    "age": "3",
    "gender": "male",
    "diagnosis": "Right lung aplasia",
    "history": "A three-month-old male child with respiratory distress and fever was sent to the radiology department to undergo chest CT.",
    "image_finding": "Right lung, right main bronchus, right pulmonary artery and right pulmonary veins are not seen.The heart and mediastinum are shifted toward the right hemithorax.Figure 1: MINIP reconstruction image shows blind-ended small rudimentary right main bronchus.Figure 2: 3D airway rendering image of the lung shows herniation of left lung parenchyma toward the right hemithorax and absence of the right main bronchus.Figure 3: Post-contrast axial image at the level of the pulmonary trunk: Displaced heart toward the right hemithorax, normal pulmonary trunk with single left pulmonary artery.Apart from right side heart shift, no significant cardiac pathology was detected with CT.",
    "discussion": "BackgroundPulmonary agenesis is a rare congenital anomaly [1] with very different figures about its incidence in the literature from 1/10, 000-12, 000, [2] 1/100, 000, [3] and 34/million live births. [4]Evidence is also different about its occurrence in men and women and involvement of the right or left lung. Nowotny T. (in 1988) mentioned approximately equal occurrence in men and women as well as right and left equality, [5] but Partha P. Roy (in 2012) described that the left lung is affected more frequently than the right and men predominate over women. [4]Half of the patients have associated congenital defects [6] involving cardiovascular, skeletal, gastrointestinal and genitourinary systems. [7] The aetiology is unclear, although genetic factors, viral agents and maternal dietary vitamin A deficiency have been implicated. [6]Lung agenesis is divided into three types: Type 1 with complete absence of lung, bronchus and vessels. Type 2 (aplasia) has a rudimentary bronchus with complete absence of lung parenchyma and type 3 (hypoplasia) is manifested as presence of variable amounts of bronchial tree, pulmonary parenchyma and supporting vasculature.Clinical perspectiveBilateral lung agenesis is incompatible with life but unilateral agenesis may present with varying degrees of severity. [4] Patients with aplastic lung are usually asymptomatic. [1] Clinical findings change with the presence of comorbid anomalies and their severity. [1] Many cases are detected during infancy because of recurrent chest infections, cardiopulmonary insufficiency or due to associated congenital anomalies, however, individuals with a single lung may survive well up to adulthood without significant complaints, of which few case reports are published. [4, 7, 8, 9]Imaging perspectiveUnilateral agenesis can be suspected with prenatal US on the basis of mediastinal shift. [10] Postnatal radiography demonstrates mediastinal shift and the absence of lung markings on effected side however cross herniation of opposite lung may cause confusion. [11] Imaging findings in pulmonary aplasia and agenesis are similar, except for the presence of a short blind-ending bronchus in aplasia. [12]Computed tomography CT helps confirm the absence of lung parenchyma, bronchus and vessels. [13]Scintigraphy shows no perfusion or ventilation in the affected side. Angiography (or) echo confirms small/absent pulmonary artery in the affected side. [11]Outcome No treatment is required in asymptomatic cases. The prognosis depends upon the functional integrity of the remaining lung as well as the presence of associated anomalies. [7]",
    "differential_diagnosis": "Right, lung, aplasia, Lung, hypoplasia, Lung, agenesia",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012700/000002.jpg?itok=EL61mdQy",
            "caption": "MINIP reconstructed image showing rudimentary right main bronchus."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012700/000003.jpg?itok=DKd08TcY",
            "caption": "3-D airway rendering\nimage of the lung shows:\nRight side herniation of left lung, absence of right main bronchus as well as normal-positioned gastric air bubble."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012700/000005.jpg?itok=8FkPFKeB",
            "caption": "Axial CT section after IV contrast injection in arterial phase, through the level of the pulmonary trunk:\n\nSingle left side pulmonary artery arising from  the pulmonary trunk."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012700/000006.jpg?itok=h5MBi1aN",
            "caption": "Coronal CT image in lung window shows herniation of left lung to the right hemithorax with some areas overinflated. (black areas)"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT",
      "CT-Angiography"
    ],
    "link": "https://www.eurorad.org/case/12700",
    "time": "23.06.2015"
  },
  "12721": {
    "case_id": 12721,
    "title": "Septic emboli in an intravenous drug abuse",
    "section": "Chest imaging",
    "age": "34",
    "gender": "male",
    "diagnosis": "Septic emboli",
    "history": "A 34-year-old previously healthy male patient presented with cough and fever, with a minimal amount of blood on coughing. He reported no significant medical history or recent travel. Laboratory examination showed elevated white blood cell count and inflammatory markers. A chest X-ray was ordered for further evaluation.",
    "image_finding": "Chest X-ray PA: Multiple peripheral pulmonary nodules (arrows), some showing cavitation. Thickening of the left para-vertebral stripe at the level of T9 (arrowhead).Contrast-enhanced CT thorax: Multiple peripheral lung nodules, some with cavitation. Para-vertebral abscess at the level of T9-10.Contrast enhanced CT thorax: Coronal MPR (multi-planar reconstruction) image shows a feeding vessel sign (arrow).Thick MIP (maximal intensity projection) section of the thorax: highlights the asymmetric peripheral distribution of the pulmonary nodules (Asterisks).Contrast-enhanced CT pelvis: Soft tissue tracts anterior to bilateral femoral veins, highly suggestive of repeated injection sites in an intravenous drug abuser. Thrombus in the left femoral vein seen as a filling defect.Chest X-ray PA: Post-antibiotic therapy X-ray shows improved status of the previously seen pulmonary nodules with cavitation and para-vertebral soft tissue swelling.",
    "discussion": "Septic pulmonary embolism is a life-threatening condition that occurs when a thrombus containing microorganisms is released into the blood vessels [1-4]. Predisposing factors include infections in the head and neck drained by cervical veins such as periodontal infections, cardiac valve disease, thrombophlebitis, immuno-compromised status, indwelling devices and intravenous drug abuse [1, 3]. Clinical history is often limited, the radiologist's role is to recognize these findings as part of the spectrum that occurs as a result of septic emboli so that appropriate treatment can be started [2].The radiographic pattern is non-specific, usually seen as ill-defined scattered asymmetric peripheral nodules, some might have varying degrees of cavitation [1-4].Other differential diagnoses that should be considered are inflammatory conditions such as Wegner\u2019s granulomatosis or rheumatoid disease, metastasis is also considered in patients who have a less acute presentation and are older [1-2]. The feeding vessel sign is considered useful even if it is more likely to be a draining pulmonary vein or an artery coursing around the nodule [5]. The role of CT is to further characterize these nodules and detect extra-pulmonary findings that can narrow down the diagnosis, which might be seen as scattered soft tissue abscesses [1].The patient\u2019s blood cultures came back positive for Staphylococcus aureus, which is most common with intravenous drug abusers [2, 4]. The echocardiogram did not reveal any valvular disease. The most likely source was the thrombus within the left femoral vein. The patient responded well to antibiotic therapy, post-therapy X-ray showed resolution of the lung nodules.Drug abuse has a multi-systemic presentation, radiology plays a key role in identifying these abnormalities and to recognize them as part of the variable presentation due to septic emboli. The radiologist should have a high clinical suspicion especially in a young previously healthy patient with no indwelling catheters or devices and no obvious infection source in the head or neck [2, 5].",
    "differential_diagnosis": "Septic, emboli, Metastasis, Wegner\\'s, granulomatosis, Rheumatoid, nodules, Tuberculosis, Silicosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012721/000001.jpg?itok=fZPX0W6z",
            "caption": "Scattered ill-defined peripheral pulmonary nodules, some showing cavitation (red arrows).  Thickened para-vertebral soft tissue at T9 level (arrowhead)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012721/000002.jpg?itok=Z8ZF_uRA",
            "caption": "Peripheral pulmonary nodule with cavitation."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012721/000003.jpg?itok=2jU7gEOP",
            "caption": "Another pulmonary nodule showing a lesser degree of cavitation."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012721/000004.jpg?itok=RjaO1j4v",
            "caption": "Left basal pulmonary nodule with cavitation (arrow). Para-vertebral soft tissue abscess (arrowhead)."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012721/000005.jpg?itok=8IpkMKov",
            "caption": "Coronal section shows an apparent sub-segmental pulmonary artery that appears to \\\"feed\\\" the right apical pulmonary nodule (arrow). This is known as the \\\"feeding vessel\\\" sign."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012721/000006.jpg?itok=AdNL_o_5",
            "caption": "Thick MIP (maximal intensity projection) section through the posterior segments of the lungs to illustrate the multiple pulmonary nodules (asterisks)."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012721/000007.jpg?itok=qGE8Nc7Z",
            "caption": "Subcutaneous tracts anterior to bilateral femoral veins (arrows).  Highly suggestive of repeated injection sites in an intravenous drug abuser."
          },
          {
            "number": "Figure 6b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012721/000008.jpg?itok=zuriUv1Y",
            "caption": "Left femoral vein thrombus seen as a filling defect."
          }
        ]
      },
      {
        "number": "Figure 7",
        "subfigures": [
          {
            "number": "Figure 7",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012721/000009.jpg?itok=ojIPiBGu",
            "caption": "Almost complete resolution of the previously seen pulmonary nodules and para-vertebral soft tissue abscess post antibiotic therapy."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Soft tissues / Skin",
      "Spine",
      "Veins / Vena cava"
    ],
    "imaging_technique": [
      "Digital radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/12721",
    "time": "18.05.2015"
  },
  "12729": {
    "case_id": 12729,
    "title": "Necrotizing pneumonia due to Klebsiella pneumoniae",
    "section": "Chest imaging",
    "age": "52",
    "gender": "male",
    "diagnosis": "Necrotizing pneumonia due to Klebsiella pneumoniae",
    "history": "A 52-year-old man presented to the emergency department with symptoms of cough, haemoptysis, low-grade fever and general weakness for over one week. The patient was an alcoholic and smoker. Significant laboratory findings included leucocytosis and neutrophilia.",
    "image_finding": "An urgent chest X-ray revealed downward bulging of the minor fissure due to massive enlargement of the right upper lobe with inflammatory exudate (Fig. 1).Transverse computed tomography (CT) shows homogeneous parenchymal consolidation in the right upper lobe (Fig. 2a). The consolidation expands and exerts mass effect on the adjacent interlobar fissure, and hilar and mediastinal lymph node enlargement is present (Fig. 2b, 2c).  The radiological interpretation was pneumonia due to Klebsiella. The patient underwent antibiotic therapy, but showed rapid progression in his respiratory symptoms. Two hours later, intubation and mechanical ventilation were performed because of shock and respiratory failure, and the patient was admitted to the intensive care unit. Two weeks later control chest radiography and CT showed dense consolidation with necrotizing areas (Fig. 3, 4a), interlobular septal thickening and ground-glass opacities in both sides of the lungs, suggesting necrotizing pneumonia (Fig. 4b). It resolved slowly with residual fibrosis in the upper lobe (Fig. 5).",
    "discussion": "Klebsiella pneumoniae is a Gram-negative bacteria and a well-known cause of community-acquired pneumonia, which accounts for less than 5% of all cases of pneumonia. It is an important type of pneumonia because of its severity, high incidence of complications, and elevated mortality [1]. For this reason, it is important to identify the risk factors and to evaluate the radiological findings as soon as possible to initiating appropriate treatment quickly.This bacterium affects people with underlying diseases, such as alcoholism, diabetes, chronic pulmonary disease and critically ill patients [2, 3]. The usual presenting symptoms are fever and cough, followed by sputum (currant-jelly sputum in some cases), dyspnoea and chest pain [4]. Alcoholics are at particular risk of bacteraemic and fatal Klebsiella pneumoniae [5].The most common plain radiographic finding is pneumonic consolidation that produces a large inflammatory exudate, causing increased volume of the affected lobe, expanding and exerting mass e\ufb00ect on the adjacent interlobar \ufb01ssure (bulging fissure sign) [6]. It may result in abscess formation and pleural effusion in complicated cases; these cases start with consolidation, followed by cavities [7].CT findings in patients with acute Klebsiella pneumoniae consisted mainly of ground-glass attenuation with consolidation and intralobular reticular opacity, which were often associated with pleural effusion (7, 8, 9). Traction bronchiectasis, enlarged lymph nodes at the paratracheal, tracheobronchial and subcarinal regions are also observed [8, 9].On the other hand, the CT findings of complicated Klebsiella pneumoniae are necrotizing pneumonia associated with pleural abnormalities; abscesses may progress to destroy a section of the lung, and multiple cavities that coalesce into one large cavity may develop, suggesting pulmonary gangrene [9, 7]. Other organisms are prone to cause necrotizing pneumonia similar to Klebsiella; the most common pathogens responsible for lung abscess are anaerobes of the oral \ufb02ora (Prevotella, Fusobacterium, Streptococcus milleri group). However, necrotizing changes may be seen in up to around 7% of those with aerobic bacterial pneumonia [7, 10].Staphylococcus aureus is an emerging cause of necrotizing pneumonia affecting young immunocompetent patients. Streptococcus pneumonia (especially type 3) and Haemophilus in\ufb02uenza have been frequently reported, and because these organisms are such common causes of pneumonia, these pathogens may cause a signi\ufb01cant fraction of cavitary pneumonias, even though cavitation is relatively rare with these pathogens [7, 8, 11, 12].Mycobacterium tuberculosis and Aspergillus are classically associated with cavitary pulmonary disease. Pseudomonas, Nocardia, Actinomyces and Enterobacter are also important for the differential diagnosis [7].Teaching points:-The bulging fissure sign is associated with Klebsiella pneumoniae infection. -A common manifestation of complicated Klebsiella pneumoniae was necrotizing pneumonia associated with pleural abnormalities.",
    "differential_diagnosis": "Necrotizing, pneumonia, due, to, Klebsiella, pneumoniae, Necrotizing, bacterial, pneumonia, due, to, Staphylococcus, aureus, Pulmonary, abscess, caused, by, anaerobes, (related, with, aspiration), Pulmonary, tuberculosis, Necrotizing, pneumonia, caused, by, Streptococcus, pneumoniae, or, Haemophilus, influenzae, Pulmonary, Nocardia, or, Actinomyces, infections, with, cavitation, Necrotizing, bronchopulmonary, aspergillosis, Necrotizing, Pseudomonas, aeruginosa, pneumoniae",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012729/000001.jpg?itok=iHAkbZ8m",
            "caption": "Extensive right upper lobe consolidation, with bulging of the horizontal fissure."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012729/000002.jpg?itok=r6OhpPkA",
            "caption": "Transverse thin-section computed tomography (CT) of the right upper lobe image shows homogeneous parenchymal consolidation."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012729/000003.jpg?itok=Ffy1BnuL",
            "caption": "In coronal reconstruction the consolidation expands and exerts mass effect on the adjacent interlobar fissure."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012729/000004.jpg?itok=d7H7QqLO",
            "caption": "Hilar and mediastinal lymph node enlargement is present."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012729/000005.jpg?itok=NU3a2cSu",
            "caption": "Sagittal view bulges convex posteroinferiorly due to rapid lobar expansion."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012729/000006.jpg?itok=gvKln3sq",
            "caption": "Progression of the necrotizing infection produced abscess as shown in the chest X-ray 2 weeks later."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012729/000007.jpg?itok=yWjIDKc7",
            "caption": "Axial CT images revealed multiple small abscess cavities coalescing to form a large cavity with loss of lung tissue, suggesting necrotizing pneumonia and lung abscess."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012729/000008.jpg?itok=oHHofssA",
            "caption": "Interlobular septal thickening, bronchial wall thickening and ground-glass opacities in both sides of the lungs."
          },
          {
            "number": "Figure 4c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012729/000009.jpg?itok=G-fJ4Aeh",
            "caption": "Coronal reconstruction also showed multiple small abscess cavities coalescing to form a large cavity with loss of lung tissue in the right upper lobe, and ground-glass opacities in both sides of the lungs."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012729/000010.jpg?itok=DhYvrLbo",
            "caption": "One month after treatment."
          },
          {
            "number": "Figure 5b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012729/000011.jpg?itok=QCgfxWlY",
            "caption": "Two months after treatment."
          },
          {
            "number": "Figure 5c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012729/000012.jpg?itok=JMliCnjN",
            "caption": "Four months after treatment: Necrotizing pneumonia resolved slowly with residual fibrosis in the upper lobe."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/12729",
    "time": "29.05.2015"
  },
  "12731": {
    "case_id": 12731,
    "title": "A case of scimitar syndrome in a young woman",
    "section": "Chest imaging",
    "age": "21",
    "gender": "female",
    "diagnosis": "Scimitar syndrome",
    "history": "A 21-year-old woman has been hospitalized for right hydronephrosis and shortness of breath; XR chest showed a diffuse opacity with disappearance of cardiac contours to the right; a chest CT revealed absence of right upper lobe, hypoplasia of right pulmonary artery and two abnormal contiguous vessels.",
    "image_finding": "The chest radiograph showed a diffuse opacity of the right lung with a dextroposition of the heart.A biphasic (arterial and venous phase) contrast enhanced CT examination of the chest revealed an asymmetry of the chest with a deviation of the mediastinum to the right due to an absence of the right upper lobe. Furthermore, the CT showed an asymmetry of the pulmonary arteries (APD right 11 mm vs APD left 14 mm). At the basal pyramid of the lower lobe two abnormal contiguous vessels were identified, a threadlike vein draining into the inferior vena cava (scimitar vein) and a small artery originating directly from the abdominal aorta corresponding to a systemic arterial supply of the right lower lobe.In addition, an aberrant subclavian artery was found.",
    "discussion": "Scimitar syndrome or hypo-genetic pulmonary syndrome is a congenital form of anomalous pulmonary venous drainage (APVD) associated with other anomalies such as hypoplasia of the right lung, dextroposition of the heart, hypoplasia of the right pulmonary artery (RPA) and anomalous systemic arterial supply from the aorta to the right lung.It was described for the first time by Cooper in 1836 and the term scimitar syndrome was coined by Naill in 1960, because of the radiographic appearance of the anomalous vein (a tubular opacity paralleling the right heart border resembling a curved Turkish sword or Scimitar). [1, 2]In these patients, pulmonary venous drainage is anomalously connected to systemic vein/s, typically to the superior or inferior vena cava (SVC or IVC) or directly to the right atrium (RA).In our case, to understand the cause of respiratory symptoms without signs of infection, a chest X-ray followed by a chest CT led to the diagnosis.Since she was born, our patient was followed for multiple anomalies such as right lower limb deformity, right kidney anomaly and asymmetry of the pulmonary arteries.This rare anomaly has an incidence of approximately 1 to 3 per 100, 000 live births. Two different groups of patients exist: adults and older children usually diagnosed during a workup for dyspnoea, fatigue, recurrent respiratory infections or as an incidental finding on a routine chest radiograph, and infants, who become symptomatic soon after birth. The adult form usually is not associated with pulmonary hypertension and typically has mild symptoms and benign prognosis, the form found in younger patients is often complicated by pulmonary hypertension and cardiac failure. [1, 2]When necessary, treatment consists of elimination of aortic collaterals by embolization with spirals or surgery by right thoracotomy access.",
    "differential_diagnosis": "Scimitar, syndrome, Pulmonary, hypertension, Pulmonary, hypoplasia",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012731/000010.png?itok=Wx7iczZm",
            "caption": "At the basal pyramid of the lower lobe two abnormal contiguous vessels can be identified, a threadlike vein draining into the inferior caval vein and a small artery originating directly from the abdominal aorta."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012731/000011.png?itok=4Z3AIa3N",
            "caption": "Small artery originating directly from the abdominal aorta corresponding to a systemic arterial supply of the right lower lobe."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012731/000012.png?itok=LM-6DcJq",
            "caption": "Vein at the basal pyramid of the right lower lobe draining into the inferior vena cava (scimitar vein)."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012731/000014.png?itok=3Bk858qG",
            "caption": "Aplasia of the right upper lobe with consequent loss of volume of the ipsilateral lung and deviation of the mediastinum to the right."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012731/000015.png?itok=nRQTg7T7",
            "caption": "Aplasia of the right upper lobe with consequent loss of volume of the ipsilateral lung."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012731/000016.jpg?itok=_sESqCkp",
            "caption": "Diffuse opacity of the right lung with dextroposition of the heart."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Arteries / Aorta",
      "Pulmonary vessels",
      "Lung"
    ],
    "imaging_technique": [
      "CT-Angiography",
      "CT",
      "Digital radiography"
    ],
    "link": "https://www.eurorad.org/case/12731",
    "time": "18.08.2015"
  },
  "12735": {
    "case_id": 12735,
    "title": "Radiotherapy-induced organizing pneumonia (ECR 2015 Case of the Day)",
    "section": "Chest imaging",
    "age": "58",
    "gender": "female",
    "diagnosis": "Radiotherapy-induced organizing pneumonia",
    "history": "A 58-year-old woman with diagnosis of breast cancer underwent left mastectomy and ipsilateral lymphadenectomy followed by chemoradiotherapy (total dose of 50 Gray administrated in 28 applications of 1.8 Gray/fr). Seven months after treatment she was referred to a oncologists for the onset of mild dyspnoea and fever. Laboratory tests revealed neutrophilia.",
    "image_finding": "Computed tomography (CT) of the chest showed ground-glass opacities (GGOs) in the left upper lobe and, less extensively, in the right upper lobe (Fig. 1-4).A parenchymal consolidation with peribronchovascular and subpleural distribution was localized in the basal anteromedial segment of the left lower lobe (Fig. 5).A focal rounded area of GGO surrounded by a complete ring of consolidation was documented in the basal posterior segment of the left lower lobe, peripherally (Fig. 6). Images of radiotherapy treatment plan configuration were also analysed. Isodose distribution showed only an insignificant radiation dose administered to the left upper lung parenchyma in contact with the irradiated chest wall (Fig. 7-9). By comparing images of the radiotherapy planning with CT images, it can be observed that lung abnormalities occurred also outside the irradiated areas. CT performed four months later, after steroid therapy, showed an almost complete resolution of bilateral lung abnormalities (Fig. 10).",
    "discussion": "Organizing pneumonia (OP) can be considered as a non-specific response to lung injury and is characterized histopathologically by intra-alveolar inflammatory cells and myofibroblasts in a connective tissue matrix [1].OP can occur as an idiopathic clinicopathological disorder (cryptogenic OP) [1, 2], though numerous causes of secondary OP are well documented and continue to increase [2, 3]. Radiotherapy-induced OP is an interesting entity occurring with an incidence of approximately 2.5% following radiotherapy, more commonly after breast cancer treatment [4]. The low-dose tangential lung radiation used during breast irradiation may initiate lymphocyte stimulation throughout the lungs, leading to a diffuse lymphocytic alveolar infiltrate with subsequent immunological and hypersensitivity reactions in the \"nonirradiated lung\" [5], that can eventually result in the classic imaging features of OP.Clinical features usually appear within 12 months of the radiotherapy completion [5]. Dyspnoea is the commonest complaint. Fever and nonproductive cough are frequent. The most common laboratory findings are neutrophilic leukocytosis and elevated erythrocyte sedimentation rate [5].Radiotherapy-induced OP can affect any part of the lung, usually outside the irradiated area [1, 5]. The radiological hallmark of OP is patchy, airspace opacity with a density ranging from ground-glass opacity to consolidation, usually bilateral (70\u201390%) and asymmetric [1] (Fig. 1). On CT, the consolidation often has a peribronchovascular [6] or subpleural distribution (Fig. 1-5) and commonly contains air bronchograms with dilated airways. Consolidation tends to migrate and to come and go even without treatment.A perilobular pattern (poorly defined opacity along interlobular septa) and the appearance of \u201creversed halo sign\u201d (ring-like opacity with central GG abnormality) (Fig. 6), found in over 50% [7] and 19% [8] of patients with OP, respectively, may help in suggesting the diagnosis.About 30\u201350% of patients demonstrate nodules [9].Other findings described in a minority of patients include: peripheral reticulation and irregular lines, large nodular or mass-like peripheral opacities, and band-like opacities with central air bronchograms [1].Radiotherapy-induced OP is promptly steroid-responsive, though with a high prevalence of relapse on withdrawal [1]. The long-term outcome appears excellent [5].Post-radiotherapy OP outside the radiation field in patients who underwent surgery and radiation therapy to treat lung cancer is exceedingly uncommon [5]. OP occurring in non-irradiated lung shows propensity to appear almost exclusively in patients who have undergone surgery and radiotherapy for the treatment of breast cancer [5].It seems to be distinct from the common sequelae of radiotherapy, such as radiation pneumonitis and radiotherapy-induced fibrosis, which usually occur within the radiation portals [10].",
    "differential_diagnosis": "Radiotherapy-induced, organizing, pneumonia, Fungal, infection, (paracoccidioidomycosis), Viral, infection, Radiotherapy-induced, organizing, pneumonia, Radiation, pneumonitis, Radiation, fibrosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012735/000001.jpg?itok=f7C0W64V",
            "caption": "The image shows ground-glass opacities (GGOs) in the apico-posterior segment of the left upper lobe. A less extensive GGO was also evident in the apical segment of the right upper lobe, with a peribronchovascular distribution."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012735/000002.jpg?itok=XZo7lz1l",
            "caption": "The image shows GGOs in the apico-posterior segment of the left upper lobe, adjacent to the left fissure."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012735/000003.jpg?itok=h2--v_P0",
            "caption": "The image shows GGOs in the subpleural areas of the anterior segment of the left upper lobe."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012735/000004.jpg?itok=E3gXIY-1",
            "caption": "The image shows GGOs in the subpleural anterior portion of the lingula."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012735/000005.jpg?itok=dorhPK5g",
            "caption": "A 19 mm parenchymal consolidation (arrow) with peribronchovascular and subpleural distribution was localized in the basal anteromedial segment of the left lower lobe, adjacent to the fissure."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012735/000006.jpg?itok=lY8l3z7X",
            "caption": "A focal rounded area of GGO surrounded by a complete ring of consolidation (reversed halo sign) with patent bronchi in the contest, in the basal posterior segment of the left lower lobe, at the periphery."
          }
        ]
      },
      {
        "number": "Figure 7",
        "subfigures": [
          {
            "number": "Figure 7",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012735/000007.jpg?itok=vPaGK3Yu",
            "caption": "Isodose distribution shows the high dose irradiated area centred on the soft tissues of the left axilla and on the chest wall. An insignificant radiation dose reaches the left upper lung parenchyma."
          }
        ]
      },
      {
        "number": "Figure 8",
        "subfigures": [
          {
            "number": "Figure 8",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012735/000008.jpg?itok=MdUtKgdY",
            "caption": "Isodose distribution shows the high dose irradiated area centred on the chest wall."
          }
        ]
      },
      {
        "number": "Figure 9",
        "subfigures": [
          {
            "number": "Figure 9",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012735/000009.jpg?itok=DgmYxen5",
            "caption": "Isodose distribution shows the high dose irradiated areas."
          }
        ]
      },
      {
        "number": "Figure 10",
        "subfigures": [
          {
            "number": "Figure 10",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012735/000010.jpg?itok=Ryk3pgkw",
            "caption": "Images show an almost complete resolution of bilateral lung abnormalities on the MDCT performed after 4-month steroid therapy"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/12735",
    "time": "18.05.2015"
  },
  "12749": {
    "case_id": 12749,
    "title": "Spontaneous pneumothorax: a complication of tuberculosis",
    "section": "Chest imaging",
    "age": "28",
    "gender": "male",
    "diagnosis": "Hydropneumothorax as the initial manifestation of postprimary tuberculosis.",
    "history": "A 28-year-old male Spanish patient presented with weight loss and anorexia for one year, in association with dyspnoea, fever, cough, expectoration and left pleuritic pain during the past week. On physical examination during chest auscultation hypophonesis was noted on the left side.",
    "image_finding": "Posteroanterior and lateral chest radiography showed a hydropneumothorax on the left side with a collapsed left lung. On the contralateral side, ill-defined nodules and consolidations in the right upper lobe and upper segment of the lower lobe were seen (Fig. 1). Tube thoracostomy was performed in the emergency department, with improvement of the symptoms.CT with intravenous contrast showed patchy areas of consolidation with air bronchogram, poorly defined margins, predominantly in the upper lobes. I addition, centrilobular nodules and the tree-in-bud pattern was observed. On the left side, several of these consolidations cavitated (Fig. 2). Also, CT revealed a loculated left pleural effusion with thickened and enhanced visceral and parietal pleura (the split pleura sign), suggestive of empyema (Fig. 3). There was no lymphadenopathy.",
    "discussion": "Pulmonary tuberculosis is a common worldwide lung infection.Classically, tuberculosis is divided into primary, common in childhood, and postprimary, usually presenting in adults [1]. The most characteristic radiological feature in primary tuberculosis is lymphadenopathy [1]. On enhanced CT, hilar and mediastinal nodes with a central hypodense area suggest the diagnosis. Cavitation is the hallmark of postprimary tuberculosis and appears in around half of patients [2]. Patchy, poorly defined consolidation in the apical and posterior segments of the upper lobes, and in the superior segment of the lower lobe is also commonly observed [1, 2].Several complications are associated with tuberculous infection, such as haematogenous dissemination (miliary tuberculosis) or extension to the pleura, resulting in pleural effusion [2]. Late complications of tuberculosis comprise a heterogeneous group of processes including tuberculoma, bronchial stenosis, bronchiectasis, broncholithiasis, aspergilloma, bronchoesophageal fistula and fibrosing mediastinitis [2].Tuberculosis is a long-recognized and well-documented cause of secondary spontaneous pneumothorax, with an incidence of approximately 5% in postprimary (pulmonary) tuberculosis patients, usually in severe cavitary disease. Overall, around 1% of patients with active tuberculosis present with secondary spontaneous pneumothorax [3, 4], nevertheless the initial presentation as spontaneous tuberculosis is exceptional.Pleural infection results from rupture of subpleural caseous lesions, resulting in accumulation of a chronic empyema. A bronchopleural fistula may occur spontaneously during the natural history of the disease. Both chronic empyema and bronchopleural fistula may result in spontaneous pneumothorax, the latter with a more acute presentation [2, 3, 4]. In our case, the poorly differentiated multifocal consolidations predominately in the upper lobes, with tree-in-bud pattern and cavitation of some of them, suggest an active post-primary tuberculosis. In addition, the patient developed a spontaneous hydropneumothorax as a complication.Tube thoracostomy is the indicated treatment, in conjunction with appropriate pharmacologic management of tuberculosis and other infections [1, 2]. We conclude that secondary spontaneous pneumothorax in patients with tuberculosis occurs especially in cases presenting a destroyed lung. It is not uncommon in the end stages of tuberculosis with a prolonged process of cavitation, spread to new areas, and subsequent fibrosis [1, 2].",
    "differential_diagnosis": "Hydropneumothorax, as, the, initial, manifestation, of, postprimary, tuberculosis., Chronic, obstructive, pulmonary, disease, (emphysema, cystic, fibrosis...), Lung, cancer, Other, infection, (coccidioidomycosis, aspergillosis, histoplasmosis...), Pneumocystis, jiroveci, (in, HIV-related, disease)",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012749/000010.jpg?itok=YAzyuNI1",
            "caption": "Chest radiograph reveals left-sided air-fluid level (arrowhead) with pneumothorax and consolidations in the right upper lobe and upper segment of the right lower lobe (arrow)."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012749/000009.jpg?itok=yqjf4xKj",
            "caption": "Chest radiograph reveals left-sided air-fluid level (arrowhead) with pneumothorax and consolidations in the right upper lobe and upper segment of the right lower lobe (arrow)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012749/000011.jpg?itok=QE_FhXFI",
            "caption": "Lung window setting reveals consolidations with cavities in the collapsed left lung (black arrow). The right upper lobe presents multiple consolidations (white arrow). Tube thoracostomy is positioned in the left pleural space(arrowhead)."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012749/000014.jpg?itok=_qpVKkDC",
            "caption": "Lung window setting reveals consolidations with cavities in the collapsed left lung (black arrow). The right upper lobe presents multiple consolidations (white arrow). Tube thoracostomy is positioned in the left pleural space (arrowhead)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012749/000016.jpg?itok=z09m5L2E",
            "caption": "Left loculated pleural effusion with thickening and enhancement of parietal and visceral pleura (black arrow). In addition, secondary to left lung collapse (arrowhead), an ipsilateral mediastinal shift is produced (white arrow)."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012749/000017.jpg?itok=b_aB89od",
            "caption": "Left loculated pleural effusion with thickening and enhancement of parietal and visceral pleura (black arrow). In addition, secondary to left lung collapse (arrowhead), an ipsilateral mediastinal shift is produced (white arrow)."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/12749",
    "time": "03.07.2015"
  },
  "12770": {
    "case_id": 12770,
    "title": "Incidental pleural lipoma in a case of calculous cholecystitis",
    "section": "Chest imaging",
    "age": "54",
    "gender": "male",
    "diagnosis": "Incidental pleural lipoma in a case of calculous cholecystitis",
    "history": "A 54-year-old male patient presented with the chief complaints of abdominal pain with dark urine for 3-4 days. The patient was a non-smoker and non-alcoholic. He gave no other significant history.",
    "image_finding": "Ultrasound of abdomen (Fig. 1) revealed multiple calculi averaging approximately 5 to 6 mm. Routine PA Chest Radiograph (Fig. 2) showed a radio-opaque lesion in the right midzone with well-defined margins superiorly, medially and inferiorly, while the lateral margin was obscured by the chest wall. The lesion showed obtuse angles with the chest wall suggesting its pleural-based origin. Chest CT (Fig. 3, 4) plain and post-contrast showed that the lesion was non-enhancing with fat attenuation of approx. -109 Hounsfield Units. The lesion measured approx. 4.7 by 3 cm.",
    "discussion": "Pleural lipomas are extremely rare benign tumours that originate from the submesothelial layers of the parietal pleural and extend into the subpleural or extrapleural space. They show a slow pattern of growth. These lesions are mostly solitary and involve both sides with equal frequencies. Rarely these lesions may cause symptoms secondary to mass effect such as cough, chest pain, dyspnoea, heaviness of the chest or even back pain. [1, 2] On chest radiograph, they appear as smooth, rounded nodules/masses. CT is the imaging modality of choice. Radiological diagnostic criteria for pleural lipomas include a well-defined mass with homogeneous fat density (-50 to -150 HU), which does not enhance on contrast administration, forms obtuse angles with the chest wall and displaces adjacent pulmonary parenchyma and vessels. [2-4] Advantages of CT include differentiating between pleural and parenchymal disease, determining the location and extent of the lesion as well as characterization of the tissue based on its attenuation. Ultrasound may help in confirming the pleural origin of the tumour, including providing information whether the lesion is cystic or solid and confirming its fat density and homogeneity. MRI is done only if there is a doubt in radiological diagnosis by CT. It gives a better delineation of the relationship between the tumour and the chest wall. MRI can also differentiate between diaphragmatic hernias and eventrations from lipomas arising near the diaphragm. However, the main role of MRI is its value in differentiating lipomas from liposarcomas.[2, 4] Management of pleural lipomas is not clearly established and is controversial. In the elderly, and especially in those patients with small and asymptomatic lesions, clinical and imaging follow-up is suggested. However, certain authors suggest surgical radical excision as the treatment of choice. The three main reasons for this are: it allows diagnosis by histopathology especially in non-homogenous lesions, allows relief of symptoms and lastly it limits the mass effect on adjacent organs. [3-5] Surgical options include open typical or muscle-sparing thoracotomy, video-assisted thoracoscopic surgery (VATS), and extirpation of pleural lipomas by a single port VATS. [2, 3] Complications, although rare, include compression of adjacent organs, rib lysis secondary to invasion of intercostal spaces and intratumoural haemorrhage causing pain and fever. There is no known secondary transformation of pleural lipomas to liposarcomas. [4, 5] Features favouring liposarcoma include large lesion size, thick septa, nodular and/or globular or non-adipose mass-like areas, decreased percentage of fat and advanced patient age. [6]",
    "differential_diagnosis": "Incidental, pleural, lipoma, in, a, case, of, calculous, cholecystitis, Liposarcoma, Hamartoma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012770/000001.jpg?itok=iWmPKKOM",
            "caption": "PA chest radiograph showed a radio-opaque lesion in the right midzone which made an obtuse angle with the chest wall. Adjacent ribs were normal."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012770/000002.jpg?itok=GeSyINUN",
            "caption": "Plain CT (axial section) showed a pleural-based fat density lesion measuring approx. 4.7 x 3 cm with HU value= -109."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012770/000003.jpg?itok=cPGKJeL6",
            "caption": "On post-contrast chest CT (axial sections) the pleural-based fat density lesion showed no enhancement with HU value remaining -109."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012770/000004.jpg?itok=vBIFnuZg",
            "caption": "Coronal CT of chest showing a right pleural-based fat density lesion."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012770/000005.jpg?itok=kdp0p6od",
            "caption": "Sagittal CT of chest showing a right pleural-based fat density lesion."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012770/000006.jpg?itok=0KbBmpA3",
            "caption": "Distended gall bladder showing multiple 6-7 mm calculi."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Abdomen",
      "Respiratory system"
    ],
    "imaging_technique": [
      "Ultrasound",
      "Digital radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/12770",
    "time": "16.06.2015"
  },
  "12804": {
    "case_id": 12804,
    "title": "Pectus carinatum in a patient with neurofibromatosis",
    "section": "Chest imaging",
    "age": "48",
    "gender": "male",
    "diagnosis": "Pectus carinatum (chondrogladiolar deformity type) in a patient with neurofibromatosis.",
    "history": "A 48-year-old male patient with history of neurofibromatosis 1 was referred to the radiology department for a follow-up Computed Tomography of his chest in order to evaluate multiple cutaneous neurofibromas and exclude the presence of intrathoracic or spinal disease.",
    "image_finding": "The CT examination of this patient revealed the presence of numerous widespread cutaneous nodules, which could be attributed to neurofibromas caused by the underlying disease. (Fig. 1) The most conspicuous cutaneous neurofibroma measured 16x4 cm in an axial plane and was situated in the left anterior chest wall. (Fig. 1) There were no paraspinal masses or widened intervertebral foramen. Regarding the lung parenchyma, extensive emphysema was present. (Fig. 2)Of note was the fact that the patient\u2019s chest was rhomboid in shape with the sternum projecting anteriorly. This configuration of the chest wall was characteristically identified on axial cross-sectional CT images. The anteroposterior diameter of the chest was 173 mm, whereas the transverse one was 279 mm. As a result, the pectus index was 1.61. (Fig. 2) Multiplanar Reconstruction (MPR) and Volume Rendering Technique (VRT) images were created to better illustrated the chest wall anatomy. (Fig. 2)",
    "discussion": "The congenital presence of anteriorly displaced sternum and adjacent costal cartilages is characterized as pectus carinatum (PC), also known as pigeon breast. [1, 2] It represents the second most common sternal congenital anomaly after pectus excavatum, with a reported prevalence of 0.675%. PC may be hereditary, affects men four times more than women and coexists with scoliosis in more than 30% of cases. Association with congenital heart disease has been described only in a minority of cases. [1, 3] PC is also reportedly associated with genetic conditions like Marfan and Noonan syndromes and rarely coexists with neurofibromatosis. [2, 4] Two main types of PC have been described, each with different surgical implications. Currarino-Silverman syndrome refers to the presence of a chondromanubrial deformity with protrusion of the manubrium and upper sternum. Chondrogladiolar deformity describes the protrusion of the middle and lower sternum (keel chest). [1-3] This type involves 95% of cases. [2] According to the literature, a third type of PC includes lateral PC with unilateral protrusion of costal cartilages and sternal rotation. [3] PC can finally be iatrogenic and represent a complication of surgery for pectus excavatum. [2]Lateral chest radiographs can successfully identify PC with increased anteroposterior diameter of the chest caused by anterior protrusion of the sternum. [1] Even if some authors consider lateral radiographs enough for preoperative work-up, CT and MRI can further evaluate sternal anatomy and provide accurate measurements. [2] The pectus index has been introduced to diagnose both pectus excavatum and pectus carinatum and assess the need for surgical correction by objectively grading the sternal malformation. This index is calculated by dividing the transverse diameter of the chest by its anteroposterior one. These diameters can be obtained by either CT or MRI. Normal values of the pectus index are 2.21 to 2.91 (mean: 2.56, standard deviation: \u00b10.35). A pectus index greater than these values is indicative of pectus excavatum, whereas an index value between 1.42 and 1.98 poses the diagnosis of pectus carinatum. [1] PC commonly causes symptoms like dyspnoea and exercise intolerance but rarely cardiac and pulmonary dysfunction. Moreover, a disturbed body image, pain, psychological distress and thus reduced quality of life are consequences of this congenital anomaly. PC becomes evident in children, especially at the time of puberty, when the deformity becomes more conspicuous. Surgical treatment of PC significantly alleviates the symptoms. [1-4] Apart from the traditional surgical reconstruction, orthotic bracing has recently emerged as an alternative treatment option in selected patients. [2, 5]",
    "differential_diagnosis": "Pectus, carinatum, (chondrogladiolar, deformity, type), in, a, patient, with, neurofibromatosis., Pectus, carinatum, (chondrogladiolar, deformity), Pectus, carinatum, (chondromanubrial, deformity), Pectus, excavatum, Complicated, surgery, for, pectus, excavatum",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012804/000001.jpg?itok=DtXF6Mp-",
            "caption": "Axial CT image identifying multiple cutaneous nodules representing neurofibromas (arrowheads)."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012804/000002.jpg?itok=0GcXkXYJ",
            "caption": "Axial CT image at the level of the manubrium reveals the larger neurofibroma situated on the left anterior chest wall."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012804/000003.jpg?itok=b-xO6MmX",
            "caption": "Axial CT image in lung window settings showing the presence of emphysema."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012804/000004.jpg?itok=ZfyxjdlX",
            "caption": "Axial CT image demonstrating the rhomboid shape of the patient\u2019s chest."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012804/000005.jpg?itok=EVcrCxRo",
            "caption": "The pectus index calculation."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012804/000006.jpg?itok=opGr7-Be",
            "caption": "Sagittal MPR image assessing the full extent of the sternal protrusion. The malformation mainly affects the middle and lower part of the sternum. This distribution of the malformation justifies its classification as chondrogladiolar type."
          },
          {
            "number": "Figure 2e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012804/000007.jpg?itok=yoNrx6LO",
            "caption": "VRT image illustrating the chest skeletal anatomy."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thoracic wall",
      "Thorax"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/12804",
    "time": "28.06.2015"
  },
  "12811": {
    "case_id": 12811,
    "title": "Diffuse pulmonary calcification in end-stage chronic renal insufficiency",
    "section": "Chest imaging",
    "age": "45",
    "gender": "female",
    "diagnosis": "Diffuse pulmonary calcification in the context of end-stage renal insufficiency",
    "history": "A 45-year-old Caucasian female patient with a prior history of chronic renal insufficiency due to medullary sponge kidney, with secondary hyperparathyroidism, was admitted in our institution for serious hypokalaemia and anaemia. The patient had neither smoking history nor signs or symptoms of respiratory disease.",
    "image_finding": "A routine chest X-ray showed multiple high density micro-nodular opacities in the upper lobes of the lungs. To better characterize those pulmonary abnormalities, a thoracic CT was requested, depicting diffuse high density nodular opacities consistent with centrilobular calcifications in the upper lobes of the lungs. A non-enhanced abdomino-pelvic CT demonstrated findings of renal pyramid calcifications related to nephrocalcinosis.",
    "discussion": "Diffuse pulmonary calcification, also known as pulmonary metastatic calcification, is a progressive interstitial process, usually related with chronically elevated serum calcium levels, in which calcium is deposited in the alveolar septa, bronchial walls and pulmonary arteriole. [1-6]Despite being a frequent complication in end-stage chronic renal insufficiency treated with haemodialysis, most patients remain asymptomatic, and a small portion develops severe respiratory symptoms, related to the extent of pulmonary calcification and fibrosis with restrictive syndrome. [2, 5-8]Conventional chest radiographs lack sensitivity and specificity for this pathology that may simulate pulmonary oedema, airspace disease or appear as diffuse interstitial infiltrates. [4, 8]The superior sensitivity of high-resolution computed tomography (HRCT) allows the detection of small lung calcifications, which can be associated with vascular calcifications and/or centrilobular ground-glass nodular opacities, with numerous poorly defined nodules measuring 3\u201310 mm in diameter. [2-5]An upper lobe predominance for metastatic pulmonary calcification has been reported, supposedly due to higher ventilation-perfusion ratio and increased alkalinity that favours calcium precipitation. [1, 6]The differential diagnosis includes lung dystrophic calcifications due to a variety of other conditions such as infections (e.g. tuberculosis), silicosis, sarcoidosis, metastatic tumour, rheumatic mitral stenosis, microlithasis and broncholithiasis, each one with different patterns of parenchymal involvement. [3, 4]It is important to be aware of this entity to correctly identify this potentially progressive and fatal cause of respiratory failure, as appropriate measures can be taken to reverse hypercalcaemia. In addition, recognition of metastatic pulmonary calcification at CT may, in some cases, obviate the need for more invasive procedures, such as open-lung biopsy, to determine the cause of a noncleaning infiltrate in a patient with end-stage renal failure.",
    "differential_diagnosis": "Diffuse, pulmonary, calcification, in, the, context, of, end-stage, renal, insufficiency, Tuberculosis, Silicosis, Sarcoidosis, Metastatic, tumour",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012811/000001.jpg?itok=sGzKyPq7",
            "caption": "Thoracic radiography showing multiple high density micronodular opacities with predominance in both upper lobes, sparing the lowest two thirds of lungs."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012811/000002.jpg?itok=5W07MbzA",
            "caption": "Axial section of thoracic CT with lung window showing diffuse high density nodular opacities within alveolar spaces."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012811/000004.jpg?itok=QFgFP5kj",
            "caption": "Coronal reconstruction of thoracic CT in lung window reveals predominance of the nodular high density opacities in the upper lung lobes."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012811/000003.jpg?itok=Rkp_rdXC",
            "caption": "Coronal reconstruction of abdomino-pelvic CT, demonstrating high density of the renal medular pyramids, consistent with nephrocalcinosis."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Kidney",
      "Lung"
    ],
    "imaging_technique": [
      "CT",
      "CT-High Resolution"
    ],
    "link": "https://www.eurorad.org/case/12811",
    "time": "22.12.2015"
  },
  "12819": {
    "case_id": 12819,
    "title": "Traumatic lung hernia: multidetector CT findings and relevance",
    "section": "Chest imaging",
    "age": "68",
    "gender": "female",
    "diagnosis": "Traumatic intercostal lung hernia",
    "history": "A lady presenting to the emergency department for persistent pain the day after a domestic fall with left-sided blunt chest trauma. She was found slightly dyspnoeic with signs of blunt impact over her left lateral chest at physical examination, with stable cardiorespiratory parameters and arterial blood gas values within normal limits.",
    "image_finding": "The patient had a history of allergy to iodinated contrast medium and normal findings on previous chest radiographs (not shown). Plain radiographs (Fig. 1) revealed post-traumatic left-sided subcutaneous emphysema from the supraclavicular region and posterior paravertebral muscles to the iliac crest, fractured 8th rib, and a sizeable basal opacity with air-fluid level consistent with pulmonary laceration. Ultrasound assessment of the spleen (Fig. 2) was hampered by \u201chazy\u201d posterior shadowing from extrathoracic emphysema. Crepitance was palpable along the left hemithorax. Urgent unenhanced multidetector CT (Fig. 3) confirmed emphysema, dislocated rib fracture and pulmonary laceration with dependent blood. Additionally, CT showed minimal ipsilateral pneumothorax, normal-sized homogeneous spleen, absent haemoperitoneum. Part of the lower left pulmonary lobe herniated outside the thoracic cage through the injured intercostal space, as further depicted by minimum-intensity projection and volume-rendering views (Fig. 3 i, j).The patient was sent to thoracic surgery to undergo prompt hernia repair.",
    "discussion": "A traumatic lung hernia (TLH) represents an uncommon consequence of blunt thoracic trauma with approximately 300 reported cases in the literature, the majority occurring after motor vehicle accidents. Represented by the protrusion of pulmonary tissue covered by pleural membranes through a traumatic defect in the thoracic wall, TLH is more likely when the injury mechanism involves a sudden marked increase of intrathoracic pressure such as in seatbelt-restrained individuals. Herniation most commonly occurs at the antero-lateral chest wall, which has limited muscular support compared to the posterior chest in the site of rib fractures and torn intercostal muscles. Alternatively, TLHs may sometimes develop in the site of costochondral junction fractures. The unspecific symptoms of TLH include pain, coughing, haemoptysis, shortness of breath. Sometimes, physical examination may detect a fluctuating mass with overlying crepitus. Sometimes, the diagnosis is delayed weeks or months after the trauma [1-4].The antero-posterior chest radiograph traditionally represents the initial technique used to investigate blunt thoracic trauma. In TLH, plain X-rays may reveal a contained radiolucency in the chest wall, which may be apparent and expand paradoxically in forced expiratory views obtained to exclude pneumothorax, or during Valsalva\u2019s manoeuvre. However, TLHs may be radiographically obscured by emphysema or haematoma, and is easily missed when the X-ray beam is not tangential to the hernia [1, 2, 5, 6]. Multidetector computed tomography (CT) is the preferred and most accurate modality to detect and characterize traumatic chest injuries, and CT findings have been consistently found to impact the patients\u2019 management. As this case exemplifies, CT including multiplanar, minimum intensity projection (minIP) and volumetric reformatted images clearly depicts the traumatic orifice in the thoracic bony and muscular cage and the herniated lung portion: the improved anatomical visualization provided by CT is of value to the thoracic surgeon for the treatment planning [1, 5-8]. Spontaneous resolution of a TLH is uncommon. Since TLHs may grow and eventually undergo incarceration or strangulation under positive-pressure ventilation, the diagnosis should be made before patients are intubated and undergo general anaesthesia for other reasons such as splenic injury. Some asymptomatic patients may be treated conservatively. Conversely, immediate open or thoracoscopic surgical exploration is required for most intercostal hernias, to assess viability of the herniated lung portion, reduce the TLH and repair the defect with a muscle flap or synthetic prosthetic graft [9, 10].",
    "differential_diagnosis": "Traumatic, intercostal, lung, hernia, Chest, wall, haematoma, /, Subcutaneous, emphysema, Chest, wall, abscess, Penetrating, thoracic, trauma, Congenital, lung, hernia, Pathologic, hernia, (infections, tuberculous, empyema, tumour), Spontaneous, lung, hernia, e.g., from, heavy, coughing, weightlifting, wind, instruments, playing, glass, blowing",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012819/000003.jpg?itok=PEfVug3W",
            "caption": "Antero-posterior (a) and oblique views (b,c) showed subcutaneous emphysema (thin arrows) of the lateral thoracic wall and supraclavicular region; fractured 8th rib (arrowhead); basal opacity with air-fluid level consistent with pulmonary laceration (short arrows)."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012819/000004.jpg?itok=RHthar0F",
            "caption": "Oblique views of the left hemithorax showed subcutaneous emphysema (thin arrows) of the lateral thoracic wall and supraclavicular region; basal opacity with air-fluid level consistent with pulmonary laceration (short arrows)."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012819/000005.jpg?itok=JKiJYRUU",
            "caption": "Oblique views of the left hemithorax showed subcutaneous emphysema (thin arrows) of the lateral thoracic wall and supraclavicular region; basal opacity with air-fluid level consistent with pulmonary laceration (short arrows)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012819/000006.jpg?itok=jca4ZTPd",
            "caption": "Ultrasound examination of the left upper abdomen showed \\\"hazy\\\" shadowing (*) from subcutaneous air which prevented visualization of the spleen."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012819/000007.jpg?itok=Wz3RAjgZ",
            "caption": "Axial images viewed at soft-tissue window settings (a...d in craniocaudal order) showed left-sided extrathoracic emphysema (+) tracking upwards to the supraclavicular fossa and the posterior paravertebral muscles."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012819/000008.jpg?itok=ZsENesF_",
            "caption": "The injured left hemithorax showed subcutaneous emphysema (+), minimal pleural effusion, dislocated fracture of the 8th rib (arrow in c), and basal pulmonary laceration with dependent blood (short arrow in d)."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012819/000009.jpg?itok=tweZuQz7",
            "caption": "The injured left hemithorax showed subcutaneous emphysema (+), minimal pleural effusion, dislocated fracture of the 8th rib (arrow in c), and basal pulmonary laceration with dependent blood (short arrow in d)."
          },
          {
            "number": "Figure 3d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012819/000010.jpg?itok=i_6hkuZk",
            "caption": "The injured left hemithorax showed subcutaneous emphysema (+), minimal pleural effusion, dislocated fracture of the 8th rib (arrow in c), and basal pulmonary laceration with dependent blood (short arrow in d)."
          },
          {
            "number": "Figure 3e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012819/000011.jpg?itok=9Bvy3MKq",
            "caption": "The spleen appeared normal-sized and homogeneous. No haemoperitoneum was present. Note subcutaneous emphysema (+)."
          },
          {
            "number": "Figure 3f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012819/000016.jpg?itok=elx00kBF",
            "caption": "Axial images viewed at lung window settings showed extrathoracic emphysema (+); minimal pneumothorax (*) and basal pulmonary laceration with dependent blood (short arrow in h)."
          },
          {
            "number": "Figure 3g",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012819/000017.jpg?itok=Gp-RsnDj",
            "caption": "Additionally, a ventral portion of the left inferior pulmonary lobe was seen herniated (arrowhead) through the 8th intercostal space.  \nNote extrathoracic emphysema (+); nondependent pneumothorax (*)."
          },
          {
            "number": "Figure 3h",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012819/000023.jpg?itok=du2NlBzH",
            "caption": "Additionally, a ventral portion of the left inferior pulmonary lobe was seen herniated (arrowhead) through the 8th intercostal space.  \nNote extrathoracic emphysema (+)."
          },
          {
            "number": "Figure 3i",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012819/000024.jpg?itok=Ftoirjae",
            "caption": "Coronal minimum-intensity projection (minIP) image comprehensively depicted minimal pneumothorax (*), extensive subcutaneous emphysema (+), air content of pulmonary laceration (short arrow), and lung hernia (arrowhead)."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Spleen"
    ],
    "imaging_technique": [
      "Ultrasound",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/12819",
    "time": "15.07.2015"
  },
  "12822": {
    "case_id": 12822,
    "title": "Disseminated tuberculosis after anti-TNF\u03b1 therapy for Crohn\\&#039;s disease",
    "section": "Chest imaging",
    "age": "55",
    "gender": "male",
    "diagnosis": "Disseminated \"miliary\" tuberculosis during biologic (adalimumab) treatment for Crohn's disease",
    "history": "Patient with long-standing history of Crohn\u2019s disease (CD) including partial colectomy, treated with adalimumab for four months due to steroid-refractory disease. Currently hospitalized with malaise, weight loss, mucohaemorrhagic diarrhoea, persistent high fever, abdominal pain without peritonitis and elevated C-reactive protein despite antibiotics, with presumptive clinical diagnosis of acute CD exacerbation.",
    "image_finding": "Prior to therapy start, radiographs (Fig. 1) excluded active pleuropulmonary lesions and signs of prior exposure to Mycobacterium tuberculosis (MTB), in agreement with a negative tuberculin skin test. Endoscopy and MR-enterography (not shown) diagnosed active ileo-colonic CD. At admission, radiographs (Fig. 2) showed the appearance of a symmetric \"hazy\" micronodular lung pattern. CT clearly depicted miliary lung involvement using maximum-intensity projection images (Fig. 3a...d), as innumerable evenly distributed tiny nodules throughout all lobes, predominantly well-demarcated, some of them subpleural.Additional CT findings were centrally hypoattenuating lower lobe subpleural consolidation (Fig. 3e..h), necrotic lymphadenopathies with peripheral rim enhancement in the subcarinal region and right hilum (Fig. 4a...d), and some sub-centimetre hypoattenuating foci in the mildly enlarged spleen (Fig. 4e). Haemocultures and stool cultures tested negative. Bronchoscopy and bronchoalveolar lavate disclosed acid- and alcohol-fast bacilli consistent with MTB, confirmed by positive DNA assay. Antitubercular treatment allowed prompt clinical improvement with regression of fever and normalisation of C-reactive protein.",
    "discussion": "Anti-tumour necrosis factor-alpha (TNF\u03b1) medications including infliximab and adalimumab represent major advancements in the treatment of chronic inflammatory and autoimmune disorders such as ankylosing spondylitis, rheumatoid arthritis and Crohn\u2019s disease (CD). However, due to its key role in immune response, TNF\u03b1 blockade may result in reactivation of recent or remotely acquired viral and mycobacterial infections. The incidence of opportunistic infections reaches 9% (3.4/100 patient-years) overall and 4% (1.6/100 patient-years) for serious occurrences. Therefore, latent infections and specifically tuberculosis (TB) should be ruled out prior to treatment start: current practice guidelines recommend screening with tuberculin skin test, chest radiographs or interferon-gamma release assays [1-3]. Furthermore, de novo TB may arise after start of anti-TNF\u03b1 despite negative screening [4, 5] or chemoprophylaxis [6]. Traditionally, primary TB occurred in childhood as a self-limiting disease manifesting with subpleural parenchymal consolidation in the middle or lower lobes (often indistinguishable from bacterial pneumonia) plus unilateral, typically right-sided paratracheal, tracheobronchial and subcarinal adenopathies with characteristic central low-density and peripheral enhancing rim; other possible manifestations of primary TB included acute bronchogenic spread, miliary TB and pleural effusion. Conversely, cavitation was the traditional hallmark of post-primary TB. Currently, primary TB is increasingly observed in previously unexposed adults. Furthermore, in immunocompromised patients such as those on TNF\u03b1 inhibitors, extensive lymphatic and haematogenous spread may result in disseminated and extrapulmonary TB forms, which evolve rapidly and eventually prove fatal if unrecognized [7-11]. Encountered in the setting of both primary and reactivated TB, the miliary pattern results from the acute haematogenous dissemination of bacilli leading to the development of innumerable tuberculous granulomas in the lungs and other organs such as the liver and spleen. Particularly in immunosuppressed patients, clinical presentation varies from insidious febrile illness with malaise and anorexia, to acute respiratory distress. Sometimes initially unremarkable, plain radiographs may show either a poorly defined \u201chaze\u201d through both lungs or the classic appearance of diffusely scattered micronodules. As this case exemplifies, CT better demonstrates miliary disease as widespread, evenly distributed innumerable micronodular infiltrates without any topographic predominance [7-9]. In conclusion, physicians and radiologists should be aware of the increased risk of TB reactivation in people on TNF\u03b1 antagonist therapies. Recognition and reporting of any suspicious abnormality suggestive of TB allows curing the disease with cessation of anti-TNF\u03b1 medication and prolonged antimycobacterial antibiotic treatment [4-6, 10-12].",
    "differential_diagnosis": "Disseminated, \"miliary\", tuberculosis, during, biologic, (adalimumab), treatment, for, Crohn's, disease, Other, opportunistic, infections, e.g., fungal, atypical, mycobacteriosis, Early, (non-cavitated), septic, emboli, Extrinsic, allergic, alveolitis, Sarcoidosis, Haematogenous, metastases, /, Neoplastic, lymphangitis, Drug-induced, lung, disorder, Cryptogenic, organizing, pneumonia, Eosinophilic, pneumonia, Crohn\u2019s, disease, related, necrobiotic, nodules, (exceptional)",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012822/000001.jpg?itok=G8q-RlYw",
            "caption": "Prior to anti-TNF\u03b1 therapy start, chest radiographs did not show active pleuropulmonary lesions and abnormal pulmonary or mediastinal calcifications suggesting prior exposure to tuberculosis."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012822/000002.jpg?itok=Jj6n6P_-",
            "caption": "Prior to anti-TNF\u03b1 therapy start, chest radiographs did not show active pleuropulmonary lesions and abnormal pulmonary or mediastinal calcifications suggesting prior exposure to tuberculosis."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012822/000003.jpg?itok=AdlBNlc3",
            "caption": "At admission radiographs showed the appearance of a \\\"hazy\\\" micronodular pattern symmetrically involving both lungs, without signs of pleural effusion."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012822/000004.jpg?itok=4cgwPXrV",
            "caption": "At admission radiographs showed the appearance of a \\\"hazy\\\" micronodular pattern symmetrically involving both lungs, without signs of pleural effusion."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012822/000005.jpg?itok=lwBLpZsz",
            "caption": "Axial 10mm maximum-intensity projection (MIP) images in craniocaudal order clearly depicted innumerable, evenly distributed tiny nodules (up to 4-5mm in size) throughout all lobes of both lungs."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012822/000006.jpg?itok=rK1BiRiy",
            "caption": "Axial 10mm maximum-intensity projection (MIP) images in craniocaudal order clearly depicted innumerable, evenly distributed tiny nodules (up to 4-5mm in size) throughout all lobes of both lungs."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012822/000007.jpg?itok=HEWiz4X0",
            "caption": "Axial 10mm maximum-intensity projection (MIP) images in craniocaudal order clearly depicted innumerable, evenly distributed tiny nodules (up to 4-5mm in size) throughout all lobes of both lungs."
          },
          {
            "number": "Figure 3d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012822/000008.jpg?itok=4AT4_ZQN",
            "caption": "Detail maximum-intensity projection (MIP) images in craniocaudal order clearly depicts the evenly distributed, mostly demarcated micronodules, some of them in a supleural location."
          },
          {
            "number": "Figure 3e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012822/000009.jpg?itok=hvUJ6PWW",
            "caption": "Additionally, in the right lower lobe a peripheral consolidation (short arrows) was seen reaching the diaphragmatic pleura, with central necrotic-like hypoattenuation (g)."
          },
          {
            "number": "Figure 3f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012822/000010.jpg?itok=Kf3AVfHw",
            "caption": "Additionally, in the right lower lobe a peripheral consolidation (short arrows) was seen reaching the diaphragmatic pleura, with central necrotic-like hypoattenuation (g)."
          },
          {
            "number": "Figure 3g",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012822/000011.jpg?itok=NhYYSv8J",
            "caption": "Additionally, in the right lower lobe a peripheral consolidation (short arrows) was seen reaching the diaphragmatic pleura, with central necrotic-like hypoattenuation."
          },
          {
            "number": "Figure 3h",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012822/000012.jpg?itok=o5puaaET",
            "caption": "Additionally, in the right lower lobe a peripheral consolidation (short arrows) was seen reaching the diaphragmatic pleura, with central necrotic-like hypoattenuation."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012822/000013.jpg?itok=0LMs5CnI",
            "caption": "Centrally hypoattenuating necrotic lymphadenopathies with peripheral rim enhancement were present in the subcarinal region (arrowheads) and at the right hilum (arrows)."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012822/000014.jpg?itok=DsWWth90",
            "caption": "Centrally hypoattenuating necrotic lymphadenopathies with peripheral rim enhancement were present in the subcarinal region (arrowheads) and at the right hilum (arrows)."
          },
          {
            "number": "Figure 4c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012822/000015.jpg?itok=M9dl95xP",
            "caption": "Centrally hypoattenuating necrotic lymphadenopathies with peripheral rim enhancement were present in the subcarinal region (arrowheads) and at the right hilum (arrows)."
          },
          {
            "number": "Figure 4d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012822/000016.jpg?itok=WbwKREuY",
            "caption": "Centrally hypoattenuating necrotic lymphadenopathies with peripheral rim enhancement were present in the subcarinal region (arrowheads) and at the right hilum (arrows)."
          },
          {
            "number": "Figure 4e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012822/000017.jpg?itok=-gTKQhWz",
            "caption": "Additionally, some tiny (sub-centimetre) hypoattenuating foci (thin arrow) were seen in the mildly enlarged spleen."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Mediastinum",
      "Spleen"
    ],
    "imaging_technique": [
      "CT",
      "CAD"
    ],
    "link": "https://www.eurorad.org/case/12822",
    "time": "06.08.2015"
  },
  "12846": {
    "case_id": 12846,
    "title": "Mediastinal mature cystic teratoma with rapid growth and rupture",
    "section": "Chest imaging",
    "age": "50",
    "gender": "male",
    "diagnosis": "Anterior mediastinal mature cystic teratoma with rapid growth and rupture",
    "history": "50-year-old male patient presented with acute onset lower anterior thoracic pain associated with vomiting and fevers. He had no relevant past medical history. There were no associated respiratory symptoms. He was initially evaluated with a chest radiograph followed by a CT scan of the chest and abdomen which showed the following.",
    "image_finding": "The frontal chest radiograph (Fig. 1a) on admission demonstrated a well-defined elongated opacity overlying the right cardiac border (with the latter not being clearly delineated). This favoured the location of the abnormality to be in the anterior mediastinum. A radiograph performed two years before was normal (Fig. 1b).Subsequent CT images (Fig. 2a-c) confirmed a rounded 9 cm well-defined anterior mediastinal mass abutting the right heart border corresponding to the radiographic abnormality. There were fluid as well as fat attenuating components within it with a small focus of hyper-attenuation (likely representing a calcific component). These imaging features favoured a mediastinal teratoma.Additionally, there was ill-defined fluid with stranding (Fig. 3a-b) extending deeply within the anterior sulcus of the anterior mediastinum beneath the costochondral articulations in keeping with a rupture (leading to the acute presentation). Moderate bi-basal posterior pleural effusions were seen but there was no pericardial fluid.",
    "discussion": "A mature cystic teratoma (dermoid cyst) is a germ-cell derived tumour composed of at least two of the three well-differentiated germ cell layers (ectoderm, mesoderm, and endoderm) [1]. The anterior mediastinum is the commonest extragonadal site for these [2]. Benign teratomas could represent around 3-12% of all mediastinal tumours. They most commonly present in the second to fourth decades of life [3]. Some articles quote an equal gender distribution while others quote a female preponderance [4, 5]. Patients are usually asymptomatic with most lesions diagnosed incidentally on chest radiographs or CT scans performed for an unrelated reason. Some may present acutely with cough, dyspnoea or chest pain if there is bronchial tree/SVC compression or mediastinal or wider thoracic rupture [3, 4]. Clinical perspectiveThe rapid growth observed in this case is unusual for a mature cystic teratoma but has been occasionally reported [6, 7, 8]. Being an adult male is also unusual considering the typical age-gender distribution of benign teratomas. Our patient presented with acute lower-anterior thoracic pain due to a rupture into the anterior mediastinal space with extension of ruptured content deeper into the anterior sulcus. Imaging perspectiveCT appearances can be variable with combinations of well-defined fat, fluid, soft tissue components and calcification. Fat-fluid levels or focal fat collections, though uncommon, are considered highly specific for a mediastinal mature teratoma [9]. Lesions are often large at presentation and may occupy a large part or all of the hemithorax [3, 4]. A rupture could render inhomogeneity of internal components and result in pleural or pericardial effusions [10]. Haemorrhage and/or infection may lead to rapid increase in size although this was not present in our case [3]. The final diagnosis was made by histological evaluation of the surgical specimen. In our case, the pathological biopsy specimen showed a cystic mass with a 5 mm thick wall containing brown to greenish fluid and a solid nodular area with a partly fatty cut surface and no other intra-cystic proliferation. Focal haemorrhage and fibrinous exudate within the cyst wall extending to the overlying surface was seen consistent with perforation [11] with no major intra-lesional haemorrhage. On microscopy, it contained cutaneous and respiratory epithelium, pancreatic parenchyma, smooth muscle and abundant adipose tissue consistent with a teratoma with no immature components or malignancy [11]. Outcome Our patient then underwent a complete surgical resection (the preferred modality of treatment for mature cystic teratoma) with an uneventful recovery [12].",
    "differential_diagnosis": "Anterior, mediastinal, mature, cystic, teratoma, with, rapid, growth, and, rupture, Cystic, thymoma, with, rupture, Mediastinal, mature, cystic, teratoma, -, with, malignant, transformation",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012846/000001.jpg?itok=LA27IXWw",
            "caption": "Frontal chest radiograph on admission demonstrates a well-defined elongated mass-like area of opacification overlying the right cardiac border. A distinct right cardiac contour is difficult to delineate."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012846/000002.jpg?itok=-GZ7TRFT",
            "caption": "A prior radiograph from two years ago of the same patient shows normal findings."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012846/000003.jpg?itok=8CRKnMnD",
            "caption": "Selected axial CT image shows an irregular but reasonably well-defined rounded right anterior mediastinal mass with fluid and fat attenuating components corresponding to the position of the radiographic abnormality."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012846/000004.jpg?itok=jS4GlNvl",
            "caption": "Selected coronal CT image further delineates the anterior mediastinal mass which again comprises fluid and fat attenuating components. A small adjacent high attenuating component may represent an early focus of calcification."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012846/000005.jpg?itok=ttk4HHJP",
            "caption": "Selected sagittal CT image shows the extent of the anterior mediastinal mass and its relationshp with the anterior thoraco-abdominal wall."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012846/000007.jpg?itok=MhOXPrHf",
            "caption": "Selected axial CT image more inferiorly shows ill-defined fluid with stranding tracking along the anterior mediastinal space extending deeply in the anterior sulcus of the anterior mediastinum."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012846/000006.jpg?itok=L1AjNa7l",
            "caption": "Selected axial CT image more superior to the previous slice shows moderate posterior bi-basal pleural effusions but without any direct communication with the mediastinal mass. There is no pericardial fluid."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "Digital radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/12846",
    "time": "21.10.2015"
  },
  "12879": {
    "case_id": 12879,
    "title": "Oesophageal schwannom",
    "section": "Chest imaging",
    "age": "44",
    "gender": "female",
    "diagnosis": "Oesophageal schwannoma",
    "history": "A 44-year-old woman, without relevant personal or familial background, presented with exertional dyspnoea and a 7-months history of progressive dysphagia. The results of the physical examination, haemogram and laboratory tests were normal.",
    "image_finding": "Chest radiograph showed a mass in the middle mediastinum (Fig. 1). Computed tomography with intravenous contrast confirmed the presence of a mass with 85 mm in diameter, between the trachea and the vertebrae (Fig. 2), extending from the thoracic outlet to the carina of the trachea, ovoid-shaped, solid and homogeneous, with clear limits. It compressed the upper thoracic oesophagus and displaced it to the left, without a clear cleavage plane with the oesophageal wall; and it compressed the posterior wall of the trachea. Involvement of adjacent mediastinal structures and local regional ganglia was not observed. Diagnostic thoracoscopy confirmed that the mass was attached to the wall of the thoracic oesophagus. Surgical resection was decided (Fig. 3), with subtotal oesophagectomy and reconstruction of the intestinal tract by retrosternal ascendant gastric plasty. The histopathological study showed that it was a schwannoma of the oesophageal wall (S100+).",
    "discussion": "Although neurogenic tumours are the most frequent ones in the posterior mediastinum, they are very rare in the middle mediastinum. Actually, approximately 30 cases of oesophageal schwannomas have been published in the literature [1].Most tumoural lesions of the oesophagus, between 90 and 95% of cases, are squamous cell carcinomas. Benign primary tumours of the oesophagus are uncommon. They are usually detected incidentally as a mediastinal mass in asymptomatic patients. More than 80% of benign tumours are leiomyomas, which are predominantly located in the mid and lower oesophagus, while schwannomas or tumours of the peripheral nerve sheaths are rare in gastrointestinal locations [2]. Oesophageal schwannomas are more frequent in women than in men, with a mean age of presentation around 54 years [3]. They are usually asymptomatic, although symptoms appear as they grow in size. Symptoms include dysphagia, dyspnoea, weight loss and thoracic pain [4]. The most frequent location is the upper portion of the oesophagus, in the middle mediastinum. Since this tumour is extremely rare, the final diagnosis is established through histopathological analysis after surgical resection [2, 5]. Schwannomas are composed of fusiform cells either densely packed (Antoni A pattern) or closely organized in association with a myxoid stroma (Antoni B pattern), which is more frequent in areas of infarction. Immunostaining was positive for protein S-100 and negative for smooth muscle markers.Total resection, generally through endoscopic or thoracoscopic enucleation, is the treatment of choice in small well-delimited lesions, where the prognosis is excellent. Tumours larger than 8 cm or malignant tumours should be treated with oesophagectomy to avoid relapse [6, 7].",
    "differential_diagnosis": "Oesophageal, schwannoma, Oesophageal, leiomyoma:, homogeneous, tumour, with, soft, parts, in, the, mid, and, lower, oesophagus., Gastrointestinal, oesophageal, tumor:, intramural, well-delimited, mass, with, heterogeneous, enhancement, on, contrast, CT., Dense, bronchogenic, cyst:, defined, rounded, mass, usually, located, in, the, mid, or, posterior, mediastinum., No, enhancement, on, contrast, CT., Duplication, cyst.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012879/000001.jpg?itok=jOU61ab_",
            "caption": "Chest radiograph reveals a large mass in the middle mediastinum."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012879/000003.jpg?itok=roONTDzx",
            "caption": "Chest radiograph reveals a large mass in the middle mediastinum."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012879/000004.jpg?itok=gNSN_jUS",
            "caption": "Contrast-enhanced axial CT reveals a circumscribed homogeneous rounded mass in the upper to middle mediastinum. The white arrow shows compression of the oesophagus."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012879/000006.jpg?itok=Yr1F8NqF",
            "caption": "CT with sagittal view showing a low-density mass surrounded by the trachea and vertebrae. The tumour also compresses the trachea."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012879/000008.jpg?itok=cknTLLG7",
            "caption": "Cut section of oesophagus showing multilobulated tumour."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Mediastinum",
      "Oesophagus"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT",
      "Percutaneous"
    ],
    "link": "https://www.eurorad.org/case/12879",
    "time": "21.07.2015"
  },
  "12893": {
    "case_id": 12893,
    "title": "Persistent left vena cava superi",
    "section": "Chest imaging",
    "age": "54",
    "gender": "male",
    "diagnosis": "Persistent left superior vena cava",
    "history": "A 54-year-old man in chemotherapy because of acute promyelocytic leukaemia was suspected of having a neutropenic infection. Because of difficult peripherel venous access, a central venous catheter (CVC) was placed for fluid and antibiotics. CVC seemed to be misplaced at control X-ray.",
    "image_finding": "Shortly after the left-sided CVC was placed, the patient had what was thought to be a vasovagal reaction and might have been hypovolaemic because of sepsis. The blood pressure dropped to 80mmHg systolic and heart rate from 80 to 40beats/min. The patient quickly received 2L saline, was placed in Trendelenburg and given antibiotics. After stabilization a supine X-ray was taken (Fig. 1). The CVC was seen running vertically in the left side of the mediastinum, laterally at the level of the aortic arch before it distally turned to the right. On the X-ray the mediastinum could be distended. The anaesthesiologists called the radiologist to discuss the X-ray. Fortunately an old thorax and abdominal CT (Fig. 2, 3) existed and the radiologist could see that the patient had a left-sided vena cava superior terminating in the right atrium, not described earlier.",
    "discussion": "A persistent left superior vena cava (PLSVC) is the most common thoracic venous anomaly described in 0.3-0.5 % of the normal background population and up to 12% of people with congenital heart abnormalities [1, 2]. Most often the right vena cava still persists and the left superior vena cava terminates in the right atrium via the coronary sinus \u2013 which was the case in this patient. A PLSVC is most often found by coincidence but is important to have in mind for cardiologist, interventional radiologist and anaesthesiologist. Especially when access is obtained from the subclavian vein on the patient\u2019s left side. When it comes to CVCs, numerous cases of misplacement have been reported [1].This case stresses the importance of performing a control X-ray after interventional procedures and reacting when the X-ray diverges from what's expected. Probably the best way to proceed is consulting the radiologist for scrutinizing older examinations \u2013 especially CT examinations should they exist.If only an X-ray exist, the radiologist should suspect a catheter in a PLSVC if the catheter is placed from the left, running in a straight line in the left side of the mediastinum and distally turning to the right. To differentiate from a misplaced CVC in the left internal mammary vein or the pericardiophrenic vein a lateral view would be of great value. A CVC in a PLSVC would be located posterior to the heart whereas the left internal mammary vein runs anterior to the heart and the pericardiophrenic vein in the anterior part of the middle mediastinum [3].Almost any imaginable misplacement of a catheter has been reported and you might only see a thoracic bleeding when the catheter is removed [1]. To differentiate a real misplaced CVC from a CVC in a PLSVC, the path of the catheter would be more twisted than described above. It's also very important to look for haemo- or pneumothorax. Most catheters can be sufficiently localised by a frontal view [3] In this case the patient was treated immediately which postponed the control X-ray. Clinically the patient was stabilized. Generally, it must be considered a safer procedure to take a control X-ray before using the CVC. In this case the distended radiopaque mediastinum in the control X-ray was because of supine position and not because of 2 L of saline in the mediastinum. The CVC was correctly placed and could be used for further treatment.",
    "differential_diagnosis": "Persistent, left, superior, vena, cava, Misplaced, central, venous, catheter, in, the, mediastinum, -",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012893/000001.jpg?itok=7UwBr8AC",
            "caption": "CVC in the lateral left mediastinum"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012893/000002.jpg?itok=Ahn4x-8O",
            "caption": "Axial"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012893/000003.jpg?itok=OIep2v-g",
            "caption": "Axial"
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012893/000008.jpg?itok=BPF07GJx",
            "caption": "Axial"
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012893/000006.jpg?itok=0vAvt_Cv",
            "caption": "Axial"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012893/000009.jpg?itok=obl-x4rF",
            "caption": "Coronal"
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012893/000010.jpg?itok=pB5You8c",
            "caption": "Coronal"
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012893/000011.jpg?itok=a6KTR3nz",
            "caption": "Coronal"
          },
          {
            "number": "Figure 3d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012893/000012.jpg?itok=0tGk5TCK",
            "caption": "Coronal"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Interventional vascular"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT-High Resolution"
    ],
    "link": "https://www.eurorad.org/case/12893",
    "time": "26.08.2015"
  },
  "12895": {
    "case_id": 12895,
    "title": "Anterior mediastinal mass consistent with primary mediastinal large B cell lymphom",
    "section": "Chest imaging",
    "age": "15",
    "gender": "male",
    "diagnosis": "Primary mediastinal large B-cell lymphoma",
    "history": "A 15-year-old male patient presented with a 3-months history of shortness of breath, decreased appetite, fatigue and fever. A chest radiograph revealed a massive left-sided pleural effusion. A chest tube was placed on the left hemithorax and the patient was sent to a referral centre.",
    "image_finding": "A chest radiograph showed a complete opacification of the left hemithorax with a deviation of the trachea and the heart to the right. Ultrasound of the left hemithorax showed a minimal loculated pleural effusion and an extensive heterogeneous mass within the left chest cavity.Thoracic and abdominal computed tomography with and without IV contrast demonstrated a 16 x 13 x 10 cm heterogeneous enhancing anterior mediastinal mass lesion without fat or calcifications but areas of necrosis. The mediastinal structures and heart were displaced towards the right side. There was a compression atelectasis of the left lung, a minimal pleural effusion on the left side and a moderate pericardial effusion. CT guided needle biopsy of the mass revealed a large B-cell lymphoma.",
    "discussion": "For anterior mediastinal masses, the classic differential diagnosis is the \u201c4 Ts\u201d; namely thymoma, thyroid, teratoma and terrible lymphoma. Germ cell tumours are common in young adults and constitute 15% of all anterior mediastinal masses in adults. Histologically they are divided into benign teratomas, seminomas and embryonal tumours which are also known as malignant teratoma or non-seminomatous tumour [5].75% of all mediastinal germ cell tumours are mature teratomas. Calcification, teeth, bone and/or fat in a lesion are indicative of a teratoma. Serum tumour markers, AFP, beta HCG are also helpful for the diagnosis of a germ cell tumour [4, 5] Mediastinal lymphomas are common, either as part of a disseminated disease or less commonly as the site of primary origin. The mediastinum is commonly affected by systemic lymphomas. Only 10% of lymphomas which involve the mediastinum are primary and the majority are Hodgkin lymphomas, accounting for 50-70%, while  non-Hodgkin lymphoma make up 15-25% [3].Primary mediastinal lymphomas are most frequently of three histologic varieties: Nodular sclerosing Hodgkin lymphomaPrimary mediastinal large B-cell lymphoma Lymphoblastic lymphomaPrimary mediastinal large B-cell lymphoma is a sub-type of diffuse large B-cell lymphoma derived from the thymus [1, 3]. It represents less than 3 % of all non-Hodgkin lymphomas [2]. It is an aggressive neoplasm affecting a younger age group with female predilection. CT demonstrates a smooth, lobulated soft tissue attenuating bulky mass, with areas of necrosis. Other features include parenchymal invasion, pleural effusion, pericardial effusion, chest wall invasion, tracheal, oesophageal and vascular compression. However, it is difficult to differentiate primary mediastinal large B-cell lymphoma from Hodgkin lymphoma and lyphoblastic lymphoma on the basis of imaging findings alone [1]. Histopathology and immunohistochemistry are necessary to distinguish these entities [2].In our case the age of the patient, clinical features, radiological appearance, laboratory findings and histopathology along with immunohistochemistry helped to establish the final diagnosis of an anterior mediastinal large B cell lymphoma.",
    "differential_diagnosis": "Primary, mediastinal, large, B-cell, lymphoma, Thymoma, Germ, cell, tumour, teratoma, Mediastinal, thyroid, Mediastinal, tuberculosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012895/000001.jpg?itok=qFC_sGZR",
            "caption": "Plain chest radiograph shows complete opacifications of left lung, with contralateral shifting of mediastinal structure and trachea."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012895/000002.jpg?itok=8jY590l0",
            "caption": "Ultrasound of the left hemithorax shows minimal loculated pleural effusion."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012895/000003.jpg?itok=XzPdJlZN",
            "caption": "Ultrasound of the left hemithorax shows a heterogeneous intrathoracic mass."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012895/000005.jpg?itok=Raiisio2",
            "caption": "Plain chest axial CT shows a large left anterior mediastinal mass lesion without fat, without calcification, displacing the heart towards the right."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012895/000010.jpg?itok=WBlqfGjj",
            "caption": "Plain chest coronal CT shows a large left anterior mediastinal mass lesion without fat, without calcification, displacing the heart towards the right."
          },
          {
            "number": "Figure 4c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012895/000014.jpg?itok=JzC44VLk",
            "caption": "Plain chest axial CT in the superior mediastinal region showing a large left anterior mediastinal mass displacing the trachea towards the right."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012895/000008.jpg?itok=yDAm78o9",
            "caption": "Axial chest CT shows an enhancing left anterior mediastinal mass compressing the aortic arch."
          },
          {
            "number": "Figure 5b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012895/000009.jpg?itok=Y5XHWIqo",
            "caption": "Axial chest CT shows an enhancing left anterior mediastinal mass compressing the left pulmonary trunk and left main bronchus."
          },
          {
            "number": "Figure 5c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012895/000013.jpg?itok=R6R3Z7nv",
            "caption": "Axial chest CT,  compressive atelectatic left lower lung with minimal left-sided pleural effusion. A left-sided thoracostomy tube is also seen in place."
          },
          {
            "number": "Figure 5d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012895/000015.jpg?itok=3CapFDZs",
            "caption": "Axial chest CT, showing a mass on the left with pericardial effusion."
          },
          {
            "number": "Figure 5e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012895/000016.jpg?itok=kN6qsEhe",
            "caption": "Coronal chest CT shows an enlarged left anterior mediastinal mass with prominent left axilliary lymph nodes."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Lymph nodes",
      "Mediastinum",
      "Thoracic wall",
      "Thorax",
      "Thyroid / Parathyroids",
      "Pulmonary vessels",
      "Management"
    ],
    "imaging_technique": [
      "Ultrasound",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/12895",
    "time": "04.10.2015"
  },
  "12918": {
    "case_id": 12918,
    "title": "Anterior mediastinal mass",
    "section": "Chest imaging",
    "age": "66",
    "gender": "male",
    "diagnosis": "Saphenous vein graft aneurysm after CABG",
    "history": "A 68-year-old man with severe chronic obstructive lung disease (COLD) was hospitalized with dyspnoea. He had a history of two acute myocardial infarctions and a coronary artery bypass grafting (CABG) performed in 1988.  A chest x-ray showed a round radiopaque structure in the anterior mediastinum and a CT was recommended.",
    "image_finding": "The chest x-ray showed an anterior mass, best seen on the lateral view (fig 1). Afterwards a contrast enhanced CT of the thorax was performed (fig 2-4). A homogeneous, rounded structure was seen in the anterior-superior mediastinum in close relation to the heart and large vessels. In the periphery some calcification was present. A vessel containing contrast was seen within the structure. The average Hounsfield value of the structure was 32. At first, the suspicion of a thymoma was raised due to the location in the anterior mediastinum. The patient was referred to a CT-guided biopsy of the suspected thymoma. Before any biopsies were taken, a senior radiologist reviewed the CT and ruled out a thymoma and correctly diagnosed a large aneurysm on the graft from the patients bypass surgery.",
    "discussion": "The mediastinum is often divided into an anterior, middle and posterior part. Fifty percent of mediastinal tumours are placed in the anterior part [1, 2]. Typical masses in the anterior mediastinum are thymoma, teratoma, seminoma, lymphoma, carcinoma, parathyroid adenoma, intrathoracic goiter, lipoma, lymphangioma and aortic aneurysm [2].With an incidence of 0, 15% cases per 100000 people thymomas are the most frequent primary tumor [1, 2]. The size of thymomas are typically 5-10cm but as large as 34cm have been reported and they are often found in the superior-anterior mediastinum on either side of the midline. Radiologically, thymomas are rounded or lobulated, they are well defined and can contain calcification, hemorrhage, necrosis and/or cysts. They can invade surrounding structures [1, 2]. Thymomas are divided into high- and low-risk depending on histology and invasiveness and classified according to the Masaoka staging system [3, 4].A saphenous vein graft (SVG) aneurysm after CABG is considered to be rare, with an incidence of less than 0, 1% [5, 6]. Most patients develop SVG-aneurysm more than 10 years after surgery (68, 5%). SVG-aneurysms of up to 10 cm have been reported and are often found as mediastinal or hilar masses. The diagnosis of a thymoma is often made on a CT-scan. It is important to evaluate complications such as fistulation, compression of nearby structures, rupture and the status of native coronaries. A supplementary coronary CT angiography can be helpful [5, 6].The patient of this case had dyspnoea because of COPD, but shortness of breath is a primary symptom of both SVG-aneurysm and mediastinal masses [1, 5]. The patient died from his COPD a year after the CT. The family did not want an autopsy. However an SVG aneurysm had been diagnosed by coronary angiography in 2008.Quite a few points can be learned from this case. It shows the importance of a relevant clinical history, knowing the possible differential diagnoses and most important the need to look into earlier diagnostic procedures. In this case several doctors, including the radiologist, missed the fact that the diagnosis of a SVG aneurism had been made several years earlier. Even though the diagnosis had not been made earlier, the information about earlier surgery in the area in question could have helped the radiologists minimize the number of differentials. This case also shows the large consequences a radiologist\u2019s diagnosis can have for further investigation and treatment. It could have been fatal if a biopsy had been taken.",
    "differential_diagnosis": "Saphenous, vein, graft, aneurysm, after, CABG, Thymus, tumours, Thyroid, tumours, Thoracic-aorta, aneurism, Lymphoma, Germ, cell, tumour",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012918/000001.jpg?itok=XPlTYp8T",
            "caption": "Anterior-superior mediastinal mass.\nBest seen in lateral view"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012918/000002.jpg?itok=cqikE88W",
            "caption": "Anterior-superior mediastinal mass."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012918/000003.jpg?itok=v1xwpvEz",
            "caption": "Anterior-superior mediastinal mass"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012918/000004.jpg?itok=ol-1qLEm",
            "caption": "Anterior-superior mediastinal mass"
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012918/000009.jpg?itok=K-EfY2qA",
            "caption": "Anterior-superior mediastinal mass"
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012918/000012.jpg?itok=txIg4iHt",
            "caption": "Anterior-superior mediastinal mass"
          },
          {
            "number": "Figure 2e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012918/000015.jpg?itok=9LaFtawd",
            "caption": "Anterior-superior mediastinal mass"
          },
          {
            "number": "Figure 2f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012918/000018.jpg?itok=Odl_bA2K",
            "caption": "Anterior-superior mediastinal mass"
          },
          {
            "number": "Figure 2g",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012918/000021.jpg?itok=OP9qHLqo",
            "caption": "Anterior-superior mediastinal mass"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012918/000022.png?itok=kGvRx_4j",
            "caption": "Anterior-superior mediastinal mass"
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012918/000023.png?itok=nRhav-K4",
            "caption": "Anterior-superior mediastinal mass"
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012918/000024.png?itok=Sj61ZWjN",
            "caption": "Anterior-superior mediastinal mass"
          },
          {
            "number": "Figure 3d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012918/000025.png?itok=rEXfTNr2",
            "caption": "Anterior-superior mediastinal mass"
          },
          {
            "number": "Figure 3e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012918/000026.png?itok=5pHcbZKm",
            "caption": "Anterior-superior mediastinal mass"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012918/000027.png?itok=GNKJd8eS",
            "caption": "Anterior-superior mediastinal mass"
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012918/000028.png?itok=CS7dOsqV",
            "caption": "Anterior-superior mediastinal mass"
          },
          {
            "number": "Figure 4c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012918/000029.png?itok=aY4XOYhX",
            "caption": "Anterior-superior mediastinal mass"
          },
          {
            "number": "Figure 4d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012918/000030.png?itok=BTxNel3e",
            "caption": "Anterior-superior mediastinal mass"
          },
          {
            "number": "Figure 4e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012918/000031.png?itok=kwRaj1RR",
            "caption": "Anterior-superior mediastinal mass"
          },
          {
            "number": "Figure 4f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012918/000032.png?itok=BfyfIMqd",
            "caption": "Anterior-superior mediastinal mass"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Cardiac",
      "Cardiovascular system",
      "Mediastinum"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/12918",
    "time": "28.09.2015"
  },
  "12920": {
    "case_id": 12920,
    "title": "Pneumomediastinum: complication of an aspirated foreign body",
    "section": "Chest imaging",
    "age": "91",
    "gender": "male",
    "diagnosis": "Pneumomediastinum secondary to an obstructive aspirated foreign body (olive stone).",
    "history": "A 91-year-old man with good quality of life was admitted to the emergency department with a cough and left pleuritic pain over the previous three days.",
    "image_finding": "A posteroanterior and lateral chest X-ray was performed and showed an extensive pneumomediastinum, extending into the neck and chest wall (subcutaneous emphysema). Some typical radiographic signs were seen: tubular artery sign, \u201cring around the artery\u201d sign, double bronchial wall sign and continuous diaphragm sign (Fig. 1).Chest CT: Extensive pneumomediastinum, which continues towards the planes of the neck and chest wall (subcutaneous emphysema) (Fig. 2). Within the left main bronchus, a 1.2 x 0.8 cm nodular structure with a hyperdense periphery is observed. The foreign body, which was later proven to be an olive stone by bronchoscopy (Fig. 3), was causative for the partial collapse of the left upper lobe and the pneumomediastinum (Fig. 4 and 5).",
    "discussion": "Pneumomediastinum is a diagnostic challenge for the radiologist because it can be caused by many thoracic as well as extrathoracic aetiologies [1]. The pathophysiological mechanism of pneumomediastinum in most cases is alveolar rupture. Alveolar rupture is caused by a pressure gradient between an alveolus and the interstitium. In our case, this occurred due to an airway obstruction by a foreign body (common cause in children, rare in adults) added to cough. Alveolar rupture initially produces pulmonary interstitial emphysema (not seen in our case). Gas then travels centrally along the bronchovascular interstitial sheaths into the mediastinum [1, 3].Other common causes are blunt or penetrating trauma, oesophageal perforation, gas-forming infections, cocaine inhalation, and extension of air from a pneumothorax [4]. Careful examination of chest radiographic findings is crucial in the diagnosis of pneumomediastinum. Radiographic signs include [1, 2, 3]:\u2022\tThymic sail sign (in infants): The thymus can become elevated and partly surrounded by air.\u2022\t\u201cRing around the artery\u201d sign: Air surrounding the pulmonary artery or its main branches.\u2022\tTubular artery sign: Pulmonary air and pneumomediastinum can surround the aorta and its main branches.\u2022\tDouble bronchial wall sign: Air outside and within the bronchial wall allows the wall to be seen.\u2022\tContinuous diaphragm sign: caused by air located posterior to the pericardium.\u2022\tExtrapleural sign: Air from mediastinum can extend laterally between the parietal pleura and the diaphragm.A rare dangerous complication is tensional pneumomediastinum due to haemodynamic compromise. CT findings include pneumomediastinum with flattening of the anterior cardiac contour, compression of the right atrium, distention of the inferior vena cava, compression of the mediastinal vessels and the main bronchi [4]. Radiographic findings of aspirated foreign bodies include a dense nodule in the tracheobronchial tree with or without obstructive pulmonary changes such as atelectasis [5, 7].Differential diagnosis of high-attenuation endobronchial lesions can be narrowed by carefully obtaining patient history and evaluating CT findings. For example, inflammatory reaction around the foreign body can simulate an endobronchial mass which, together with obstruction image findings, should be differentiated from endobronchial carcinoma [6].Bronchoscopy can be necessary, especially to remove the aspirated foreign body.",
    "differential_diagnosis": "Pneumomediastinum, secondary, to, an, obstructive, aspirated, foreign, body, (olive, stone)., Broncholithiasis, caused, by, calcified, lymph, nodes, Intrabronchial, tumours",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012920/000001.jpg?itok=PDuwuwaQ",
            "caption": "Abundant subcutaneous emphysema (yellow arrows) and pneumomediastinum: tubular artery sign (red arrows), \u201cring around the artery\u201d sign (blue triangle only in 1b) and continuous diaphragm sign (yellow triangle)."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012920/000002.jpg?itok=FdIRnX6K",
            "caption": "Abundant subcutaneous emphysema (yellow arrows) and pneumomediastinum: Tubular artery sign (red arrows), \u201cRing around the artery\u201d sign (blue triangle only in 1b) and Continuous diaphragm sign (yellow triangle)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012920/000003.jpg?itok=jylIbl0k",
            "caption": "Axial chest CT, window settings image that reveals pneumomediastinum (red arrows) and subcutaneous emphysema (yellow arrows)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012920/000004.jpg?itok=2oY0vNDa",
            "caption": "Axial chest CT. Lung window settings image that reveals pneumomediastinum (red arrows) and in the left main bronchus a nodular image with a hyperdense periphery measuring 1.2 x 0.8cm. (yellow arrow)."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012920/000005.jpg?itok=_vKKh2s6",
            "caption": "Axial (A) and coronal (B) chest CT. mediastinum window settings image that reveals in the left main bronchus a nodular image with a hyperdense periphery measuring 1.2 x 0.8cm. Probably an aspirated foreign body (yellow arrow)."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012920/000006.jpg?itok=Jlg8Zw8p",
            "caption": "Axial (A) and coronal (B) chest CT. mediastinum window settings image that reveals in the left main bronchus a nodular image with a hyperdense periphery measuring 1.2 x 0.8cm. Probably an aspirated foreign body (yellow arrow)."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012920/000007.jpg?itok=LnvgPJX4",
            "caption": "Bronchoscopy image confirming the finding of an aspirated foreign body (Olive stone)."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Mediastinum",
      "Respiratory system"
    ],
    "imaging_technique": [
      "CT-High Resolution",
      "Experimental",
      "Digital radiography"
    ],
    "link": "https://www.eurorad.org/case/12920",
    "time": "13.10.2015"
  },
  "12943": {
    "case_id": 12943,
    "title": "Cryptogenic organizing \u201cnon resolving\u201d pneumonia: a recurrent disease.",
    "section": "Chest imaging",
    "age": "71",
    "gender": "female",
    "diagnosis": "Cryptogenic organizing pneumonia (COP).",
    "history": "A healthy patient presented with a 2-week history of fever, shortness of breath and a non-productive cough. Physical examination revealed crackles over the lower right hemithorax.Serology for viral agents, blood and sputum cultures, immunological and tumour markers were all within normal range.The initial treatment was antibiotics for the clinical suspicion of pneumonia, but symptoms persisted.",
    "image_finding": "Chest x-ray followed by high resolution computed tomography (HRCT) were performed. The HRCT abnormalities mirror the radiographic appearances showing bilateral patchy consolidations with groundglass opacities, air bronchogram and bronchial dilatations in a peripheral distribution mainly in the right lung (Fig. 1, 2).Bronchoalveolar lavage specimens were smear and culture negative. Lung biopsy was undertaken showing distal airways filled by fibromyxoid plugs of granulation tissue (Fig. 3).High doses of oral corticosteroid were commenced with dramatic clinical improvement after 72-hours and near complete resolution of consolidations by the 10th day (Fig. 4).On follow-up, steroid dose was decreased, but 1 month later, fever recurred and consolidations reappeared (Fig. 5). Steroid dose was increased and complaints disappeared.Oral corticosteroids were gradually tapered down and the patient was asymptomatic for 4 months. Last HRCT showed an almost complete disappearance of lesions, although ground glass densities still persisted, mainly in the left upper lobe (Fig. 6).",
    "discussion": "Organizing pneumonia or its idiopathic form, cryptogenic organizing pneumonia (COP) is a clinic-pathologic entity described by Davison and colleagues in 1983 [1]. Organizing pneumonia was formerly known as bronchiolitis obliterans organizing pneumonia (BOOP), a term coined by Epler and co-workers in 1985 [2].The term COP is preferred because it conveys the essential features of the syndrome [polypoid granulation tissue within alveolar ducts and alveoli with or without organization within bronchioles (\u201cpolypoid bronchiolitis obliterans\u201d)] and avoids confusion with airway diseases such as constrictive bronchiolitis obliterans [2-4].COP is a type of interstitial pulmonary disease included in the classification of the American Thoracic Society and European Respiratory Society statement on the classification of idiopathic interstitial pneumonias (IIP) in the group of major IIP [5].The true incidence of COP is unknown (1-7/100.000) [6]. Similarly affects men and women in fifth and sixth decade of life [7], mostly in non-smokers.A short-history (median: <3 months) of dyspnoea, cough and fever is the most common form of presentation [5, 7, 8]. Haemoptysis and pleurisy could be seen too. Because of these symptoms a chest x-ray followed by HRCT are usually the first imaging methods to try to establish the diagnosis. The relatively non-specific radiological findings and the absence of response to traditional treatment lead to additional studies such as bronchoalveolar lavage and open biopsy.The most important radiological findings are bilateral and asymmetric consolidations commonly associated with ground-glass densities with a peripheral and peribronchovascular distribution, predominating in middle and lower lobes, which may change their location [8-12].Less frequent manifestations are solitary or multiple nodules or masses [11, 12], reverse (atoll) halo sign [10, 15], thick bands of consolidation extending towards the pleura and crazy-paving pattern [13]. The diagnosis of COP is established by combining clinical, radiological and histological criteria. Initial therapy depends on severity of symptoms, pulmonary function tests and radiological extension. The majority of patients recover completely with corticosteroid treatment but also relapse. Fibrosis is common with similar findings to those seen in non-specific interstitial pneumonias [5, 13, 14, 16].COP is a form of IIP that can be easily mistaken for both clinical and radiological lung diseases.\u2022Non-specific pattern of reparative response of lung to the injury to a non-identifiable cause.\u2022Should be considered in the differential diagnosis of patients with short-history of breathlessness, cough and fever. \u2022Typical radiologic manifestations: patchy consolidations and ground-glass opacities that may change their location, resolve without treatment and reappear. \u2022Fast corticosteroid response with a good prognosis.",
    "differential_diagnosis": "Cryptogenic, organizing, pneumonia, (COP)., Community, acquired, pneumonia., Adenocarcinoma, in, situ, or, minimally, invasive, (bronchoalveolar, carcinoma)., Pulmonary, lymphoma., Pulmonary, vasculitides., Sarcoidosis., Chronic, eosinophilic, pneumonia., Other, idiopathic, interstitial, pneumonias.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012943/000001.jpg?itok=oeY3NgpV",
            "caption": "Posteroanterior conventional chest x-ray revealed bilateral patchy air-space consolidations."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012943/000002.jpg?itok=qyLmLa1N",
            "caption": "Left lateral chest x-ray showed areas of consolidation with a lower predominance."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012943/000003.jpg?itok=UATBXFFS",
            "caption": "Axial HRCT showed consolidations with ground-glass opacities, air bronchogram and bronchial dilatation predominantly peripheral and subpleural distribution in whole lobes and segments of both lungs mainly in the right lung."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012943/000005.jpg?itok=dlsLhnsh",
            "caption": "Histological picture of video-assisted thoracoscopic surgery lung biopsy sample with haematoxylin and eosin stain showed polypoid granulation tissue within bronchioles, alveolar ductus and alveoli (arrow)."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012943/000004.jpg?itok=fde4K5u_",
            "caption": "The specimens from the right lower and middle lobes showed preservation of the lung architecture with intra-alveolar plugs of fibrin (arrow), associated with organizing pneumonia (intraluminal loose connective tissue within the alveolar ducts and bronchioles)."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012943/000006.jpg?itok=2tyIqdf3",
            "caption": "Infiltration of airways and interstitium with mononuclear cells and foamy macrophages accompanies granulation tissue within distal airways (arrow)."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012943/000007.jpg?itok=8CgpVQy9",
            "caption": "Axial HRCT after 10 days of continuous high dose corticosteroid therapy showed important diminution of the consolidation areas in both lungs."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012943/000008.jpg?itok=C7TGga6o",
            "caption": "One month follow-up after tapering steroid dose, HRCT showed ground-glass densities that become more widely spread and new ground-glass opacities were seen at the upper lobes bilaterally predominance in left superior lobe."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012943/000009.jpg?itok=TjCUsGCg",
            "caption": "Four months follow-up after increasing the steroid dose, HRCT showed an almost complete disappearance of lesions, although ground-glass densities still persisted, mainly in the left upper lobe."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax",
      "Lung"
    ],
    "imaging_technique": [
      "CT-High Resolution",
      "Conventional radiography",
      "Experimental",
      "Percutaneous"
    ],
    "link": "https://www.eurorad.org/case/12943",
    "time": "03.12.2015"
  },
  "12951": {
    "case_id": 12951,
    "title": "Nasogastric feeding tube in right main bronchus? Bochdalek Hernia the missing piece of puzzle",
    "section": "Chest imaging",
    "age": "61",
    "gender": "female",
    "diagnosis": "Right sided Bochdalek Hernia",
    "history": "A 61 year old woman presented with pneumonia and respiratory failure. She was intubated and ventilated due to worsening dyspnea. Chest X-ray after nasogastric tube insertion showed tube projecting over the anatomical area of the right main and right lower lobe bronchi. Multiple attempts of nasogastric tube insertion showed similar findings (Fig1). CT revealed diagnosis.",
    "image_finding": "CT Abdomen and Pelvis with Oral and IV contrast showed a big defect in the right part of the diaphragm, right of the midline, containing herniated fat and stomach. The tip of the nasogastric tube is seen within the stomach, however the stomach is located at the right side of the chest due to the big hiatus hernia. Bilateral pleural effusion - right greater than left - associated with bilateral dependent opacities consistent with atelectasis versus consolidation. No pneumothorax was seen.",
    "discussion": "Diaphragmatic hernias are either congenital or traumatic. Bochdalek hernia (BH) is a type of congenital diaphramatic hernia (CDH). CDH are caused by defect in the diaphragm musculature, which has been described in the history about 400 years ago. These CDH are described as various types depending upon the site of anatomical defect. If the defect is in posterior-lateral aspect of diaphragm it is called as Bochdalek hernia, which was named in the honor of professor Victor Alexander Bochdalek, who was a professor of anatomy at Prague in 1848 who originally described this condition [1]. During fetal development diaphragm develops from septum transversum, it divides the abdominal structures from thoracic cavity.The pleuroperitoneal folds fuse with septum transversum to complete formation of diaphragm, the defect in the fusion results in diaphragmatic hernia. Bochdalek hernia is a relatively rare finding, seen in 1 in 3000 to 4000 live births. The majority of them are depicted in childhood, but they can also rarely be seen in adults. In a study based on 13.138 cases, the incidence of Bochdaleck hernia in adults was 0.17% as reported by Mullin et al [2].Diagnosis of BH is difficult as it can have a varied presentation. The patient can be asymptomatic and BH can be a finding on auscultating the chest where bowel sounds are heard or can present with severe abdominal pain and signs of intestinal obstruction hence a high index of suspicion is necessary.When presented with abdominal pain and distention, they have a tendency to be seen more on the left side and seen more common in males [3]. The clinical signs which guide towards diagnosis of BH were described by Fingerhut et al and consist of postprandial respiratory symptoms, abdominal or chest symptoms exacerbated by supine position or physical exertion and abnormalities seen in radiographic imaging in supine position [4, 5]. There are different imaging modalities available to aid making the diagnosis, plain chest X-ray which may show intestines in the thorax, CT scan in cases of traumatic hernia where the site of injury can be visualized. The management of BH is surgical. The surgical techniques vary and have changed over the year from traditional laparotomy to laparoscopic surgery. BH was successfully operated in 1901 by Aue [6], while laparoscopic repair was performed by Al-Emadi [7] for the first time in 1998. The approach for the repair depends on the presentation, most of them are done as elective repair but emergency laparotomies are also conducted for the strangulated hernias.",
    "differential_diagnosis": "Right, sided, Bochdalek, Hernia, Morgagni\\'s, Hernia, Traumatic, rupture, of, diaphragm, with, gut, contents, herniating, to, chest.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012951/000001.png?itok=PhslnljK",
            "caption": "Chest X Ray AP view. Nasogastric tube seen in the radiolucent area of trachea and right main bronchus"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012951/000002.png?itok=xyyjslZi",
            "caption": "Chest X Ray AP view. Nasogastric tube seen in the radiolucent area of trachea and right main bronchus"
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012951/000003.png?itok=vqCzuDhj",
            "caption": "Chest X Ray AP view. Nasogastric tube seen in the radiolucent area of trachea and right main bronchus"
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012951/000004.png?itok=yx5vX6-S",
            "caption": "Chest X Ray AP view. Nasogastric tube seen in the radiolucent area of trachea and right main bronchus. Note right lower zone consolidation."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012951/000005.png?itok=TicjdqtW",
            "caption": "CT Chest Lung Window Axial View \nNGT is seen behind right main bronchus (marked with red arrow) Bilateral consolidation and effusions are also seen"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012951/000006.png?itok=2AcUfSNA",
            "caption": "CT Chest Lung Window Axial View \nNGT is seen behind right main bronchus (marked with red arrow) Bilateral consolidation and effusions are also seen"
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012951/000007.png?itok=csUlGzwh",
            "caption": "CT Chest Lung Window Axial View \nNGT is seen bent in a loop (marked with red arrow) Bilateral consolidation and effusions are also seen"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012951/000008.png?itok=A9ofrvUo",
            "caption": "CT Chest Axial View Mediastinal Window\nNGT is seen behind right main bronchus. Note Bilateral pleural effusion - right greater than left - associated with bilateral dependent opacities consistent with atelectasis/consolidation."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012951/000009.png?itok=224oot09",
            "caption": "CT Chest  Mediastinal Window Axial View\nNGT is seen behind right main bronchus (arrow) Note Bilateral pleural effusion - right greater than left - associated with bilateral dependent opacities consistent with atelectasis/consolidation."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012951/000010.png?itok=qHXIMPkn",
            "caption": "CT Chest Axial View Mediastinal Window\nNGT is seen behind right main bronchus (arrow).Note Bilateral pleural effusion - right greater than left - associated with bilateral dependent opacities consistent with atelectasis/consolidation."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012951/000011.jpg?itok=Cqgi9dA9",
            "caption": "CT Scan Chest and Abdomen reconstructed image. Intact diaphragm can be seen above spleen (yellow arrows) while stomach is seen heriating through the defect marked by red arrows."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012951/000012.png?itok=uSTJsNe-",
            "caption": "Axial CT Chest lung window. Diaphragm defect marked by red arrows surrounding the abdominal fat and stomach, effusions green arrows, consolidation yellow arrows."
          },
          {
            "number": "Figure 4c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012951/000013.png?itok=n1xDWHDH",
            "caption": "Axial CT Chest. Diaphragm defect marked by red arrows surrounding the abdominal fat and stomach."
          },
          {
            "number": "Figure 4d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012951/000014.png?itok=tO-GKrKo",
            "caption": "Axial CT Chest. Diaphragm defect marked by yellow arrows surrounding the abdominal fat and stomach."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Gastrointestinal tract",
      "Thorax"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/12951",
    "time": "16.11.2015"
  },
  "12956": {
    "case_id": 12956,
    "title": "Unicentric Castleman disease",
    "section": "Chest imaging",
    "age": "36",
    "gender": "male",
    "diagnosis": "Unicentric Castleman disease as a posterior mediastinal mass.",
    "history": "A 36-year-old man, with a history of smoking (9 UPY) and dyslipidemia was referred to thoracic surgery consultation due to an alteration in his routine chest X-ray. The patient was asymptomatic.",
    "image_finding": "The posteroanterior chest radiograph revealed a left inferior paravertebral mass of smooth contours. Thoracic CT with intravenous contrast showed a left paravertebral and para-aortic mass, of soft tissue density, with well-defined limits and homogeneous contrast enhancement. Its axial diameters were 6.3 x 2.9 cm. In addition, inferiorly there were small paravertebral nodules. The patient was submitted to VATS (Video-assisted thoracoscopic surgery) with resection of the posterior mediastinal mass. Pathological results were consistent with Castleman disease, classic hyaline vascular type.Follow-up chest radiograph shows no pathological findings.",
    "discussion": "A.\tThe differential diagnosis of posterior mediastinum lesions includes: neurogenic tumours or cysts, lymph nodes, oesophageal tumours, extramedullary haematopoiesis, enterogenic cysts, meningoceles, azygos vein anomalies and Bochdalek hernias [1]. B.\tSolid masses of the posterior mediastinum range from neurogenic tumours, lymph nodes, Non-Hodgkin lymphomas, oesophageal tumours and extramedullary haematopoiesis [1].C.\tCastleman disease is a lymphoproliferative disorder that occurs in 70% of cases in the chest, 15% in the neck, and 15% in the abdomen and pelvis [2]. The most common form of presentation is as a solitary lymphadenopathy, but it can present with systemic symptoms and multicentric disease. D.\tThe disease may be unicentric or multicentric. The unicentric form is most commonly the hyaline vascular histological type, which represents 90% of the cases. The multicentric type has been associated with the infection of Human Herpes Virus-8 [3].E.\tHyaline vascular Castleman disease usually manifests as an asymptomatic mass lesion in young adults, with a median age of 30-40 years. Treatment usually includes curative surgical resection and/or steroid treatment or systemic chemotherapy for aggressive forms. This form of Castleman disease has the best prognosis.F.\tThe radiologic appearance of hyaline vascular Castleman disease is that of a solitary enlarged lymph node or localized nodal masses that demonstrate intense homogeneous contrast enhancement.",
    "differential_diagnosis": "Unicentric, Castleman, disease, as, a, posterior, mediastinal, mass., Neurogenic, tumours, Oesophageal, tumours, Non-Hodgkin\\'s, lymphoma, Extramedullary, haematopoiesis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012956/000001.png?itok=FT2r3JmO",
            "caption": "Posteroanterior chest X-ray demonstrates a left paravertebral mass, of smooth contours, that follows the left paraspinal line."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012956/000002.png?itok=TFBo_1rq",
            "caption": "Lateral chest X-ray shows a very subtle soft tissue density over the vertebral bodies of TVIII and TIX."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012956/000003.png?itok=Jni7R47B",
            "caption": "Thoracic CT (axial section on mediastinal window) showed a left paravertebral mass, of soft tissue density, located at the posterior mediastinum."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012956/000004.png?itok=nMLQVrsc",
            "caption": "Contrast-enhanced CT (axial section on mediastinal window) reveals the mass had homogeneous enhancement."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012956/000005.png?itok=9QSweo49",
            "caption": "Coronal chest CT demonstrating the left paraaortic mass."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012956/000006.png?itok=b1vmqfEK",
            "caption": "Sagittal chest CT showing the posterior mediastinal mass and its anatomic relationship with the heart borders and aorta."
          }
        ]
      },
      {
        "number": "Figure 7",
        "subfigures": [
          {
            "number": "Figure 7",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012956/000007.png?itok=hYzv-8os",
            "caption": "Follow-up posteroanterior chest X-ray after VATS surgery: no pathological findings."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "CT",
      "Conventional radiography",
      "Digital radiography"
    ],
    "link": "https://www.eurorad.org/case/12956",
    "time": "03.09.2015"
  },
  "12974": {
    "case_id": 12974,
    "title": "Pulmonary Langerhans cell histiocytosis",
    "section": "Chest imaging",
    "age": "40",
    "gender": "female",
    "diagnosis": "Pulmonary Langerhans cell histiocytosis",
    "history": "A 40-year-old female long term smoker presented with 3-4 months of non-productive cough and dyspnoea. She was otherwise well and did not have symptoms related to any other system. Initially she was evaluated with CT chest (showing findings below). There was a re-evaluation with follow-up CT after 8 months following cessation of smoking.",
    "image_finding": "The initial chest CT images (figure 1a-g) show multiple small (5-10 mm) ill defined pulmonary nodules which have an overall predilection towards the upper and middle lobes. The costophrenic recess are spared. Some nodules appear solid while others show cavitation. This scan also shows diffuse airway thickening with scattered centrilobular emphysematous changes suggestive of a smoking related airway disease. The overall lung volumes were preserved. No mediastinlal lymphadenopathy. The subsequent follow up CT (figure 2a-g) after cessation of smoking shows dramatic interval response with resolution of most nodules and with no new or developing change.",
    "discussion": "Pulmonary Langerhans cell histiocytosis (PLCH) is an idiopathic disorder characterised by an abnormal proliferation of Langerhans cells (a dendritic cell) in the lungs (1, 3-4). As seen in our patient, LCH in adults is usually a single system disease limited to the lungs. However, LCH may also be a multi system disorder in which essentially any part of the body can be affected. Multisystem LCH is more common in the paediatric population with peak incidence between 1-3 years of age.In adults, the condition almost exclusively manifests in smokers.Clinical perspective:Patients usually present with a non productive cough and/or dyspnoea. Non specific constitutional symptoms may also be present while approximately 25% can be asymptomatic. Occasionally the presenting symptom can be a spontaneous pneumothorax.(5)Imaging perspective:Plain radiography in early changes can show a diffuse bilateral reticulonodular pattern with an upper and middle lobar predilection(4). During the course of the disease, small cysts can form within the nodular opacities. The lung volumes are typically preserved. Associated lung hyperinflation may be seen at times.CT scans confirm small nodular lesions with a typical upper to mid zonal predilection with sparing of costophrenic recesses.(3-4) The nodules seen in the early stage of the disease are typically small (ranging around 1-10mm size) and are mostly centrilobular in distribution. The margins of the nodules are irregular. During the course of the disease, nodules may cavitate forming cystic spaces of variable wall thickness (1-2, 3-4). Bizarre shaped cysts may form during the later stage of the disease.Outcome:The typical imaging findings supported by long-term smoking history(2) were the clue to diagnosis. The excellent clinical and radiological improvement following cessation of smoking was further supportive of the diagnosis. Pertinent negative features such as absence of vasculitic markers such as ANCA as well as absence of clinical features of systemic sepsis, mediastinal lymphadenopathy helped to further narrow the differential diagnosis.Teaching points:This can highlight the typical imaging findings in the appropriate clinical context in being confident of diagnosis by imaging and therefore obviating need for invasive tissue diagnosis. The patient has had a good clinical response and has remained well to date following cessation of smoking.",
    "differential_diagnosis": "Pulmonary, Langerhans, cell, histiocytosis, Pulmonary, vasculitides, (e.g., Wegeners, granulomatosis), Septic, emboli, Sarcoidosis, (nodular, forms)",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012974/000002.jpg?itok=zT4jBRzw",
            "caption": "Multiple ill-defined small (5-10 mm) pulmonary nodules with an overall upper-middle lobe predilection with sparing of costophrenic recesses. Some nodules appear solid with others showing cavitation."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012974/000004.jpg?itok=gTBHDgFg",
            "caption": "Multiple ill-defined small (5-10 mm) pulmonary nodules with an overall upper-middle lobe predilection with sparing of costophrenic recesses. Some nodules appear solid with others showing cavitation."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012974/000007.jpg?itok=4Ay-iLJL",
            "caption": "Multiple ill-defined small (5-10 mm) pulmonary nodules with an overall upper-middle lobe predilection with sparing of costophrenic recesses. Some nodules appear solid with others showing cavitation."
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012974/000011.jpg?itok=XpqdMmL1",
            "caption": "Multiple ill-defined small (5-10 mm) pulmonary nodules with an overall upper-middle lobe predilection with sparing of costophrenic recesses. Some nodules appear solid with others showing cavitation."
          },
          {
            "number": "Figure 1e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012974/000013.jpg?itok=jq5V_-YC",
            "caption": "Multiple ill-defined small (5-10 mm) pulmonary nodules with an overall upper-middle lobe predilection with sparing of costophrenic recesses. Some nodules appear solid with others showing cavitation."
          },
          {
            "number": "Figure 1f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012974/000019.jpg?itok=P32fEOxJ",
            "caption": "Multiple ill-defined small (5-10 mm) pulmonary nodules with an overall upper-middle lobe predilection with sparing of costophrenic recesses. Some nodules appear solid with others showing cavitation."
          },
          {
            "number": "Figure 1g",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012974/000021.jpg?itok=BqoPGTKF",
            "caption": "Multiple ill-defined small (5-10 mm) pulmonary nodules with an overall upper-middle lobe predilection with sparing of costophrenic recesses. Some nodules appear solid with others showing cavitation."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012974/000024.jpg?itok=BCYvLr2X",
            "caption": "The subsequent follow up CT scan (figure 2a-e) after cessation of smoking shows dramatic interval response with resolution of most of the nodules and with no new or developing change."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012974/000026.jpg?itok=3LtTeeVN",
            "caption": "The subsequent follow up CT scan (figure 2a-e) after cessation of smoking shows dramatic interval response with resolution of most of the nodules and with no new or developing change."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012974/000028.jpg?itok=Hf_WtmpH",
            "caption": "The subsequent follow up CT scan (figure 2a-e) after cessation of smoking shows dramatic interval response with resolution of most of the nodules and with no new or developing change."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012974/000030.jpg?itok=8dbfGYRO",
            "caption": "The subsequent follow up CT scan (figure 2a-e) after cessation of smoking shows dramatic interval response with resolution of most of the nodules and with no new or developing change."
          },
          {
            "number": "Figure 2e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012974/000032.jpg?itok=YFrhQ78H",
            "caption": "The subsequent follow up CT scan (figure 2a-e) after cessation of smoking shows dramatic interval response with resolution of most of the nodules and with no new or developing change."
          },
          {
            "number": "Figure 2f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012974/000033.jpg?itok=H9L0Jm6n",
            "caption": "The subsequent follow up CT scan (figure 2a-e) after cessation of smoking shows dramatic interval response with resolution of most of the nodules and with no new or developing change."
          },
          {
            "number": "Figure 2g",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012974/000034.jpg?itok=o_iuC61v",
            "caption": "The subsequent follow up CT scan (figure 2a-e) after cessation of smoking shows dramatic interval response with resolution of most of the nodules and with no new or developing change."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT-High Resolution"
    ],
    "link": "https://www.eurorad.org/case/12974",
    "time": "03.12.2015"
  },
  "12979": {
    "case_id": 12979,
    "title": "Dysphagia Lusori",
    "section": "Chest imaging",
    "age": "61",
    "gender": "female",
    "diagnosis": "Dysphagia Lusoria due to aberrant right subclavian artery",
    "history": "A middle aged lady presented with 2 years history of progressive dysphagia to solids. Her physical examination was unremarkable except evidence of recent weight loss. All routine laboratory investigations, chest x-ray and ECG were normal. Her endoscopy did not reveal anything. Contrast enhanced CT chest revealed an unusual finding.",
    "image_finding": "The upper oesophagus is dilated and fluid. There is an aberrant right subclavian artery passing behind the oesophagus which could be contributing to the apparent dilatation. No mediastinal or hilar lymphadenopathy. The heart is enlarged. There isatelectasis in both lower and the right middle lobes and smooth fatty pleural thickening at the left lung base.",
    "discussion": "Among different congenital anomalies of aortic arch, aberrant right subclavian artery is considered most common and occurs in 0.5% to 1.8% of cases [1]. The anomaly can be explained on Edward\u2019s hypothesis which describes involution of fourth vascular arch with the right dorsal aorta. The seventh intersegmental artery remains attached to the descending aorta and this persisting intersegmental artery becomes the right subclavian artery. Differential growth shifts the origin cranially and it lies close to the origin of the left subclavian artery. It originates dorsally and therefore has a retro-oesophageal course [2]. Although most cases of this anomaly are asymptomatic, but symptoms may appear when a ring completely encircles the trachea or oesophagus. Extrinsic compression of oesophagus may lead to dysphagia. This phenomenon was first described in 1794 by a London physician David Bayford as a post-mortem finding in a woman who had lifelong dysphagia and eventually died of starvation. He named it \u201cDysphagia Lusoria\u201d which means dysphagia by freak of nature [3].Klink Hamer [4] observed that in symptomatic cases aberrant right subclavian artery was associated with a bicarotid trunk (common origin of right and left carotid arteries).The diagnosis of Dysphagia Lusoria is difficult as the symptoms are nonspecific. Endoscopy may miss the diagnosis in 50% of cases although a pulsating mass may be visualized. Barium swallow may demonstrate a diagonal impression at the level of T3-T4. Digital subtraction angiogram, contrast enhanced CT or MRI of thorax is perhaps the best diagnostic test that could pick up the abnormality. Angiogram is needed for pre-operative assessment [5].Management Of dysphagia lusoria depends on the severity of the condition and it ranges from dietary adjustments only to surgical resection [6]. First successful repair was reported by Robert Gross [7]. Initial reports revealed that simple division without blood flow restoration can cause ischemia of the arm. Bailey et al. in 1965 [8] attached distal end of divided vessel to ascending aorta. Cooley anastomosed distal end to right common carotid [9] This method was favoured by others but there is a possibility of cerebral ischemia with this approach. Mok et al. [10] recommended to anastomose the end to aortic arch with or without a graft. Since then numerous alternatives have been described. Some recommend an endovascular or hybrid approach to this anomaly. Endoluminal grafts have also been reported especially in presence of aneurysm [11].Our patient was managed conservatively with dietary readjustments and showed improvement with significant weight gain in 6 months.",
    "differential_diagnosis": "Dysphagia, Lusoria, due, to, aberrant, right, subclavian, artery, Achalasia, Neuromauscular, Interinsic, lesions, Extrinsic, compression",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012979/000001.png?itok=lirSaSm_",
            "caption": "Coronal Section CT Chest. Aberrant right subclavian artery is seen crossing behind oesophagus (marked by yellow arrow)"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012979/000002.png?itok=KwtInxVB",
            "caption": "Coronal Section CT Chest. Aberrant right subclavian artery is seen behind oesophagus (marked by yellow arrow)"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012979/000003.png?itok=IL66bom2",
            "caption": "CT Chest transverse Section.\nAberrant right subclavian artery is seen crossing behind oesophagus and arching towards infraclavicular region (yellow arrows). Dilated oesophagus is apparent in front of the crossing vessel."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000012979/000004.png?itok=VtgH0zDd",
            "caption": "CT Chest Transverse Section.\nAberrant right subclavian artery is seen crossing towards infraclavicular region (yellow arrows). Dilated oesophagus is apparent in front of the crossing vessel."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/12979",
    "time": "31.08.2015"
  },
  "13005": {
    "case_id": 13005,
    "title": "A large aneurysmal bone cyst of the rib",
    "section": "Chest imaging",
    "age": "22",
    "gender": "female",
    "diagnosis": "Aneurysmal bone cyst of the rib",
    "history": "A 22-year-old female patient with complaint of right side chest pain and discomfort in association with right shoulder and back pain for more than 2 years. In radiology department chest radiography and ultrasound were performed followed by chest CT and MRI examinations.",
    "image_finding": "Chest radiography showed a large opacity in the middle and lower zones of the right hemithorax (Fig. 1) while the chest ultrasound showed a lobulated cystic lesion with echogenic internal septations (Fig. 2). For further investigation an unenhanced and contrast-enhanced CT was performed, which demonstrated a large expansile multiloculated cystic lesion in the right hemithorax originating from the posterior arch of 8th rib. The mass lesion measured 9.9x7x8.8 cm. Some of the loculation within the lesion demonstrates fluid-fluid level and the septations inside the cyst were clearly enhanced after IV contrast injection (Fig. 3). MRI T2 weighted images confirmed a multiloculated cystic structure with fluid-fluid level as well (Fig. 4).",
    "discussion": "For the first time, aneurysmal bone cyst of the rib (ABC) was reported by Jaffe and Lichtenstein in 1942 [1]. ABC can affect all the ribs except the last 3 and as a whole the involvement of ribs comprises 2.7% of all ABC cases [2]. The main aetiology of the disease is unknown, however, the disturbance in arterio-venous circulation could mostly be the reason [3]. Another mentioned aetiology of ABC is the increased pressure of venous circulation or trauma, which causes bone absorption and formation of blood- filled cysts [4]. ABCs usually occur primarily but some cases demonstrate secondary to lesions like fibrous dysplasia, angiochondroblastoma, haemangioendothelioma, cartilogenous haematoma or giant cell tumours [2]. The tumour is an expansile destructive bone lesion containing various sizes of cystic structures filled by blood or serum. The cysts are separated by septas which are composed of loose spindle cells or benign giant cell septas [4]. A palpable lump with limited movement, pathological fracture and pain are the main features of ABC, but in 29% of cases the tumour is totally asymptomatic and is found incidentally in a routine chest X-ray [5]. CT and MRI images demonstrate multiple cavernous spaces which are filled by fluid-fluid levels [3]. The radiographic differential diagnosis comprises giant cell tumour, plasmocytoma, chondrosarcoma, fibrous dysplasia, chondormyxoid and metastasis [5]. Ewing sarcoma and eosinophilic granuloma are included in the differential diagnosis as well [4]. Core needle biopsy specimens can be performed for confirmation of the diagnosis. Biopsy needs to be done carefully due to risk of bleeding from blood cavities inside the ABC [2]. The histopathological examination reveals a non-malignant bone lesion that is composed of blood-filled cysts and trabeculae. The cysts are lined with cuboidal cells consisting of osteoid tissue, fibroblasts and giant cells [1, 2]. Different treatment strategies have been proposed for ABC; surgical removal, radiotherapy, cryotherapy, sclerotheraphy and embolization. The best option with the lowest risk of recurrence is total excision [6]. In surgery following the removal of the tumour the affected part of the rib is cut as well. The recurrence rate is between 11-31%. Non-operable cases can be treated by radiotherapy [7]. Selective arterial embolization is another choice of treatment, especially for those ABCs which are difficult for surgery due to site or size [6].",
    "differential_diagnosis": "Aneurysmal, bone, cyst, of, the, rib, Plasmocytoma, Chondrosarcoma, Fibrous, dysplasia, Chondormyxoid, Giant, cell, tumour",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013005/000001.jpg?itok=-U8lHsXW",
            "caption": "Large opacity in the middle and lower zones of the right hemithorax."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013005/000002.jpg?itok=dIxHkpKk",
            "caption": "Lobulated cystic lesion with echogenic internal septations in the right hemithorax."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013005/000005.jpg?itok=RGjLSKup",
            "caption": "Large expansile multiloculated cystic lesion in the right hemithorax originating from posterior arch of 8th rib."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013005/000006.jpg?itok=jOJlVveL",
            "caption": "Multiloculated cystic structure with fluid-fluid level originating from right 8th rib."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Musculoskeletal bone",
      "Thorax",
      "Lung"
    ],
    "imaging_technique": [
      "Digital radiography",
      "Ultrasound",
      "CT",
      "MR-Functional imaging"
    ],
    "link": "https://www.eurorad.org/case/13005",
    "time": "04.10.2015"
  },
  "13012": {
    "case_id": 13012,
    "title": "Post-traumatic left diaphragmatic rupture with intrathoracic stomach herniation",
    "section": "Chest imaging",
    "age": "22",
    "gender": "male",
    "diagnosis": "Left diaphragmatic tear with intrathoracic herniation of the stomach",
    "history": "A 22-year-old male patient with no medical history was admitted to our department for an abdominal CT after abdominal trauma following a high-speed traffic accident. The patient presented immediately after the trauma with breathing difficulties and a stable haemodynamic status.",
    "image_finding": "Clinical evaluation revealed a fracture of the femur and the left iliac wing.Chest radiography showed an elevation of the left diaphragmatic dome with an irregular aspect of its distal end (Fig. 1).Abdominal ultrasound revealed a pelvic effusion with a suspicion of a dehiscence of the bladder wall that made an abdominal CT necessary.Abdominal CT revealed an elevation of the left diaphragmatic dome with a defect measuring 2 cm with a gastric trans-diaphragmatic hernia, which was best seen on the sagittal reformation (Fig. 2).The so called \"collar sign\", consisting of a constriction of the stomach at the site of the diaphragmatic tear, was seen on the coronal reformation (Fig. 3). The dependent viscera sign was shown on the axial section: the stomach was in direct contact to the posterior chest wall because it was not supported by the injured diaphragm (Fig. 4a).",
    "discussion": "Diaphragmatic rupture often results from blunt abdominal trauma, which is usually associated with motor-vehicle accidents and hence is predominant among young men. Estimated incidence is ~4.5% (range 0.8-8%) of patients who suffer blunt abdominal or lower thoracic trauma [1, 2]. The most common herniated viscera are the stomach and colon. The left hemidiaphragm is involved 3 times more frequently than the right, possibly because the liver has a buffering effect.Clinical presentation varies depending on the mechanism of injury (blunt vs penetrating) and the presence of associated injuries. Symptoms of diaphragmatic injuries are frequently masked by associated injuries. As the diaphragm is integral to normal ventilation, injuries can result in significant ventilatory compromise. A history of respiratory difficulty and related pulmonary symptoms may indicate diaphragmatic disruption [3], in fact our patient had breathing difficulties immediately after the accident.Diaphragmatic tears rarely occur in isolation. These patients often have associated thoracic and/or abdominal injuries or may have concomitant head or extremity trauma as is the case of our patient who had a fracture of the femur and a dehiscence of the bladder wall. Chest radiography is the most important diagnostic technique, it can show a blurred and irregular aspect of the hemidiaphragm, an elevation of the diaphragmatic dome, an intrathoracic bowel pattern or presence of nasogastric tube in the chest [3].In abdominal CT, direct discontinuity of the hemidiaphragm (Fig. 2) may be seen with or without intrathoracic herniation of abdominal contents. CT may show characteristic signs of diaphagmatic rupture including: the collar sign (a waist-like constriction of the herniating hollow viscus at the site of the diaphragmatic tear, which is classic for diaphragmatic rupture (Fig. 3)) ; the dependent viscera sign (when a patient with a ruptured diaphragm lies supine at CT examination, the herniated viscera are no longer supported posteriorly by the injured diaphragm and fall to a dependent position against the posterior ribs (Fig. 4a); focal diaphragmatic thickening; thoracic fluid abutting the abdominal viscera [4].MRI may aid diagnosis because it visualizes the diaphragm\u2019s anatomy. It is indicated in cases of uncertain diagnosis in a patient with stable condition, in cases of patient who will not be explored surgically or for late diagnosis [3].",
    "differential_diagnosis": "Left, diaphragmatic, tear, with, intrathoracic, herniation, of, the, stomach, Congenital, diaphragmatic, hernia, Diaphragmatic, eventration",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013012/000008.jpg?itok=w69bm1lP",
            "caption": "Chest X-ray showing an elevation of the left hemidiaphragm with an irregular aspect of its distal end."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013012/000009.jpg?itok=2MyxIulu",
            "caption": "Abdominal CT coronal section showing the collar sign."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013012/000014.jpg?itok=5lBvzRT_",
            "caption": "Abdominal CT sagittal section showing the diaphragmatic rupture."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013012/000015.png?itok=8OXZEFp1",
            "caption": "Abdominal CT axial sections showing the dependent viscera sign (a); intra-thoracic stomach hernia (b) and the diaphragm in the upper abdomen (c, d)."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Abdomen"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/13012",
    "time": "04.11.2015"
  },
  "13100": {
    "case_id": 13100,
    "title": "Left ventricle hydatid cyst",
    "section": "Chest imaging",
    "age": "22",
    "gender": "female",
    "diagnosis": "Left ventricle hydatid cyst",
    "history": "A 22-year-old female patient presented with right upper quadrant pain and chest pain. Her past medical history was unremarkable.",
    "image_finding": "On CT, a thick-walled cystic lesion was noted within the lumen of the left ventricle with contact to the interventricular septum (Fig. 1, 2). In addition, a large thick-walled cystic lesion was seen in the lower lobe of the left lung (Fig. 1, 2). Multiple thick-walled cystic lesions were seen in the liver (Fig. 2, 3). All cysts were hyopodense and did not show any calcifications.Based on the imaging findings, hydatid disease was suspected.",
    "discussion": "The first case of cardiac hydatidosis was reported by Williams in 1836 [3]. The prevalence of cardiac hydatidosis is very low, accounting for only 0.5 to 2% of hydatid disease [1, 2].Cardiac involvement is believed to occur through coronary artery circulation, pulmonary veins or by direct contact with hydatid cysts originating from the liver or the lung.The left ventricle is the most common site (50-60%) due to the thickness of the myocardium, followed by the right ventricle (15%), the interventricular septum (9%), left atrium (8%), right atrium (4%) and interatrial septum (2%) [2]. Hydatid cyst fluid is a very potent anaphylactic substance. If a hydatid cyst ruptures into the cavity of the heart, the cyst fluid may cause anaphylaxis and the cyst membrane may cause an embolus. Rupture into the pericardial cavity may lead to pericarditis, effusion, or cardiac tamponade [2].Most patients with cardiac hydatidosis have no symptoms because hydatid cysts grow very slowly. Clinical presentations are extremely variable and directly related to the location and size of the cysts. Only approximately 10% of patients, especially those with large hydatid cysts, have clinical manifestations. Vague pericardial pain is the most common presenting symptom [1].The diagnosis of cardiac echinococcosis is mainly based on the combination of clinical suspicion, cardiac imaging and serologic tests [4]. Echocardiography, CT and MRI can show the cystic nature of the mass and its relation to the cardiac chamber. CT best shows wall calcification [1].Echocardiography is a highly sensitive and specific tool for the diagnosis of cardiac hydatid disease and shows the effect of the lesion on ventricularorvalvular functions [4].On MR imaging, hydatid cysts usually appear as oval-shaped lesions, which are hypointense on T1 weighted images and hyperintense on T2 weighted images. The cysts may be single or multiple, uniloculated or multiloculated and thin or thick-walled [1].Surgery is the treatment of choice in cardiac hydatidosis, although antihelminthic drugs have been used in the preoperative and postoperative periods since 1977 [1]. To prevent complications, open heart surgery with cardiopulmonary bypass and systemic arterial clamping is performed to prevent dissemination in case of cyst rupture.",
    "differential_diagnosis": "Left, ventricle, hydatid, cyst, Cardiac, tumour, Left, ventricle, aneurysm",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013100/000001.png?itok=yaou473w",
            "caption": "Cystic lesion within the lumen of the left ventricle. A second cyst is seen in the lower lobe of the left lung."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013100/000002.png?itok=k_O5yNUf",
            "caption": "Low attenuation cystic lesion inside the left ventricle with multiple cystic lesions in the liver and a cystic lesion in the lower lobe of the left lung."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013100/000003.png?itok=3sQyuDPR",
            "caption": "Cystic lesion inside the left ventricle with multiple cystic lesions in the liver and multiple cystic lesions in the peritoneum."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Cardiovascular system",
      "Abdomen"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/13100",
    "time": "22.12.2015"
  },
  "13142": {
    "case_id": 13142,
    "title": "Costal cartilage fracture",
    "section": "Chest imaging",
    "age": "17",
    "gender": "male",
    "diagnosis": "Costal cartilage fracture.",
    "history": "A 17-year-old male presented at the emergency department complaining of pain in his left anterior chest after a direct trauma while practicing physical exercise. Radiography was negative for fracture and pneumothorax. Two weeks later, the patient returned to the hospital complaining of no improvement and CT was performed.",
    "image_finding": "TC demonstrated cortical discontinuity of the left 8th costal cartilage, involving the middle region and with displacement. There were no rib fractures.",
    "discussion": "Patients with chest injuries are frequently seen in our daily medical practice. Although acute rib fractures, healing fractures with callus formation, or those associated with other injuries may be readily identified with radiography, costal cartilage fractures are not radiographically recognizable unless the fracture involves a cartilage that has undergone physiologic calcification [1, 2].Fractures of costal cartilages have rarely been reported in the literature; whether they are truly exceptional or just underdiagnosed is unknown.Computed tomography (CT) is sometimes performed in cases of unexplained acute posttraumatic parasternal pain, or chronic painful parasternal lump and detects an overlooked costal fracture. Costal fractures are recognized by visualizing focal interruption in the relatively high costal cartilage density. Displacement of the adjacent segments and soft-tissue swelling may be present. Focal calcifications may be appreciated surrounding subacute or chronic fractures. In lesions involving the chondrocostal or chondrosternal junctions, a thin area with gas density may be seen within the fracture cleft [3]. Costal cartilage fractures can be also identified by ultrasound as a focal interruption in the linear echogenic anterior margin of the hypoechogenic cartilages [2, 4]. The main advantages of this method are the absence of ionizing radiation and widely availability. It also offers easy multiplanar scanning capability, which is similarly obtained with multiplanar reformatted images in CT. Initial conservative treatment is recommend and surgery is reserved for refractory and complicated cases [1]. This case highlights the difficulty in establishing the diagnosis based on clinical examination and standard radiographs alone.",
    "differential_diagnosis": "Costal, cartilage, fracture., Costochondritis, Tietze\u2019s, syndrome, Cyriax\u2019s, syndrome",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013142/000001.png?itok=I6C_Bg3w",
            "caption": "There were no rib fractures, as demonstrated on this TC reconstruction."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013142/000002.png?itok=cyhr2phj",
            "caption": "TC demonstrated cortical discontinuity of the left 8th costal cartilage, involving the middle region and with displacement."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013142/000003.png?itok=S8TqweSk",
            "caption": "TC demonstrated cortical discontinuity of the left 8th costal cartilage, involving the middle region and with displacement."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013142/000004.png?itok=TV4hiNKJ",
            "caption": "TC demonstrated cortical discontinuity of the left 8th costal cartilage, involving the middle region and with displacement."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013142/000005.png?itok=Ni0FBrRW",
            "caption": "TC demonstrated cortical discontinuity of the left 8th costal cartilage, involving the middle region and with displacement."
          },
          {
            "number": "Figure 2e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013142/000006.png?itok=2BKETUXw",
            "caption": "TC demonstrated cortical discontinuity of the left 8th costal cartilage, involving the middle region and with displacement."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Emergency"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/13142",
    "time": "16.11.2015"
  },
  "13153": {
    "case_id": 13153,
    "title": "Kartageners syndrome",
    "section": "Chest imaging",
    "age": "19",
    "gender": "male",
    "diagnosis": "Kartagener's syndrome",
    "history": "A 21 year-old male came with complaints of breathlessness since one month, chronic cough with expectoration and nasal congestion since 15 years. On physical examination bilateral wheeze and basal crackles were audible, with heart sounds being best heard on the right side of the chest.",
    "image_finding": "Ultrasound revealed situs inversus with liver and IVC on the left and spleen and aorta on the right. There was mild ascites in the abdomen and the pelvic cavity [Figure 1]. Chest radiograph revealed dextrocardia, haziness with bilateral cystic bronchiectasis in the mid and lower lung zones [Figure 2]. HRCT Chest shows trilobed left lung and bilobed right lung [Figure 3]. Axial unenhanced CT image of the abdomen showed a situs inversus totalis- liver and IVC on the left and spleen and aorta on the right[ Figure 4]. HRCT chest image showed extensive cystic bronchiectasis distributed in both lungs with a predominance in the lower lobes. Few centrilobular micronodules representing mucoid impaction with few areas of ground glass opacities are seen in the left lower lobe [Figure 5]. CT paranasal sinuses revealed mucosal thickening in bilateral maxillary sinuses suggestive of sinusitis [Figure 6]",
    "discussion": "A. Kartagener's syndrome[KS] is a subset of primary ciliary dyskinesias and is a genetic condition with an autosomal recessive inheritance comprising a triad of situs inversus, bronchiectasis and sinusitis[1]. It has incidence of 1:20, 000 to 1:60, 000 live births[2]. Pathophysiology for recurrent sinusitis, bronchiectasis and situs inversus is the ultrastructural and functional defects of ciliary motility [3].Without functional nodal cilia in the KS patients during embryonic period, thoracoabdominal orientation is random [4].B. Clinical findings are chronic recurrent rhino-sinusitis , productive cough, Nasal polyps , otitis media and significant shortness of breath. Some patients have severe obstructive impairment that is worse than patients with Cystic Fibrosis at a comparable age [4].C. Imaging plays a vital role in diagnosing this condition. A set of radiological tests including chest Radiograph, HRCT Chest , CT Abdomen and CT PNS can lead us to conclusive diagnosis of Kartagener\u2019s syndrome. Chest X-ray may reveal dextrocardia and bronchiectasis. To look for situs inversus ultrasound can be performed which shows spleen and aorta on the right and liver and IVC towards the left. Axial unenhanced CT of the abdomen can show situs inversus totalis with dextrocardia.HRCT chest shows cystic bronchiectasis in lower lobes of both the lungs. It is important to differentiate it from cystic fibrosis as the thick walled bronchiectasis with intervening lung is often densely fibrotic and retracted in CF but not in KS. Bronchiectasis is usually present in the more dependent lobes such as the middle and lower lobes in KS , in contrast to the upper lobes most affected in CF [5]. CT PNS can reveal pansinusitis. With this set of imaging findings which is more than conclusive electron microscopy can be done otherwise to reveal ciliary dyskinesia. D.Screening tests like nasal nitrous oxide measurement, saccharin test and analysis of dynein proteins can be done. Electron microscopy (EM) is the more accredited test, even though it does not exist only one gold standard[6]. Treatment requires chest physiotherapy, antibiotics with good H.influenzae, S. aureus and S. pneumoniae coverage[7]. Lobectomy should be done in severe localised bronchiectasis. Lung transplantation is an option in end-stage lung disease[4].E. Kartagener's syndrome is a rare condition and its proper diagnosis will result in early treatment and better prognosis of this disease. Prompt detection and treatment can prevent its complications as well[8].",
    "differential_diagnosis": "Kartagener's, syndrome, Cystic, fibrosis, Primary, and, secondary, ciliary, dyskinesias, Alpha-1-antitrypsin, deficiency",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013153/000001.png?itok=FnvQTAbS",
            "caption": "Dextrocardia with haziness and bilateral cystic bronchiectasis in the mid and lower lung zones."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013153/000002.png?itok=5VtB2R9n",
            "caption": "Cystic bronchiectasis in both lungs with predominance in lower lobes. Few centrilobular micro nodules representing mucoid impaction with few areas of ground glass opacities are seen in the left lower lobe."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013153/000005.png?itok=gkMKR6LR",
            "caption": "Right sided spleen and aorta \nLeft sided liver and IVC"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013153/000006.png?itok=vJhMwjE5",
            "caption": "Coronal and axial images of trilobed left lung and bilobed right lung. Yellow arrow shows horizontal fissure in left lung"
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013153/000007.png?itok=ra31pweL",
            "caption": "Coronal and axial images show oblique fissure in left lung"
          },
          {
            "number": "Figure 4c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013153/000013.png?itok=Hrba2JSz",
            "caption": "Saggital image shows bilobed right lung."
          },
          {
            "number": "Figure 4d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013153/000014.jpg?itok=pBrzMfH0",
            "caption": "Trilobed left lung. Arrows show horizontal and oblique fissure in left lung"
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013153/000011.png?itok=CDhhTqJt",
            "caption": "Fig 1A shows right sided spleen (situs inversus)"
          },
          {
            "number": "Figure 5b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013153/000012.png?itok=WngQ1QLZ",
            "caption": "Fig 1b shows left sided liver suggesting situs inersus"
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013153/000015.jpg?itok=g33uI2uR",
            "caption": "Mucosal thickening in bilateral maxillary sinuses suggestive of sinusitis."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Abdomen",
      "Ear / Nose / Throat",
      "Spleen",
      "Liver"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT-High Resolution",
      "CT",
      "Ultrasound"
    ],
    "link": "https://www.eurorad.org/case/13153",
    "time": "03.12.2015"
  },
  "13154": {
    "case_id": 13154,
    "title": "Inflammatory Myofibroblastic Tumour (IMT) of the lung",
    "section": "Chest imaging",
    "age": "27",
    "gender": "male",
    "diagnosis": "Inflammatory myofibroblastic tumour.",
    "history": "An asymptomatic non-smoking 27-year-old male patient presented with a positive Quantiferon test performed for latent TB screening and went on to have a Chest X Ray (CXR) to exclude active TB.",
    "image_finding": "PA-CXR demonstrated a large solitary nodule projected behind the right hemidiaphragm, with no evidence of cavitation, calcification or adjacent lung parenchymal abnormality [Fig. 1a]. Lateral-CXR confirmed this posteriorly in the right lower lobe [Fig. 1b].The patient underwent non-contrast-CT, through the lesion, followed by a post-contrast-CT of chest and abdomen. CT was performed with a 64-row CT-scanner (Siemens Healthcare, UK). Acquisition parameters used in spiral CT acquisitions were: 120kV and 110mA, with iterative reconstruction. The contrast medium was Omnipaque300.CT images confirmed the presence a well-defined lesion, with smooth margins, in the postero-basal segment of the right lower lobe, with no calcification or cavitation, but heterogeneous enhancement, pre-contrast density was 16HU (SD 7.8), post-contrast density was 50 HU (SD 23) [Fig. 2-6].No other abnormality was seen on CT. CT-guided biopsy was performed and a histopathological diagnosis of inflammatory myofibroblastic tumour of the lung was made [Fig. 7].The patient underwent surgical resection.",
    "discussion": "Inflammatory Myofibroblastic Tumors (IMT) were first described in the lung by Brunn in 1939 [1]. In 2002, the World Health Organization (WHO) classification defined IMT as a distinctive lesion composed of myofibroblastic spindle cells with an inflammatory infiltrate of plasma cells, lymphocytes and eosinophils [2]. Despite being considered a non-malignant lesion, according to an update based on the latest (4th edition) WHO classification of soft tissue tumor done in 2013, IMT is classified as a true neoplasm rather than a reactive process [2, 3, 4]. Mutations of Anaplastic Lymphoma Kinase (ALK) gene and ALK-receptor gene are observed in approximately 40-100% of IMT, depending on the anatomical site where it arises [5, 6]. A relation between IMT and IgG4-Syndrome has been reported in the literature [5], even though Bhagat et al. tried to distinguish IMT and IgG4-related inflammatory pseudotumour [7].The lungs are the commonest site for IMT, but involvement of orbits, gastro-intestinal and genitourinary tract also occurs [5]. IMT is found most commonly in children and young adults, has no gender or racial prediliction, and is extremely rare (0.04-1% of all lung tumours) [2].Pulmonary IMT (PIMT) represents a low grade malignant lesion, with slow and local growth [5]. However,  a more aggressive behaviour with distant metastatic spread has been described and for this reason resection was thought to be prudent [8]. Patients with IMT are usually asymptomatic, as in our case, or may present with non-specific symptoms [2]. PIMT usually appear as a solitary, well-circumscribed peripheral lung mass, with a predominance for the lower lobes [6]. Calcification of the mass is unusual, the presence of intralesional calcium can occur in up to 15% of cases [9].On CT there is an heterogeneous or homogeneous enhancement pattern [6]. Some authors described the possibility of atypical Hypertrophic Pulmonary Osteoarthropathy (HPO) in PIMT patients, with abnormal periosteal formation [2]. Local expansion may cause significant morbidity and occasional death. The treatment of choice of PIMT is surgery. The prognosis after complete surgical resection is excellent [6]. A broncoscopic resection can be an useful alternative to surgery [10]. In cases of extensive involvement or inoperable patients (patients with poor pulmonary function and comorbidity) radiotherapy, corticoids and chemotherapy may be employed [6]. PIMT, although rare, should be considered in the differential diagnosis for an incidental peripheral pulmonary mass or nodule seen on CXR or CT in patients typically under 40 years old.",
    "differential_diagnosis": "Inflammatory, myofibroblastic, tumour., Endobronchial, carcinoid, tumour, Adenoid, cystic, carcinoma, Mucoepidermoid, carcinoma, Granuloma, Hamartoma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013154/000001.jpg?itok=QpHNCAv5",
            "caption": "CRX: PA projection, demonstrated a large solitary nodule projected behind the right hemidiaphragm"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013154/000018.jpg?itok=pIQUItpm",
            "caption": "CRX: Lateral projection, showing the large nodule posteriorly in the right lower lobe"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013154/000003.jpg?itok=X5o_tYwT",
            "caption": "Coronal image generated using MPR and averaging from original CT data"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013154/000019.jpg?itok=ysnH6yFb",
            "caption": "Sagittal image generated using MPR and averaging from original CT data"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013154/000005.jpg?itok=UelZOxbK",
            "caption": "CT without contrast: axial view with the mediastinal window"
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013154/000017.jpg?itok=nZwhcstE",
            "caption": "CT without contrast: sagittal view with the mediastinal window"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013154/000007.jpg?itok=kNTkoCL7",
            "caption": "CT without contrast: axial view with the lung window"
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013154/000016.jpg?itok=DxQ4__Zh",
            "caption": "CT without contrast: sagittal view with the lung window"
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013154/000011.jpg?itok=lyE2i0-j",
            "caption": "CT with contrast: axial view"
          },
          {
            "number": "Figure 5b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013154/000012.jpg?itok=hn91Xv7A",
            "caption": "CT with contrast: sagittal view"
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013154/000013.jpg?itok=N_EySRwS",
            "caption": "This figure demonstrates the heterogeneous enhancement of the lesion"
          },
          {
            "number": "Figure 6b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013154/000014.jpg?itok=2jNSik4R",
            "caption": "This figure demonstrates the heterogeneous enhancement of the lesion"
          }
        ]
      },
      {
        "number": "Figure 7",
        "subfigures": [
          {
            "number": "Figure 7",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013154/000015.jpg?itok=6--7En0A",
            "caption": "Microscopy: a solid lesion, replacing the normal lung parenchyma, of regular spindle-shaped-cells and inflammatory cells. Foamy macrophages forming xanthomatous appearance. Immunohistochemistry shows strong positivity for ALK (D5/F3 antibody\u2013Ventana) confirming the diagnosis of IMT."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "Digital radiography",
      "CT",
      "Experimental"
    ],
    "link": "https://www.eurorad.org/case/13154",
    "time": "16.11.2015"
  },
  "13162": {
    "case_id": 13162,
    "title": "A strange case of pulmonary embolism",
    "section": "Chest imaging",
    "age": "78",
    "gender": "male",
    "diagnosis": "Echinococcal pulmonary circulation embolism",
    "history": "A 78-year-old man, ex-smoker, in treatment with oral anticoagulants for permanent atrial fibrillation was referred for a chest X-ray in order to investigate an episode of haemoptysis, longstanding cough and recurrent bronchitis. A hepatic cyst, probably hydatid in nature, was identified during preoperative assessment for elective cholecystectomy 20 years ago.",
    "image_finding": "Chest X-ray (Fig. 1) demonstrated multiple nodular opacities in the right upper lobe.Contrast enhanced Chest-CT demonstrated the presence of filling defects in the right middle and inferior lobe pulmonary arteries, compatible with embolism (Fig. 2a-b). Lobulated non-calcified opacities in bilateral upper lobes and left lower lobes were noted. These structures correspond to dilated segmental and subsegmental pulmonary arteries, filled with hypodense material (Fig. 2c-d). Echocardiography showed no signs of increased right ventricular pressure. A partially calcified multi-loculated cyst was detected in liver segments III-IV, compatible with echinococcal cyst, the left hepatic vein could not be delineated (Fig. 2d-e). PET-CT showed intense uptake of 18F-FDG at the level of the nodes (max SUV 4, 4), without other signs of increased metabolic activity.",
    "discussion": "Embolization of echinococcal cysts to pulmonary arteries is rare [1-3] and it is caused by hepatic cysts in communication with hepatic veins/inferior vena cava or ruptured cysts in right cardiac chambers [2-5]. Arterial obstruction results from daughter cysts without thrombosis and is classified as a non-thrombotic pulmonary arterial embolism [2, 5]). In our case, infiltration of the left hepatic vein resulted in diffuse pulmonary arterial tree embolization without significant involvement of lung parenchyma.The main clinical symptoms are cough, dyspnoea, haemoptysis and acute chest pain [6]. Patients with these symptoms are usually referred to the Radiology Department for Chest CT to rule out pulmonary thromboembolism. Enhanced CT demonstrates occlusion and enlargement of the pulmonary arterial tree by hypodense content; the differential diagnosis can therefore be other causes of embolism (thrombotic, septic and neoplastic) and pulmonary artery sarcoma. Clinical history (knowledge of hydatid infestation) and presentation are essential to achieve the correct diagnosis. When hydatid embolism is suspected, radiologists should search for the source of the emboli (hepatic cysts in communication with hepatic veins/vena cava, ruptured cyst in the right cardiac chambers). MRI can be useful in the differential diagnosis, demonstrating the high signal in the T2-weighted sequences typical of cysts.Pulmonary artery sarcoma is characterized by low-attenuating filling defect which can extend into lung parenchyma or mediastinum and shows diffuse enhancement.Cases of hydatid pulmonary embolism are classified into three groups accordig to clinical course: acute fatal cases, subacute pulmonary hypertension cases resulting in death within 1 year and chronic pulmonary hypertension cases [2, 5, 7]. Our patient did not present with severe acute symptoms, neither did he develop chronic pulmonary hypertension. The patient is being regularly followed with echocardiography and shows no signs of increasing right ventricle pressure. To confirm our diagnosis, the patient underwent VATS biopsy: a diagnosis of gigantocellular fibrogranulomatous nodules with ischemic necrosis and exogenous material referable to fragments of parasites was made. Treatment of choice for hydatid pulmonary embolism is surgery. Given the anesthesiologic risk due to the permanent atrial fibrillation and the surgical risk of rupture of the artery or of the cyst with anaphylactic shock, we decided on repeated cycles of albendanzole and follow-up, in agreement with the patient. After 2 years the patient reports a substantial stability in his symptomatology. The last follow up CT (Fig 3a-b) showed an increased extent of pulmonary arterial tree involvement; albendanzole therapy was then again started.",
    "differential_diagnosis": "Echinococcal, pulmonary, circulation, embolism, Pulmonary, thromboembolism, Pulmonary, artery, Sarcoma, Septic, embolism, Tumor, embolism",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013162/000002.jpg?itok=jehWvlcE",
            "caption": "Chest X-ray shows multiple bilateral nodular opacities (arrows) associated with parenchymal bands"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013162/000003.jpg?itok=Qkl6IIRe",
            "caption": "These images demonstrate hypodense filling defects in the right middle lobe artery and in a segmental artery of left inferior lobe, compatible with embolism."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013162/000004.jpg?itok=VseBXyXT",
            "caption": "These images demonstrate hypodense filling defects in right middle lobe artery and in a segmental artery of left inferior lobe, compatible with embolism."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013162/000005.jpg?itok=QvsXYkPn",
            "caption": "There are multiple bilateral tubular polilobulated opacities extending from the hylum to the peripheral zones of both lungs. The opacities have variable diameter (maximum 15 mm) and seem to be in continuity with pulmonary arteries."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013162/000009.jpg?itok=xc5lq_hL",
            "caption": "A large multiloculated partly calcified echinococcal cyst is seen in III-IV hepatic segment; the lesion is in continuity with the left hepatic vein, which is not detectable, being filled with hypodense material."
          },
          {
            "number": "Figure 2e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013162/000006.jpg?itok=VO4C1MqX",
            "caption": "A large multiloculated partly calcified echinococcal cyst is seen in III-IV hepatic segment; the lesion is continuity with left hepatic vein, which is not detectable, being filled with hypodense material."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013162/000007.jpg?itok=zuFGWCBB",
            "caption": "Follow up CT shows a marked increase of the pulmonary artery tree involvement."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013162/000008.jpg?itok=wFdUnfyH",
            "caption": "Follow up CT shows a marked increase of the pulmonary artery tree involvement."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax",
      "Abdomen"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/13162",
    "time": "18.02.2016"
  },
  "13181": {
    "case_id": 13181,
    "title": "A case of tracheal obstruction presenting as COPD",
    "section": "Chest imaging",
    "age": "66",
    "gender": "female",
    "diagnosis": "Primary Obstructive Squamous Cell Carcinoma of the Trachea (Stage T3) [7]",
    "history": "A 66-year-old woman presented with sudden-onset shortness of breath and wheeze, triggered by smoke and cold on a background of recurrent pneumonia. Auscultation demonstrated expiratory wheeze and decreased air entry throughout. She was treated for Chronic Obstructive Pulmonary Disease. On consultant review, stridor was noted, leading to further imaging.",
    "image_finding": "On presentation, an initial CXR (Fig. 1) showed a hyper-inflation of the chest and a flattening of  the hemi-diaphragms. A tracheal stenosis at the clavicular level was overlooked. Chest CT with contrast (Fig. 2) showed a reduction of the tracheal lumen, below the thyroid, extending 3.5 cm inferiorly, with compression of the oesophagus. Urgent bronchoscopy showed a 90% narrowing, and biopsies revealed a moderately differentiated squamous cell carcinoma. The tumour was debulked by diathermy excision, and a tracheostomy was inserted, fitting a T-tube to stent the trachea and maintain luminal patency. Follow-up CT (Fig. 3) was performed to re-stage the growth, demonstrating residual tumour left of - and left posterior to the T-tube (measuring 13 mm in depth). The bronchial walls appear thickened throughout, and two new tree-in-bud opacities are noted in the right upper lobe.Further bronchoscopy and CXR (Fig. 4) confirmed the T-tube to be in a satisfactory position.",
    "discussion": "A.\tBackgroundThe trachea is a rare origin for tumours,  accounting for fewer than one percent of respiratory tumours [1]. The incidence of primary tracheal malignancy is 0.1 per 100, 000 population per year, and the 10-year survival rate is 6-7% [2]. More than half of these tumours are squamous cell carcinomas (54.5%) [3].B.\tClinical PerspectiveProgressive dyspnoea, cough, and phlegm are symptoms present in both chronic obstructive pulmonary disease and in tracheal malignancies which may mask the manifestation of the latter [4, 5]. The presence of stridor is a distinctive feature of an upper airway obstruction. Stridor is a harsh sound of a vibrating nature due to turbulent airflow, and can be inspiratory, expiratory, or biphasic. The different types are most commonly due to obstruction above the glottis, obstruction at/below the lower trachea, or a result of a glottic/subglottic lesion, respectively [6].C.\tImaging PerspectiveRadiologically, tracheal cancers can be broadly divided in the following: intra-luminal, wall-thickening, and exophytic [3]. Due to the largely hyper-inflated chest on the initial CXR, it was easy to attribute the presenting symptoms of dyspnoea to the patient\u2019s COPD, and overlook the tracheal stenosis that disguised under the sternal shadow. In addition, the patient was partially rotated, further complicating identification. Fortunately, a CT chest uncovered the underlying pathology, leading to prompt diathermic resection. Bronchoscopy further enabled the team to assess the severity, phenotype, and histology of the tumour, confirming the cause and degree of stenosis. D.\tOutcomeThe patient was treated palliatively due to comorbidities and the severity of her symptoms. She was profoundly cachexic and received adjuvant radiotherapy with 27 Gy (six fractions, twice per week - over five weeks). Although intended to be palliative, follow up CTs and biannual chest radiographs show no signs of recurrence up to this date, eight years after initial presentation. Of note, her follow-up CXRs are less hyper-inflated, though we did not have lung function tests available for comparison.E.\tTeaching pointsThis case reminds us of the importance of review areas when interpreting CXR. Presenting symptoms may be due to the contributory effects of multiple pathologies, and to consider this on presentation is crucial, especially in complex patients with a number of comorbidities. This case also reminds us of the diagnostic benefit of stridor--clinical examination ultimately prompted further imaging.",
    "differential_diagnosis": "Primary, Obstructive, Squamous, Cell, Carcinoma, of, the, Trachea, (Stage, T3), [7], Chronic, obstructive, pulmonary, disease, Pulmonary, fibrosis, Thyroid, malignancy, Foreign, body, airway, obstruction",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013181/000001.png?itok=NeJWbgDf",
            "caption": "Initial PA Chest X-Ray on presentation, demonstrating a tracheal stenosis at the level of the clavicle and a hyper inflated chest with flattened hemi-diaphragms, consistent with COPD."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013181/000002.png?itok=__5xn7TR",
            "caption": "Coronal thoracic CT demonstrating a marked narrowing of the trachea, below the level of the thyroid, with a 3.5 cm inferior extension."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013181/000003.png?itok=AJA-Umb7",
            "caption": "Transverse thoracic CT demonstrating a significant reduction in tracheal luminal diameter with the absence of any focal lung lesions, suggestive of a primary tumour. The oesophagus appears compressed. Mediastinal lymph nodes are not seen."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013181/000004.png?itok=IFt5NlZk",
            "caption": "Transverse thoracic CT showing the T-tube in place, with residual tumour left and left-posterior to it (13 mm in depth)."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013181/000005.png?itok=SYKbianK",
            "caption": "Transverse thoracic CT demonstrating bronchial wall thickening and emphysema throughout the lungs."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013181/000006.png?itok=lu2PqOeJ",
            "caption": "Chest X-Ray following the insertion of the T-tube, confirming it is in a satisfactory position."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Respiratory system"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/13181",
    "time": "07.01.2016"
  },
  "13193": {
    "case_id": 13193,
    "title": "Iatrogenic oesophageal perforation after pneumatic balloon dilatation for achalasi",
    "section": "Chest imaging",
    "age": "83",
    "gender": "male",
    "diagnosis": "Iatrogenic esophageal perforation after balloon dilatation for achalasia. Conservative treatment.",
    "history": "An elderly male suffering from malaise, limited oral intake and weight loss since a few months, recently diagnosed with achalasia presented to our hospital. There were several comorbidities including atrial fibrillation, congestive heart failure, multifactorial anaemia, melaena from bleeding metaplastic gastric polyp, renal function impairment. Worsening of epigastric pain shortly after pneumatic balloon dilatation (anticoagulation withdrawn before procedure).",
    "image_finding": "After oesophagogastroduodenoscopy and upper digestive radiographic study (Fig.1) revealed abnormal oesophageal motility, manometry diagnosed achalasia with non-relaxing lower sphincter. Following pneumatic balloon dilatation (Fig.2a), the patient complained of epigastric pain with radiographic (Fig.2b) appearance of pneumomediastinum and minimal pleural effusions suggesting oesophageal perforation. To provide a consistent basis for therapeutic choice, multidetector CT-oesophagography (Fig.3) was performed using peroral opacification with diluted water-soluble iodinated contrast. CT depicted patent gastroesophageal lumen, and confirmed minimal bilateral pleural effusions plus moderate diffuse pneumomediastinum mostly located near the distal thoracic oesophagus. Additionally, the dorsal aspect of the distal thoracic oesophagus showed segmental asymmetric soft-tissue thickening consistent with intramural iatrogenic injury. Without mediastinal fluid collections and extraluminal leakage of ingested contrast, surgeons opted for conservative treatment including parenteral nutrition, antibiotics and transfusions. The patient remained afebrile and haemodynamically stable. Before discharge, radiographic follow-up (Fig.4) showed decreasing pneumomediastinum, persistent minimal pleural effusions.",
    "discussion": "Achalasia is a rare neurodegenerative oesophageal motility disorder, characterised by decreased peristalsis and impaired relaxation of the lower oesophageal sphincter (LOS), resulting from inflammatory damage to the visceral myoenteric plexus. Achalasia usually manifests in adulthood with dysphagia, regurgitation, chest pain and weight loss. Whereas oesophageal manometry is the gold standard diagnostic technique, endoscopy allows ruling out mechanical obstruction, particularly a malignant stricture. Normal barium esophagography findings do not rule out achalasia, and the classical \u201ctapering\u201d appearance of the distal oesophagus with aperistalsis and upstream dilatation represents chronic disease [1-4] . Pneumatic balloon dilatation (PBD) is the first-line nonsurgical option to palliate achalasia by disrupting the LOS muscle fibers. Alternative treatments include open or laparoscopic Heller myotomy, and the recently introduced endoscopic oesophagomyotomy. PBD and surgery demonstrated similar efficacy (85-90% mid-term symptomatic relief) [1-3, 5]. Although repeated dilatation may be required, PBD is minimally invasive and generally well tolerated. The potentially serious complication represented by iatrogenic oesophageal perforation (IOP) occurs in 0.37%-4.3% of patients, is more frequent in elderly patients and associated with prolonged hospitalization and occasional mortality. IOP may be detected intraprocedurally or manifest hours or days later with pain, hypotension or fever [6, 7]. When plain radiographs are initially obtained, IOP may be heralded by mediastinal widening, pneumomediastinum, pleural effusion or hydropneumothorax. However, diagnostic delay may result from technically insufficient views, absent or subtle radiographic signs. Fluoroscopic contrast oesophagography (FCO) may confirm IOP with excellent specificity but moderate (~75%) sensitivity via demonstration of water-soluble contrast extravasation, but is cumbersome in critically ill patients. As this case exemplifies, multidetector CT-oesophagography (CT-O) represents the ideal \u201cone-stop shop\u201d technique to rapidly and comprehensively diagnose IOP. Signs include segmental oesophageal mural thickening, periesophageal air or fluid collections, pneumomediastinum, left-sided pleural effusion or hydropneumothorax. With injuries to the oesophago-gastric junction, extraluminal air may dissect inferiorly in the abdomen Mural discontinuity and contrast leakage into mediastinum or pleural space represents the most specific sign of full-thickness perforation. Since CT has 100% estimated sensitivity and negative predictive value, performing FCO is unnecessary after negative CT findings [8-11]. Management of IOP depends on severity: conservative treatment (nil per mouth, parenteral nutrition, intravenous antibiotics) is feasible provided that sepsis is absent, and CT excludes heavy contamination or contrast extravasation in mediastinum, pleural space, or peritoneum. Oesophageal stenting is an increasingly appealing option. Alternatively, surgical drainage, perforation repair and myotomy are required [6, 7, 12].",
    "differential_diagnosis": "Iatrogenic, esophageal, perforation, after, balloon, dilatation, for, achalasia., Conservative, treatment., Uncomplicated, pneumatic, balloon, dilatation, in, achalasia, Mediastinitis, /, mediastinal, abscess, Pleural, empyema, Extraluminal, contrast, medium, extravasation, Peritonitis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013193/000001.jpg?itok=DRfY4_iC",
            "caption": "The distal half of the oesophagus showed abnormal contractions consistent with a motility disorder, initially interpreted as diffuse oesophageal spasm."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013193/000004.jpg?itok=VYChmnBe",
            "caption": "The distal half of the oesophagus showed abnormal contractions consistent with a motility disorder, initially interpreted as diffuse oesophageal spasm. The lower oesophageal sphincter appeared tight but patent, without upstream dilatation."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013193/000005.jpg?itok=GWkYH1Ee",
            "caption": "The distal half of the oesophagus showed abnormal contractions consistent with a motility disorder, initially interpreted as diffuse oesophageal spasm. The lower oesophageal sphincter appeared tight but patent, without upstream dilatation."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013193/000006.jpg?itok=tZWjPpjT",
            "caption": "The pneumatic balloon (\u00a7) was positioned along a guidewire across the lower oesophageal sphincter, inflated under combined endoscopic and fluoroscopic guidance and dilated up to 35 mm. Dilatation was judged effective with minimal self-limiting bleeding."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013193/000007.jpg?itok=_bdmx5tm",
            "caption": "Three hours after pneumatic balloon dilatation, plain chest radiograph showed appearance of minimal bilateral pleural effusions (arrowheads) and of pneumomediastinum (arrows) outlining the cardiovascular structures."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013193/000010.jpg?itok=vfGJbm9r",
            "caption": "Follow-up radiographs before discharge (day 7) showed mild decrease of pneumomediastinum (arrows), stable pleural effusions (arrowheads), minimal residual paravertebral air (+) on the left side."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013193/000011.jpg?itok=gdvBt7cU",
            "caption": "Follow-up radiographs before discharge (day 7) showed mild decrease of pneumomediastinum (arrows), stable pleural effusions (arrowheads), minimal residual paravertebral air (+) on the left side."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013193/000019.jpg?itok=Lgp30kAy",
            "caption": "Axial images viewed at lung window settings showed moderate diffuse pneumomediastinum (arrows), opacified oesophageal lumen (thin arrows) without extraluminal leakage of ingested iodinated contrast."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013193/000013.jpg?itok=hbRSSiTY",
            "caption": "Axial images (in craniocaudal order) showed moderate diffuse pneumomediastinum (arrows), opacified oesophageal lumen (thin arrows) without extraluminal leakage of ingested iodinated contrast."
          },
          {
            "number": "Figure 4c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013193/000029.jpg?itok=kCouyqoL",
            "caption": "Axial images (in craniocaudal order) showed moderate diffuse pneumomediastinum (arrows), opacified oesophageal lumen (thin arrows) without extraluminal leakage of ingested iodinated contrast."
          },
          {
            "number": "Figure 4d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013193/000018.jpg?itok=OLw3gDAO",
            "caption": "Pneumomediastinum (arrows) mostly collected (*) surrounding the distal intrathoracic oesophagus (thin arrow). Note absent extraluminal leakage of ingested iodinated contrast."
          },
          {
            "number": "Figure 4e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013193/000032.jpg?itok=oqxuJhxb",
            "caption": "Pneumomediastinum (*) mostly collected surrounding the distal intrathoracic oesophagus (thin arrow). Note absent extraluminal leakage of ingested iodinated contrast, minimal bilateral pleural effusion (+)."
          },
          {
            "number": "Figure 4f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013193/000030.jpg?itok=j30r33Ja",
            "caption": "Additionally, asymmetric soft-tissue thickening (short arrows) was noted at the dorsal aspect of the distal thoracic oesophagus consistent with intramural injury at site of pneumatic balloon dilatation. Note perioesophageal pneumomediastinum (*), opacified oesophageal lumen (thin arrow)."
          },
          {
            "number": "Figure 4g",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013193/000023.jpg?itok=04Aidk8O",
            "caption": "Additionally, asymmetric soft-tissue thickening (short arrows) was noted at the dorsal aspect of the distal thoracic oesophagus consistent with intramural injury at site of pneumatic balloon dilatation. Note opacified oesophageal lumen (thin arrow)."
          },
          {
            "number": "Figure 4h",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013193/000027.jpg?itok=pq_7EG5K",
            "caption": "Sagittal and coronal maximum-intensity projection (MIP) reconstructions showed patent, opacified gastroesophageal lumen (thin arrows) without extraluminal leakage of ingested iodinated contrast. Note severe aortic valve calcifications. (incidental finding)."
          },
          {
            "number": "Figure 4i",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013193/000028.jpg?itok=m0BE19Ry",
            "caption": "Sagittal and coronal maximum-intensity projection (MIP) reconstructions showed patent, opacified gastroesophageal lumen (thin arrows) without extraluminal leakage of ingested iodinated contrast."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Oesophagus",
      "Mediastinum"
    ],
    "imaging_technique": [
      "Fluoroscopy",
      "CT",
      "CT-Angiography"
    ],
    "link": "https://www.eurorad.org/case/13193",
    "time": "22.12.2015"
  },
  "13238": {
    "case_id": 13238,
    "title": "Asymptomatic large intrathoracic lipoma: case report and literature review",
    "section": "Chest imaging",
    "age": "24",
    "gender": "male",
    "diagnosis": "Intrathoracic lipoma",
    "history": "We are presenting a case of 24-year-old Caucasian male patient, with a body mass index (BMI) 25 kg/m2, who was referred to our institution for further examination, because of a undefined expansile thoracic mass found on a routine chest X-ray examination. The patient did not present with any symptoms.",
    "image_finding": "The CXR demonstrated a well-circumscribed homogeneous shadow, which was inseparable from the lateral thoracic wall. Widening of the third intercostal space was also described. Remaining intrathoracic status was found normal. Contrast-enhanced CT scan was performed, depicting an extensive lipomatous formation sized 124 x 60 x 116 mm, located dorsolaterally on the right side, next to the upper right pulmonary lobe, averaging -107 HU. The mass was for the most part located adjacent to the external contour of the thoracic wall, and partially extending between the intercostal space of the third and fourth rib, which were displaced by the formation. The mass did not demonstrate significant contrast uptake. The patient underwent fine needle aspiration of the mass, which demonstrated mature adipocytes with no cellular atypia. In consultation with the thoracic surgeon, we have decided not to perform any further invasive procedures. The patient was referred for regular X-ray follow-ups.",
    "discussion": "Lipomas, are well-known neoplasms, classified into two types according to the location, subcutaneous and deep-seated lipomas [1]. They are also considered to be more common in obese patients [2, 3]. Our patient did not fit this criterion, considering his BMI of 25 kg/m2 . The intrathoracic lipomas arise from epipleural fatty tissue, which coincides with our patient. Thoracic lipomas can also be divided into two classes, entirely intrathoracic (the more common type) and the hourglass or transmural type [4]. While the tumour is usually incidentally detected on a CXR, the CT scan is the standard for accurate detection of thoracic lipomas. CT allows a definitive diagnosis by demonstrating a homogeneous fat attenuation mass (-50 to -150 HU). The density may not be entirely uniform because lipomas often contain fibrous stroma [5, 6]. There is always a radiological diagnostic challenge between lipoma and liposarcoma, especially liposarcoma with low-grade malignancy. Definitive diagnosis here can be achieved only by pathohistological examination such as percutaneous biopsy. There is still no consensus regarding management of asymptomatic lipoma. Some authors suggest radiologic follow up, but other authors recommend surgical excision because the possibility of liposarcoma cannot be excluded [2]. Most patients remain asymptomatic, but since lipomas are able to grow to a significantly large size, they may incite compression symptoms [7, 8]. Pleural lipomas can also cause complications such as intratumoral haemorrhage, and they can invade intercostal spaces and induce rib osteolysis [7, 9]. As for our patient, despite a significant tumour mass he did not have any symptoms, and although he had ribs displacement, the CT scan did not show any signs of rib osteolysis. Tumours consisting of uniform, mature fat without cytologic atypia are diagnosed histologically as lipomas. Tumours that consist predominantly of mature fat with a variable number of atypical spindled cells (usually accompanied with collagenization), and lipoblasts are diagnosed as well-differentiated liposarcomas [2, 10]. As reported by Jayle et. al. secondary transformation of lipoma into liposarcoma has never been reported in the literature, that is why excision of the tumour should not be performed to prevent such an evolution [11]. With that in mind, we should consider surgical resection in three cases: in case of inhomogeneous mass, when we cannot exclude the presence of the liposarcoma, when adjoining organs are severely compressed, and if the presence of tumour mass causes symptoms [11].",
    "differential_diagnosis": "Intrathoracic, lipoma, Intrathoracic, lipoma, Liposarcoma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013238/000001.jpg?itok=DtX7Eby1",
            "caption": "Initial image depicting medially convex homogeneous opacity in the upper right region of the chest."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013238/000002.jpg?itok=hXx1Bc3d",
            "caption": "Axial post contrast CT in mediastinal window depicting the homogeneously low density mass at the right lateral and dorsal chest wall."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013238/000003.jpg?itok=cD_voGO2",
            "caption": "Axial post contrast CT with lung windowing."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013238/000004.jpg?itok=iKJNot2J",
            "caption": "Sagittal CT image through the mass demonstrates intrathoracic spread of the mass (hourglass type)."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "Digital radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/13238",
    "time": "16.04.2016"
  },
  "13240": {
    "case_id": 13240,
    "title": "Agenesis of right lung",
    "section": "Chest imaging",
    "age": "3",
    "gender": "female",
    "diagnosis": "Agenesis of right lung",
    "history": "A 3-year-old female patient presented with complains of cough and cold for 1 month. She had suffered from many similar episodes in the past.",
    "image_finding": "Contrast-enhanced CT showed an absence of the right lung, right pulmonary artery and right main bronchus. There was a compensatory hyperinflation of the left lung and marked mediastinal shift was seen towards the right side with the heart located in the right hemithorax. The left main bronchus as well as the left lung appeared normal. These imaging findings are diagnostic for a complete agenesis of the right lung.",
    "discussion": "Dysmorphic pulmonary abnormalities, defined as the absence of a whole lung or lobes are classified into three categories: Type 1 (Agenesis): Complete absence of lung bronchus and no vascular supply to the affected side. Type 2 (Aplasia): Rudimentary bronchus with complete absence of pulmonary parenchyma. Type 3 (Hypoplasia): Presence of variable amounts of bronchial tree, pulmonary parenchyma and supporting vasculature [3].It has been hypothesized that abnormal blood flow in the dorsal aortic arch during the 4th week of gestation (embryonic phase) causes pulmonary agenesis [2]. Its incidence is nearly the same in men and women. Left-sided agenesis is more common and those patients live longer than patients with right-sided agenesis [3]. Pulmonary agenesis and aplasia are frequently observed in association with other malformations such as diaphragmatic defects, kidney anomalies, extrapulmonary sequestration, musculoskeletal defects or congenital heart disease [1]. Pulmonary hypoplasia can be primary or secondary. Primary pulmonary hypoplasia, in which a cause cannot be elucidated, is much less common than secondary hypoplasia. The majority of cases of secondary hypoplasia are due to a process limiting the thoracic space for lung development, which can be intrathoracic or extrathoracic. The most common intrathoracic cause is a congenital diaphragmatic hernia, which can be left-sided (75%\u201390%), right-sided (10%) or bilateral (5%). The most common extrathoracic cause is severe oligohydramnios, occurring secondary to either fetal genitourinary anomalies (renal agenesis, cystic renal dysplasia, and urinary tract obstruction) or prolonged rupture of membranes. A hypoplastic thorax occurs in skeletal dysplasias (thanatophoric dysplasia) in which a small and rigid thoracic cage causes pulmonary hypoplasia [2].Patients with dysmorphic pulmonary abnormalities are usually asymptomatic. Recurrent infections can increase the breathing distress [1].Normograms have been published that illustrate the relationship between thoracic circumference and gestational age. A thoracic circumference below the 5th percentile for gestational age indicates pulmonary hypoplasia. Other parameters indicating pulmonary hypoplasia are a chest-trunk length ratio under 0.32 and a femur length\u2013abdominal circumference ratio under 0.16 [2].Diagnosis of dysmorphic pulmonary abnormalities can be made using CT, bronchoscopy, pulmonary angiography, and MRI [1]. Imaging findings in pulmonary aplasia and agenesis are similar, except for the presence of a short blind-ending bronchus in aplasia. Postnatal radiography demonstrates diffuse opacification of the involved hemithorax with ipsilateral mediastinal shift. CT helps to confirm the absence of the lung parenchyma, bronchi, and pulmonary artery on the involved side [2].Overall prognosis in dysmorphic pulmonary abnormalities depends on the affected side, functional integrity of the remaining lung tissue as well as the presence of associated anomalies [3].",
    "differential_diagnosis": "Agenesis, of, right, lung, Total, atelectasis, Diaphragmatic, hernia, Diaphragmatic, eventration, Pneumonia, Pleural, effusion, Pneumonectomy",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013240/000001.png?itok=o-yH3a_6",
            "caption": "CT shows an opaque right hemithorax with a shift of the mediastinum towards the ipsilateral side. The right main bronchus is not visualised."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013240/000004.png?itok=tD1KVzcL",
            "caption": "Contrast-enhanced CT of the chest shows absence of the right lung and compensatory hyperinflation of the left lung."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013240/000005.png?itok=d3Z2QNqt",
            "caption": "Contrast-enhanced CT of the chest shows a shift of the mediastinum towards the right side. The right bronchus is not visualized and the left main bronchus appears normal."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013240/000006.png?itok=QxLipU3-",
            "caption": "Axial CT in the lung window shows a hyperinflation of the left lung parenchyma."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013240/000007.png?itok=QKNWymW8",
            "caption": "Axial CT in the lung window shows absence of the right lung and a hyperinflation of the left lung parenchyma which extends into the right hemithorax."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013240/000008.png?itok=glr2E931",
            "caption": "CT thorax coronal view shows left main bronchus originating from the trachea. Right main bronchus is not visualised. (This feature differentiates lung agenesis form lung aplasia)."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013240/000009.png?itok=NGo_o-p2",
            "caption": "CT thorax shows hyperinflated left lung, which pushes the heart into the right hemithorax."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT",
      "CT-High Resolution"
    ],
    "link": "https://www.eurorad.org/case/13240",
    "time": "30.12.2015"
  },
  "13273": {
    "case_id": 13273,
    "title": "Subpleural lung cysts associated to Down syndrome.",
    "section": "Chest imaging",
    "age": "3",
    "gender": "male",
    "diagnosis": "Subpleural lung cysts associated to Down syndrome.",
    "history": "Two patients of 3 and 12 years of age with Down syndrome and treated congenital heart disease (CHD) underwent chest computed tomography (CT) for the assessment of recurrent pneumonias and control of the CHD, respectively. At the time the CT was performed, both were asymptomatic from the cardiorespiratory point of view.",
    "image_finding": "In the 3 year-old patient, chest x-ray revealed multiple cystic spaces distributed in the subpleural parenchyma of both lungs, with a bilateral interstitial pattern that predominated in the upper lobes. High resolution computed tomography (HRCT) confirmed the presence of small lung cysts that extended along the subpleural regions and pulmonary fissures of both lungs in association with linear thickening of the interstitial space in the upper lobes, simulating a honey comb pattern, in addition to the known scoliosis.The HRCT findings were less accentuated in the older patient, in which small lung cysts along the subpleural regions and bronchovascular bundles were found, with a minor degree of parenchymal involvement. In the chest radiograph these findings were not evident.",
    "discussion": "Subpleural lung cysts (SLC) are multiple small cystic dilatations that may be found along the lung periphery, pulmonary fissures and bronchovascular bundles in children with DS [1].This association was first described in 1986 in two infants who were found to have cystic lung disease at autopsy. The largest case series investigating this association was an autopsy series of 89 infants, in which 20% were found to have subpleural cysts [1].Their aetiology and prevalence remains uncertain but it is well known that pulmonary hypoplasia is a feature of DS and might be related to their development [1, 2]. It is believed that the cysts are caused by a decreased number of alveoli, alveolar enlargement, smaller alveolar surface area and deficiency of elastic fibers in the entrance rings to the alveoli [2, 3]. The new classification system developed by the Children's Interstitial Lung Disease (ChILD) Research Cooperative considers SLC an alveolar growth abnormality associated to chromosomopathies.Significant association between SLC and CHD in children with DS has been described [2].The clinical relevance of SLC in DS is yet poorly understood [2]. It is not clear how much these cysts can affect respiratory function independently of CHD, because they have been reported as an incidental finding in patients with DS without CHD [3].Chest radiograph is usually the first imaging technique used in the evaluation of infants with suspected ILD because its availability and low dose of radiation delivery, but it may be neither sufficient nor specific to make definite diagnosis [1].CT is more sensitive in detecting ILD and more precise in characterizing the extent and distribution of the disease. However it is not without risks and should be performed only when there is a high clinical suspicion. Strategies for CT radiation dose reduction such as lowering the tube current or tube voltage must be considered, without deteriorating the diagnostic quality of the study. It has been reported that the CT image quality obtained by conventional HRCT is comparable to reconstructed images obtained from multidetector CT (MDCT) and its overall radiation dose is lower, so HRCT can be sufficient for the diagnosis, with the disadvantage that it may underestimate the extent and miss other abnormalities. The mortality rate of children with SLC is unknown, but it has been postulated that the mortality of CHD may be increased when they are associated.",
    "differential_diagnosis": "Subpleural, lung, cysts, associated, to, Down, syndrome., The, differential, diagnosis, has, to, be, made, with, other, diseases, such, as, lymphangioleiomyomatosis, Cystic, bronchiectasis, or, peripheral, fibrosis, as, seen, in, collagenvascular, diseases",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013273/000001.jpg?itok=E7cbJywN",
            "caption": "3 year old patient: chest x-ray shows multiple small cysts that predominates in the subpleural regions and in the upper lobes of both lungs associated with linear thickening of the interstitial space"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013273/000002.jpg?itok=hNuF5ecY",
            "caption": "HRCT in the axial and coronal planes demonstrates multiple small lung cysts along the subpleural regions and pulmonary fissures (yellow arrows) of both lungs and thickening of the interstitial space, with upper lobes predominance"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013273/000003.jpg?itok=v4QdAUSM",
            "caption": "12 year old patient HRCT in the axial and coronal planes manifests the presence of small cyst along the subpleural regions and bronchovascular bundles (red arrows)"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013273/000004.jpg?itok=dzdbpuiz",
            "caption": "12 year old patient: chest x-ray in supine position did not showed any pathologic finding neither in the pulmonary parenchyma nor in the mediastinum. Median sternotomy wires secondary to previous cardiac surgery."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT-High Resolution",
      "Digital radiography"
    ],
    "link": "https://www.eurorad.org/case/13273",
    "time": "30.12.2015"
  },
  "13288": {
    "case_id": 13288,
    "title": "Unusual association of parvo-virus with Morgagni hernia, mistaken for patch of consolidation",
    "section": "Chest imaging",
    "age": "5",
    "gender": "male",
    "diagnosis": "Morgagni's hernia with herniation of left liver lobe",
    "history": "A 5-year-old boy presented with the chief complaints of cough, shortness of breath and fever for one week. Fever was moderate to high-grade and not associated with chills and rigor. Cough was non-productive. There was a history of 4-5 episodes of respiratory distress.",
    "image_finding": "X-ray chest PA view was performed which revealed a right para-cardiac opacity in relation to right cardiac border and right hemi-diaphragm. There was no evidence of air-bronchogram, cavitatory changes or calcification. The lesion showed a sharp interface with adjacent lung parenchyma. The rest of the lung field and cardio-thoracic radiograph was normal. The patient showed positive titre for parvo-virus antibodies and based on the X-ray findings, the patient was treated as a case of viral pneumonia considering the radio-opacity as consolidation. There was no improvement on antibiotic course, radio-opacity persisted on subsequent chest radiograph. The patient was then advised to undergo CECT Thorax. CT scan was performed on PHILIPS 64 Slice CT Scanner, which revealed herniation of left liver lobe along with greater omentum through right sterno-costal hiatus. The rest of the finding in the lung were normal. No associated lymphadenopathy was noted.",
    "discussion": "Giovanni Morgagni first described the substernal herniation of abdominal contents into the thoracic cavity, based on observations made during autopsy examinations [1]. The diaphragmatic defect described by both Morgagni and Dominique Larrey (Napoleon\u2019s chief surgeon) is a triangular space between the muscle fibres of the diaphragm that originate from the xiphoid of sternum and the costal margin and insert on the central tendon of the diaphragm. This potential space of hernia lies just posterolateral to the sternum at the level of seventh rib on either side of the xiphoid process. Herniation through right sternocostal hiatus is called Morgagni\u2019s hernia (MH) and herniation through left sternocostal hiatus is called Larrey\u2019s hernia. The majority of Morgagni hernias are right-sided, because of the protection provided by the pericardial sac on the left side. Hernial contents included greater omentum (42.1%), transverse colon (36.5%), liver (6.5%) and stomach (5.3%) [2].It is frequently asymptomatic and is generally diagnosed incidentally during the investigation of other conditions [3]. Where symptoms are present, these are usually due to compression of thoracic organs. Accordingly, patients may present with respiratory distress. Additionally, recurrent chest infections and gastrointestinal symptoms (vomiting, abdominal pain and bleeding) have been reported in subjects with previously undiagnosed Morgagni's hernia. The child in our case had a history of recurrent chest infection and came with symptom of high-grade fever, non-productive cough and shortness of breath. The rarity of this congenital diaphragmatic hernia (CDH) and the non-specific symptoms may lead to a delay in diagnosis, particularly in childhood [4].Our patient was in seemingly good clinical health at birth. At about 2 years of age, the patient developed seizures and was diagnosed tuberculomas in the brain on CT. It was reported that the patient had suffered three episode of chest infection and for that chest radiography had been performed, where the diagnosis of pneumonia was made on the basis of radiological findings. The patient experienced symptomatic relief but radio-opacity in the right cardio-phrenic angle persisted. In the literature, herniation of liver is mentioned as uncommon herniating component (~6.5%) and is associated with poor prognosis as compared to other herniating components.Morgagni's CDH is a rare malformation, which is difficult to diagnose with simple radiographs. Herniation of the left lobe of the liver can be a component of MH, which could be not well appreciated on chest radiograph. CT would be the preferred imaging modality for diagnostic confirmation and operative planning in children.",
    "differential_diagnosis": "Morgagni's, hernia, with, herniation, of, left, liver, lobe, Morgagni's, hernia, RT, para-cardiac, condolidation",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013288/000001.jpg?itok=5dIzT7PH",
            "caption": "Chest X-ray PA view shows radio-opacity involving the RT cardio-phrenic angle partially silhouetting the RT cardiac border. The radio-opacity showed sharp interface with adjacent lung parenchyma."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013288/000002.jpg?itok=05sa7-F_",
            "caption": "Axial mediastinal (A) and lung (B) window showed a homogenous soft tissue density in RT cardio-phrenic angle abutting and displacing the pericardium and RT ventricle with clear interface. Sharp delineation with lung parenchyma is noted."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013288/000003.jpg?itok=knM1Mkeu",
            "caption": "Coronal (A) and Sagittal (B) reformatted images showed herniation of LT lobe of liver along with vasculature into the RT sterno-costal space with shifting of heart towards LT side."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Anatomy",
      "Lung",
      "Spine",
      "Education"
    ],
    "imaging_technique": [
      "CT",
      "CT-High Resolution"
    ],
    "link": "https://www.eurorad.org/case/13288",
    "time": "27.03.2016"
  },
  "13322": {
    "case_id": 13322,
    "title": "Kartagener&#039;s syndrome; two cases in siblings",
    "section": "Chest imaging",
    "age": "26",
    "gender": "male",
    "diagnosis": "Kartagener's syndrome",
    "history": "Two brothers (26-year-old and 17-year-old) with clinical history of chronic cough with sputum, sometimes haemoptysis and dyspnoea since birth, were referred to our radiology department. The patients also had a history of headache with chronic nasal discharge.",
    "image_finding": "Case 1 (26-year-old): The chest radiography shows dextro-cardia and right-sided fundic air bubble. The chest CT revealed cystic bronchiectasis throughout both lungs predominantly in the right lower lobe and some of the dilated bronchi are filled with mucus. Significant numbers of opacities with tree-in-bud appearance in the lungs bilaterally with slightly increased in lungs volume. Dextro-cardia is also appreciated with right-sided aortic arch. Included sections from the abdomen demonstrate inverse position of the liver and spleen. Paranasal sinuses radiography shows significant mucosal thickening in the bilateral maxillary, frontal and ethmoid sinuses, representing sinusitis. Case 2 (17-year-old): The Chest CT shows bilateral bronchiectasis with significant small pulmonary opacities with tree-in-bud appearance. Dextro-cardia is visualized with right-sided aortic arch. Included sections from the upper abdomen show inverse position of the liver and spleen. Mucosal thickening is noted in the maxillary sinuses bilaterally on radiography.",
    "discussion": "Kartagener's syndrome was first described in 1904 by Siewert as a condition characterized by a combination of bronchiectasis, chronic sinusitis and situs inversus. However, Manes Kartagener recognized this clinical triad as a distinct congenital syndrome in 1933. [1, 4, 5, 6] Kartagener's syndrome is a subset of primary ciliary dyskinesias, characterised by ultrastructural genetic defect causing impaired ciliary motility resulting in recurrent chest and sinus infections and infertility. Although patients are symptomatic since childhood the age at which diagnosis is made is variable. [3, 5]Kartagener's syndrome (KS) is a rare genetic condition, inherited via an autosomal recessive pattern [2, 4, 5, 6]. Its incidence is about 1 in 20, 000-30, 000 live births [2, 4, 5]. Male patients with this syndrome are almost invariably infertile because of immotile spermatozoa. [4, 5]The pathophysiology of primary ciliary dyskinesia is the absence and/or dysmorphic features of the dynein arms in airway cilia due to a variety of specific mutations in cilia coding genes. [1, 5, 6]The symptoms of this condition are non-specific and common in many other more frequent respiratory conditions. Furthermore, clinical manifestations can easily be mistaken for commonly occurring infections. [1]Patients with primary ciliary dyskinesia suffer from recurrent chest and sinus infections since childhood but diagnosis is usually delayed due to low index of suspicion. Early diagnosis may help in improvement of lung function, quality of life and life expectancy. It is more common in middle and lower lobes of the lungs. The frontal sinuses are hypoplastic and often nasal polyps are also seen. [2]A high index of suspicion is required for early diagnosis to offer appropriate treatment for infertility and preservation of lung function. [3]Screening tests include exhaled nitric oxide and saccharin test to assess nasal epithelial muco-ciliary function. Biopsy of nasal or tubal mucosa and ciliary beat pattern & frequency analysis using video recording, and electron microscopic confirmation of the ultrastructural ciliary defect is considered diagnostic. In our cases these tests were not performed and the diagnosis was clinico-radiological as in various earlier case reports.In conclusion, primary ciliary dyskinesia and Kartegener's syndrome should be considered as a possible diagnosis in young patients with lower and upper respiratory tract infections. [2]",
    "differential_diagnosis": "Kartagener's, syndrome, Cystic, Fibrosis, Primary, ciliary, dyskinesia",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013322/000001.jpg?itok=2yE4ddbg",
            "caption": "Chest radiograph; showing dextrocardia and fundic bubble on the right side."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013322/000002.jpg?itok=vUGteIlY",
            "caption": "Chest topogram; shows dexrocardia and right side gastric air bubble."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013322/000003.jpg?itok=yEp6BF4s",
            "caption": "Axial CT section; shows bronchiectasis in the right lower lobe."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013322/000004.jpg?itok=6-7W8ODD",
            "caption": "Axial CT section; shows bronchiectasis in the left upper lobe."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013322/000005.jpg?itok=h7mpiBvI",
            "caption": "CT abdomen axial section; showing transposition of viscerae (spleen in the right side and liver in the left side)."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013322/000006.jpg?itok=kjyQmoAp",
            "caption": "CT abdomen axial section; shows right-sided spleen and left-sided spleen and stomach, suggesting Situs Inversus."
          }
        ]
      },
      {
        "number": "Figure 7",
        "subfigures": [
          {
            "number": "Figure 7",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013322/000007.jpg?itok=ymJrYcBs",
            "caption": "PNS radiograph; shows chronic sinusitis."
          }
        ]
      },
      {
        "number": "Figure 8",
        "subfigures": [
          {
            "number": "Figure 8",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013322/000008.jpg?itok=XmmrRUpu",
            "caption": "PNS radiograph; shows chronic maxillary sinusitis with hypoplasia of frontal sinuses."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Respiratory system",
      "Abdomen"
    ],
    "imaging_technique": [
      "Digital radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/13322",
    "time": "05.02.2016"
  },
  "13324": {
    "case_id": 13324,
    "title": "Un unsual cause of chronic cough: broncholithiasis",
    "section": "Chest imaging",
    "age": "30",
    "gender": "male",
    "diagnosis": "Broncholithiasis",
    "history": "An otherwise healthy 30-year-old man presented with a 4-week history of nonproductive cough accompanied by dyspnoea on exertion. He denied any history of fever, night sweat, or weight loss.",
    "image_finding": "Thoracic computed tomography (CT) with a wide window setting showed impacted endobronchial calci\ufb01ed lesions located in the laterobasal segment of the left lower lobe; with no bronchial wall change, atelectasis or obstructive pneumonitis in the involved segment.There was also mild bronchiectasis in several segmental bronchi bilaterally, without any wall thickening or parenchymal alteration.No other signs of pathology were found elsewhere in this examination.",
    "discussion": "Broncholithiasis is an unusual condition characterized by the presence of calci\ufb01ed or ossi\ufb01ed material within the bronchial lumen [1].The incidence of this anomaly is only 0.1% to 0.2% of all lung diseases [2].A broncholith is frequently constituted by erosion and displacement of a calci\ufb01ed adjacent lymph node into the lumen of the bronchus and is generally correlated with long-lasting foci of necrotizing granulomatous lymphadenitis. These calci\ufb01ed lymph nodes are generally the consequence of chronic granulomatous infection: histoplasmosis in the USA and tuberculosis in the rest of the world [3].Broncholithiasis may also be due to: aspiration of bone tissue or foreign material that calcifies in situ; erosion by and displacement of ossi\ufb01ed bronchial cartilage plates or migration of calci\ufb01ed material from pleural plaque or the kidney to a bronchus [1].Most commonly, broncholithiasis manifests as nonproductive cough frequently associated with haemoptysis.Less frequently, it is revealed by secondary infection after obstruction of the distal portion of the lung causing pain, chills, and fever [1, 4]. A history of lithoptysis (expectoration of calci\ufb01ed material) may indicate the diagnosis in some cases.Plain chest X-ray may show a calci\ufb01ed nodule and/or airway obstruction (atelectasis, bronchiectasis, mucoid impaction, or expiratory air trapping) [5, 4]. Chest radiography often fails to show the calci\ufb01cation within the bronchus. CT generally provides helpful information in the evaluation of suspected broncholithiasis [6, 7, 8]. A calci\ufb01ed material that is either endobronchial or peribronchial associated with \ufb01ndings of bronchial obstruction (atelectasis, obstructive pneumonitis, or bronchiectasis) can be strongly suggestive of broncholithiasis.Multiplanar reformation of helical CT data is generally useful to show whether the calci\ufb01ed nodule is endobronchial or peribronchial.Therapeutic options include observation, bronchoscopic treatment, and surgery.Bronchoscopic removal can be considered in uncomplicated cases with easily movable broncholith, otherwise surgical resection (segmentectomy, lobectomy, or pneumectomy) is preferred [9, 10].",
    "differential_diagnosis": "Broncholithiasis, Tracheobronchial, amyloidosis, with, calcification, Primary, endobronchial, infection",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013324/000001.jpg?itok=pmVmbQKP",
            "caption": "Thoracic CT with a wide window setting: bronchiectasis and impacted endobronchial calci\ufb01ed lesions located in the laterobasal segment of the left lower lobe; with no bronchial wall change, atelectasis or obstructive pneumonitis."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013324/000002.jpg?itok=D734xlO0",
            "caption": "Thoracic CT with a wide window setting: bronchiectasis  and impacted endobronchial calci\ufb01ed lesions located in the laterobasal segment of the left lower lobe; with no bronchial wall change, atelectasis or obstructive pneumonitis."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013324/000003.jpg?itok=8Mznlyjd",
            "caption": "Thoracic CT with a wide window setting: bronchiectasis  and impacted endobronchial calci\ufb01ed lesions located in the laterobasal segment of the left lower lobe; with no bronchial wall change, atelectasis or obstructive pneumonitis."
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013324/000004.jpg?itok=P9FESG3U",
            "caption": "Sagittal reformation: impacted endobronchial calci\ufb01ed lesions located in the laterobasal segment of the left lower lobe; with no bronchial wall change, atelectasis or obstructive pneumonitis."
          },
          {
            "number": "Figure 1e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013324/000005.jpg?itok=hguXx8Mr",
            "caption": "Sagittal reformation: impacted endobronchial calci\ufb01ed lesions located in the laterobasal segment of the left lower lobe; with no bronchial wall change, atelectasis or obstructive pneumonitis."
          },
          {
            "number": "Figure 1f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013324/000006.jpg?itok=XnQOK4ZI",
            "caption": "Sagittal reformation: impacted endobronchial calci\ufb01ed lesions located in the laterobasal segment of the left lower lobe; with no bronchial wall change, atelectasis or obstructive pneumonitis."
          },
          {
            "number": "Figure 1g",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013324/000007.jpg?itok=XlxQyEdn",
            "caption": "Coronal reformation: impacted endobronchial calci\ufb01ed lesions located in the laterobasal segment of the left lower lobe; with no bronchial wall change, atelectasis or obstructive pneumonitis."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013324/000008.jpg?itok=ut2kfoGY",
            "caption": "Lung CT: bronchiectasis in the left upper lobe"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013324/000009.jpg?itok=WbBx-kV-",
            "caption": "Lung CT: bronchiectasis in the right upper lobe"
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013324/000015.jpg?itok=9pcow69b",
            "caption": "Lung CT: bronchiectasis in the right lower lobe"
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013324/000016.jpg?itok=oZeU_7fM",
            "caption": "Sagittal reformation: bronchiectasis in the right upper lobe"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/13324",
    "time": "04.03.2016"
  },
  "13326": {
    "case_id": 13326,
    "title": "Pulmonary and paranasal sinus aspergillosis",
    "section": "Chest imaging",
    "age": "52",
    "gender": "female",
    "diagnosis": "Angioinvasive aspergillosis",
    "history": "52-year-old woman, known for myeloid leukaemia, underwent chemotherapy and two allogeneic haematopoietic stem cell transplantations. Four months later, the patient presented with a marked pancytopenia and desaturation to 80% on ambient air.",
    "image_finding": "On the first non-enhanced chest computed-tomography (CT), nodules and masses surrounded by a halo of ground-glass attenuation were visualized (Figure 1). On the follow-up, a chest X-ray showed an increased patchy consolidations and ill-defined nodular opacities (Figure 2). On the follow-up CT scan performed 5 days later, these nodules and consolidations have increased in size, and involved now all the lobes (Figure 3 a/b).Because of obstructive nasal symptoms, a maxillo-facial CT was performed, and which confirmed a spontaneous hyperdense nodule in the paranasal sinuses, typically found in aspergillosis (Figure 4 a/b).",
    "discussion": "Aspergillus is a ubiquitous airborne filamentous fungus. It is inhaled by humans and is then eliminated through their mucociliary system via their internal immune mechanisms. Aspergillus development occurs in case of immunocompromised patient or in patients with airway pathology, pulmonary cavitation or asthma.There are four different patterns of pulmonary aspergillosis: allergic bronchopulmonary aspergillosis, aspergilloma, semi-invasive aspergillosis, and invasive aspergillosis.The invasive aspergillosis principally affects severely immunocompromised patients. The most common is the angioinvasive form (80% of cases). It relates to a pulmonary vasculature invasion, responsible for thrombosis, pulmonary haemorrhage and infarction. The airways invasive form (20%) is linked to the airways wall and peribronchial invasion. The acute tracheobronchitis (5%) is caused by an invasion of proximal bronchi or trachea [1-2].The angioinvasive aspergillosis is the most severe form, due to its rapid evolution and non-specific symptoms.It affects mainly neutropenic patients after hematopoietic stem cells transplantation, during chemotherapy for leukaemia or after transplantation (heart/lungs).The severity of neutropenia as well as its duration are the main risk factors [3-4].The clinical presentation is nonspecific symptoms such as cough, dyspnoea, chest pain, fever or haemoptysis. The disease can spread to other organs through the vascular system.Chest radiography often shows patchy segmental or lobar consolidations or multiple, ill-defined nodular opacities.Chest CT shows consolidations and nodules surrounded by ground glass opacities, defined by the \u201chalo sign\u201d. The nodules are the result of coagulation necrosis whereas the ground glass opacities are caused by alveolar haemorrhage. Pulmonary infarction and pleural effusion may also be observed [2-5].The excavation of the nodules, called \u201cair crescent sign\u201d, coincides with the resolution of neutropenia. It represents the separation of necrotic and healthy parenchyma. The involvement of the nasal cavity and paranasal sinuses could be found. Acute invasive fungal sinusitis is a rapidly progressing infection, which concerns immunocompromised patients. The acute sinusitis is characterized by a hypoattenuating sinuses filling with air-fluid levels on noncontrast CT. Dense elements within those fillings are a specific sign of fungal infection. At a later stage, bone erosions could be observed resulting in intracranial, intraorbital or intracavernous extension [6]. The diagnosis is confirmed by the detection of Aspergillus antigens in serum or bronchoalveolar lavage, Aspergillus hyphae by a direct examination or DNA by PCR.Voriconazole is the treatment of choice. However, the overall mortality rate remains around 30%-50% [4].",
    "differential_diagnosis": "Angioinvasive, aspergillosis, Candida, infection, Wegener\u2019s, granulomatosis, Kaposi\u2019s, sarcoma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013326/000001.jpg?itok=Vj89CeXB",
            "caption": "Non-enhanced chest CT: multiple nodules (arrows) surrounded by a halo of ground-glass attenuation (halo sign), corresponding to an angioinvasive form of aspergillosis."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013326/000003.jpg?itok=nFbfaZDN",
            "caption": "Increased consolidations (stars- Fig. 3a)."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013326/000004.jpg?itok=kG875QIM",
            "caption": "Multiples nodules surrounded by ground glass opacities (arrows- Fig 3b)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013326/000005.jpg?itok=1p7tsz0P",
            "caption": "Partial filling of the sinuses of the face, with air-fluid levels in support of acute sinusitis signs. Presence of spontaneously dense elements within sphenoidal and maxillary sinuses (arrows), evoking the diagnosis of invasive aspergillosis infection."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013326/000006.jpg?itok=79cFlqwZ",
            "caption": "Patchy consolidations and profuse ill-defined nodular opacities (arrows)."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Ear / Nose / Throat"
    ],
    "imaging_technique": [
      "CT-High Resolution",
      "Conventional radiography"
    ],
    "link": "https://www.eurorad.org/case/13326",
    "time": "06.03.2016"
  },
  "13351": {
    "case_id": 13351,
    "title": "Tuberculous Pericarditis",
    "section": "Chest imaging",
    "age": "28",
    "gender": "male",
    "diagnosis": "Tuberculous Pericarditis (definite diagnosis)",
    "history": "A previously healthy 28 year-old male, from Guinea Bissau, who had lived in Europe for 4 years, presented to the emergency department with fever, dry cough, dyspnoea and weight loss (15kg in 3 months). Physical examination revealed fever (38.2\u00baC) and reduced respiratory sounds in the left hemithorax. HIV and HBV infections were detected.",
    "image_finding": "- Chest X-Ray: Cardiac silhouette enlargement and opacification of the lower half of the left hemithorax- Chest Ultrasound and Echocardiography: Pleural effusion with echoes and pericardial thickening as well as complex pericardial effusion with echoes and septa (images not available)- Chest CT: Necrotic mediastinal lymph nodes; large pericardial effusion with septa and irregular thickening of the pericardium; large pleural effusion with nodular pleural thickening;random pulmonary micronodules- Cardiac MRI: Necrotic mediastinal lymph nodes; large pleural effusion; large pericardial effusion with septa and irregular thickening of the pericardium; signs of constrictive pericarditis",
    "discussion": "Background - Tuberculous pericarditis, caused by Mycobacterium tuberculosis, is rare in developed countries, but is an important aetiology of pericarditis in Africa, owing to the HIV epidemic. - Pericardial involvement comes from lymphatic spread of M.tuberculosis from peribronchial, peritracheal, or mediastinal lymph nodes or by hematogenous spread from primary tuberculous infection [1].Clinical Perspective - Tuberculous pericarditis presents clinically in 3 forms: pericardial effusion, constrictive pericarditis or a combination of both.- Tuberculous pericardial effusion presents with nonspecific symptoms, such as fever, night sweats, fatigue, and weight loss. Chest pain, cough, and breathlessness are common.- Patients with constrictive pericarditis present with symptoms of heart failure (dyspnoea, orthopnea, fatigability) and may have liver enlargement and ascites. - Pericardiocentesis is recommended in all patients in whom TB is suspected [1].Imaging Perspective - Chest radiograph may show an enlarged cardiac shadow (>90%), active pulmonary TB features (30%) and pleural effusion (40-60%).- Transthoracic echocardiography is the first-line technique for pericardial disease and to guide pericardiocentesis. Effusion with fibrinous strands is typical but not specific [1].- Chest CT and MRI enable detection of pericardial effusion and thickening of the pericardium, while showing enlarged mediastinal lymph nodes, and parenchymal or pleural abnormalities [1]. CT is the best modality for pericardial calcifications [2, 3]. Calcification is a nonspecific response to chronic inflammation, not a definite sign of tuberculous aetiology [3].- The diagnosis of constrictive pericarditis is aided by CT and MR. The typical appearance is thickening of the pericardium +/- calcifications (>4mm); constrictive symptoms are required for diagnosis. Other imaging findings include tubular-shape of the right ventricle, atrial enlargement, dilatation of the IVC, pleural effusion and ascites [2, 3].- Cardiac MRI was performed to exclude other causes of right heart failure and coexistent restrictive cardiomyopathy. It did not bring any additional information, besides confirming the findings.- A definite diagnosis requires demonstration of tubercle bacilli in pericardial fluid or histologic section of the pericardium. A probable diagnosis is based on unexplained pericarditis in a patient with tuberculosis elsewhere, a lymphocytic pericardial exudate with elevated ADA activity or good response to a trial of antituberculosis chemotherapy [4].Outcome- Treated with antituberculosis chemotherapy with or without pericardiectomy [4]. Preoperative CT and MRI allow surgical planning [3].- This patient started antituberculous chemotherapy and is continuing treatment in outpatient care. He is expected to start antiretroviral therapy for HIV soon. No surgical treatment was needed until now.Take Home Message, Teaching Points- Tuberculous pericarditis should be considered in all cases of pericarditis without a rapidly self-limited course [1].",
    "differential_diagnosis": "Tuberculous, Pericarditis, (definite, diagnosis), Tuberculous, pericarditis, Pericardial, metastasis, (namely, from, lung, cancer), Pericardial, mesothelioma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013351/000001.jpg?itok=gZ4VFvZ1",
            "caption": "Chest X-Ray: Cardiac silhouette enlargement (blue arrow) and opacification of the left hemithorax (orange arrow)"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013351/000002.jpg?itok=nUD7fOh9",
            "caption": "Chest CT with i.v. contrast: Necrotic lymph nodes (blue arrow); pleural thickening with pleural effusion (orange arrow)"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013351/000003.jpg?itok=mzqbuBax",
            "caption": "Chest CT with i.v. contrast: Irregular pericardial thickening (blue arrow), and large pericardial effusion (orange arrow."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013351/000004.jpg?itok=qAnpk3oA",
            "caption": "Chest CT: Randomly distributed micronodules throughout the lung parenchyma"
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013351/000005.jpg?itok=1ImInpaK",
            "caption": "Cardiac MRI: Axial cine images show large pleural effusion (orange arrow), mediastinal lymph nodes (green arrow), pericardial effusion with septa (blue arrow), and flattened right ventricle (purple arrow)"
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013351/000006.jpg?itok=EkYXwQnP",
            "caption": "Cardiac MRI: Sagittal cine images show large pleural effusion (orange arrow), pericardial effusion with septa (blue arrow), irregular thickening of the pericardium (green arrow), and flattening of the right ventricle (purple arrow)"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT",
      "MR"
    ],
    "link": "https://www.eurorad.org/case/13351",
    "time": "15.03.2016"
  },
  "13363": {
    "case_id": 13363,
    "title": "Hamman\\&#039;s syndrome - pneumomediastinum, subcutaneous emphysema and pneumorachis",
    "section": "Chest imaging",
    "age": "24",
    "gender": "female",
    "diagnosis": "Spontaneous pneumomediastinum, subcutaneous emphysema and pneumorachis",
    "history": "A 24 year-old female came to the emergency department complaining of increased dyspnoea over the last hours. She also reported cough and thoracic pain. On arrival the patient had tachycardia, tachypnea. The patient was previously healthy and denied any trauma or drug abuse.",
    "image_finding": "The chest radiograph (Figure 1) revealed the presence of free air in the supra-clavicular soft tissues, consistent with subcutaneous emphysema. Air could also be identified outlining the mediastinal pleura, along with the continuous diaphragm sign, confirming the presence of pneumomediastinum.The non-contrast-enhanced CT (Figure 2) demonstrated subcutaneous emphysema, pneumomediastinum, as well as the presence of air in the cervical canal, consistent with pneumorachis. The track of air contacting the cervical deep soft tisses to the vertebral canal can be seen through the conjugated foramen.",
    "discussion": "Pneumomediastinum is a condition defined by the presence of air in the mediastinum. Most frequently it is secondary to trauma, endobronchial or oesophageal procedures, surgery or hollow organ perforation [1]. Spontaneous pneumomediastinum was first described by Hamman in 1939 [2] when no obvious cause is identified. It is more common in youngsters, between the 2nd and the 4th decade, especially in males. Precipitating factors such as cough, labor [3] or drug abuse have been described.The Macklin effect [4] establishes that alveolar rupture occurs due to increased intrathoracic pressure, which results in air dissecting the bronchovascular sheath until the mediastinum. Thoracic pain, cough and dyspnoea are the clinical signs. Air may extend to other nearby structures, such as the soft tissues of the head and neck, resulting in subcutaneous emphysema. A crepitus on palpation of the affected body region is a characteristic sign, while neck pain is a rare one.Rarely, air in the deep cervical tissues of the neck may also reach the spinal canal through the intervertebral foramina [5], causing pneumorachis. Most frequently it is asymptomatic, but signs of spinal cord compression may develop. The chest radiograph is a good first-line technique in the evaluation of pneumomediastinum and might reveal: continuous diaphragm sign, air outlining the mediastinic structures, pneumopericardium, ring around artery sign or the tubular artery sign. It may also show air in the soft tissues of the chest or neck and the gingko leaf sign if air is seen involving the pectoralis major muscle.The CT is a more sensitive technique, being able to show small amounts of free air, not visible in the chest radiograph. It also has the advantage of establishing a better anatomy for the mediastinic free air and reveal the presence of lung pathology such as subpleural bullae that might have caused the pneumomediastinum. CT can also reveal the presence of pneumorachis.Treatment is supportive, with oxygen, sedatives and analgesics being usually sufficient. Recurrence is uncommon and also responds to conservative measures.",
    "differential_diagnosis": "Spontaneous, pneumomediastinum,, subcutaneous, emphysema, and, pneumorachis, Pneumothorax, Pneumopericardium",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013363/000001.png?itok=_6A_1wTv",
            "caption": "Chest raddiograph demonstrating air in the soft tissues of the neck (asterisk) and free air outlining mediastinic vessels and the left mediastinic pleural (arrows)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013363/000002.jpg?itok=_K_kLmqi",
            "caption": "CT revealing the presence of air dissecting the mediastinic structures and extending to the soft tissues of the neck."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013363/000003.jpg?itok=RVc5Eg67",
            "caption": "CT revealing the presence of air dissecting the mediastinic structures. No lung parenchymal abnormalities are seen."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013363/000004.png?itok=zJ78zOwG",
            "caption": "Non-contrast-enhanced CT with soft-tissue window and MIP reconstruction revealing subcutaneous emphysema as well as air extending through the conjugated foramen to the vertebral canal (arrow), consistent with pneumorrachis."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax",
      "Neuroradiology spine"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/13363",
    "time": "28.02.2016"
  },
  "13387": {
    "case_id": 13387,
    "title": "Pulmonary interstitial gas surrounding lung metastases",
    "section": "Chest imaging",
    "age": "25",
    "gender": "male",
    "diagnosis": "Progressive NSGCT, extensive pulmonary interstitial emphysema and pulmonary lacunae.",
    "history": "A 25-year-old patient with stage IV metastatic testicular germ cell cancer, Tx N2 M1; including pulmonary metastases, developed progressive respiratory compromise during intensive induction chemotherapy. On minimal exertion he desaturated to oxygen saturations of 70%. CTPA was negative for pulmonary emboli and bronchoalveolar lavage specimens were negative for atypical infections.",
    "image_finding": "CT thorax at initial deterioration demonstrated inflammatory interstitial thickening of the lower lobes bilaterally and right upper and middle lobes. Nine days later repeat CT showed progressive pulmonary appearances with significant progression of patchy ground-glass opacification, cavitation of a right upper lobe mass and formation of pulmonary interstitial emphysema (PIE) and extensive pneumomediastinum extending to the neck. Low attenuating gas-filled cysts surrounding pulmonary lesions, a small left apical pneumothorax and pretracheal adenopathy were also seen. Despite a change in chemotherapy regimen repeat plasma beta-hCG levels rose indicative of tumour progression. Unfortunately he deteriorated further with worsening hypoxia \u2013 requiring intensive care admission. Ventilation was considered inappropriate due to his lung architecture. There were no further treatment options and palliative measures were commenced - he died 24 hours later.",
    "discussion": "Background & Clinical Perspective:Testicular tumours are the most common solid malignant tumour in men aged between 20 and 39 years [1.] The overall prognosis is excellent when compared to other cancers; dependent on tumour histology and stage and largely attributable to effective chemotherapy. Germ cell tumours account for over 90% of testicular cancers and are split evenly between seminomas and non-seminomatous germ cell tumours (NSGCTs). NSGCTs contain embryonal stem cells and can be classified into: embryonal, teratoma, choriocarcinoma, yolk sac tumour or mixed. [2]This patient had choriocarcinoma subtype with extensive lung and liver metastases (stage III) and considered of poor prognosis; therefore, with 48% chance of 5-year survival with chemotherapy. Stage III patients are stratified into good, intermediate or poor prognosis: with their overall 5-year survival with primary chemotherapy treatment, 92%, 80% and 48% respectively. [3] Pulmonary Interstitial Emphysema (PIE) is a rare condition whereby air dissects within the pulmonary interstitium: typically in the peribronchovascular sheaths, interlobular septa, and visceral pleura, as a result of alveolar and terminal bronchiolar rupture. It results in the formation of cystic structures with an associated inflammatory reaction. PIE leads to compression of adjacent functional lung tissue and vascular structures - hindering both ventilation and pulmonary circulation. It is typically seen in neonates receiving ventilatory support but has been observed very rarely in adults, usually associated with mechanical ventilation. In other cases, the cause could be air trapping from mechanical obstruction, necrotizing pneumonia, decreased lung compliance or mechanical trauma. Interstitial air may resolve spontaneously or progress with decompression into adjacent spaces causing pneumomediastinum, pneumothorax, pneumopericardium, pneumoperitoneum or subcutaneous emphysema which if large enough can be life-threatening. [4, 5] Therefore the early detection of PIE, particularly in ventilated patients, and subsequent management could reduce progression to severe barotrauma.Imaging Perspective:Early features of PIE can be subtle but include the characteristic lucent halo. Chest X-ray findings include parenchymal and subpleural cysts, perivascular halos, intraseptal air, and linear lucencies extending to the mediastinum. CT findings are more readily identifiable and include air tracking along the bronchovascular sheaths, parenchymal stippling, and cysts. [6, 7] PIE has previously been reported in a patient with metastatic choriocarcinoma under chemotherapy. [8]The appearance of thin-walled cavities arising at the sites of pulmonary metastases from germ cell tumours treated with chemotherapy has previously been described and termed \u2018pulmonary lacunae\u2019. They occur with a prevalence of approximately 7% in patients with multiple pulmonary metastases from testicular teratoma. [9]",
    "differential_diagnosis": "Progressive, NSGCT,, extensive, pulmonary, interstitial, emphysema, and, pulmonary, lacunae., Drug-related, pneumonitis, Atypical, infection, such, as, pneumocystis, jirovecii, pneumonia, \u2013, undetected, by, bronchoalveolar, lavage, Gas-filled, cysts, surrounding, a, number, of, the, pulmonary, lesions:, either, rapid, tumour, shrinkage, or, pneumatocoele, formation, due, to, infection., Rapid, progression, of, metastatic, pulmonary, nodules",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013387/000001.jpg?itok=5XS_R_k0",
            "caption": "Axial CT Chest demonstrating extensive pulmonary metastases, each with a halo of gas, and interstitial thickening."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013387/000002.jpg?itok=lfTvV0cs",
            "caption": "Axial CT Chest demonstrating extensive pulmonary metastases, each with a halo of gas, and inflammatory interstitial thickening."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013387/000003.jpg?itok=yOp46LxJ",
            "caption": "Coronal CT Chest demonstrating extensive pulmonary metastases, each with a halo of gas, and inflammatory interstitial thickening."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013387/000006.jpg?itok=AYiQ4sG2",
            "caption": "Cavitation of right upper lobe mass."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013387/000007.jpg?itok=ZL6gJFkS",
            "caption": "Halo of gas surrounding pulmonary metastases."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013387/000008.jpg?itok=CKe7dS4z",
            "caption": "Presence of pulmonary interstitial gas and pneumomediastinum."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013387/000009.jpg?itok=9cl_8KPy",
            "caption": "Significant patchy ground-glass opacification, cavitation of a right upper lobe mass and formation of pulmonary interstitial gas with extensive pneumomediastinum. Small left apical pneumothorax is also present."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013387/000010.jpg?itok=rYjPxen3",
            "caption": "Halos of gas surrounding pulmonary metastases."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/13387",
    "time": "12.03.2016"
  },
  "13388": {
    "case_id": 13388,
    "title": "Hemoptysis in pulmonary tuberculosis - contrast CT scan diagnosing Rasmussen\u2019s  aneurysm",
    "section": "Chest imaging",
    "age": "45",
    "gender": "male",
    "diagnosis": "Rasmussen\u2019s aneurysm",
    "history": "A 45-year-old male patient came to us with a history of massive haemoptysis two weeks before with  complaints of low grade fever, weight loss, loss of appetite and shortness of breath for two months.He had a remote history of pulmonary tuberculosis treated with a full course of therapy in the distant past.",
    "image_finding": "Posteroanterior chest radiograph showed airspace consolidation in the right upper lobe (image unavailable).Contrast-enhanced transverse Computed Tomography (CT) scan obtained at level of the trachea using mediastinal window setting showed a round cavitary lesion in the right upper lobe with intracavitary material and air surrounding it.CT scan obtained 15 mm inferiorly showed contrast-enhancing round vascular structure in the consolidative lesion. The lesion enhancement was similar to the adjacent pulmonary artery.CT angiogram demonstrated that this lesion is a saccular Rasmussen aneurysm. CT scan showed also branching nodular and linear opacities (tree-in-bud signs) and centrilobular small nodule in the right lung and the left upper lobe.Based on the imaging and clinical features (sputum positive for acid-fast bacilli) a diagnosis of pulmonary tuberculosis with Rasmussen\u2019s aneurysm was made. Antitubercular treatment was started, and the patient was referred to a university hospital for endovascular management of the aneurysm.",
    "discussion": "Rasmussen\u2019s aneurysm (RA) is an uncommon complication of pulmonary tuberculosis. It may form months to years after formation of the sequellar cavity [1]. Fritz Waldemar Rasmussen, a Danish physician, was the first who described 11 cases of pulmonary aneurysms in patients with tuberculosis in 1868 [2].He described the RA as a pulmonary vessel traversing the wall of a tuberculous pulmonary sequellar cavity with its aneurysmal dilatation into this cavity [2].Pulmonary tuberculosis has many complications and sequelae including bronchiectasis, pulmonary fibrosis, aspergilloma (in the cavity of post primary pulmonary tuberculosis), broncholithiasis, empyema, hypertrophy of the bronchial artery and RA. RA has the most devastating course of all these complications, and needs urgent and aggressive management; otherwise it can lead to death due to massive haemoptysis [1].Progressive weakening of the arterial wall arises when granulation tissue takes the place of both the adventitia and the media. This granulation tissue is then gradually replaced by fibrin, causing thinning of the arterial wall, constitution of pseudoaneurysm, and consecutive rupture [3, 4].RAs are frequently peripheral and beyond the branches of main pulmonary artery [5]. The prevalence of pulmonary aneurysms detected by multidetector CT in a large retrospective series of 189 patients with massive haemoptysis from tuberculosis was 6.9% [6]. Attentive evaluation of unenhanced and post-contrast CT scan of lungs will show focal contrast enhancement in the aneurysm [7]. CT angiography or Digital Subtraction Angiography (DSA) can confirm the diagnosis. This may be the first clue to the correct cause of the haemoptysis. Endovascular occlusion of the neck of the pulmonary aneurysm is generally successful in managing the haemoptysis [8]. Steel coils are the best occlusive material; but when vascular access is impossible, thrombin and cyanoacrylate injection percutaneously under fluoroscopic and ultrasound guidance can be used [8, 9].Even if uncommon, RA are a significant aetiology of massive haemoptysis in patients with tuberculosis. Accurate evaluation of the post-contrast CT examination may be useful in suggesting the correct diagnosis.",
    "differential_diagnosis": "Rasmussen\u2019s, aneurysm, Behcet, disease, Hughes-Stovin, syndrome, Mycotic, aneurysm, Intracavitary, haematoma, Aspergilloma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013388/000001.jpg?itok=Bypjo8pM",
            "caption": "Axial CT scan with lung window setting and maximum intensity projection: branching nodular and linear opacities (tree-in-bud signs) and centrilobular small nodule in the right lung."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013388/000002.jpg?itok=qQTGqQ-X",
            "caption": "Axial CT scan with lung window setting and maximum intensity projection: branching nodular and linear opacities (tree-in-bud signs) and centrilobular small nodule in the right lung."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013388/000003.jpg?itok=614MGwmc",
            "caption": "Axial CT scan with lung window setting and maximum intensity projection: branching nodular and linear opacities (tree-in-bud signs) and centrilobular small nodule in the right lung."
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013388/000004.jpg?itok=--gqdmz6",
            "caption": "Coronal reformation with lung window setting and maximum intensity projection: branching nodular and linear opacities (tree-in-bud signs) and centrilobular small nodule in the right lung and the left upper lobe."
          },
          {
            "number": "Figure 1e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013388/000005.jpg?itok=J5d_7S7t",
            "caption": "Coronal reformation with lung window setting and maximum intensity projection: branching nodular and linear opacities (tree-in-bud signs) and centrilobular small nodule in the right lung and the left upper lobe."
          },
          {
            "number": "Figure 1f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013388/000010.jpg?itok=lLWPBk_w",
            "caption": "Coronal reformation with lung window setting and maximum intensity projection: branching nodular and linear opacities (tree-in-bud signs) and centrilobular small nodule in the right lung and the left upper lobe."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013388/000008.jpg?itok=7L_-Dpiz",
            "caption": "Unenhanced CT scan obtained 15 mm inferiorly: consolidative lesion in the right upper lobe."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013388/000006.jpg?itok=FsNfD8sq",
            "caption": "Post contrast CT scan obtained 15 mm inferiorly: contrast-enhancing round vascular structure in the consolidative lesion."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013388/000009.jpg?itok=ohqV3gqa",
            "caption": "Contrast-enhanced transverse CT scan obtained at the level of the trachea with mediastinal window setting: round cavitary lesion in the right upper lobe with intracavitary material and air surrounding it."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013388/000011.jpg?itok=KwufPBO0",
            "caption": "CT angiogram shows a solitary peripheral pulmonary artery aneurysm."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013388/000012.jpg?itok=UTBu9Sx0",
            "caption": "CT angiogram shows a solitary peripheral pulmonary artery aneurysm."
          },
          {
            "number": "Figure 4c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013388/000013.jpg?itok=iNA0rI4u",
            "caption": "CT angiogram shows a solitary peripheral pulmonary artery aneurysm."
          },
          {
            "number": "Figure 4d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013388/000014.jpg?itok=grg9ksee",
            "caption": "CT angiogram shows a solitary peripheral pulmonary artery aneurysm."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT",
      "CT-Angiography"
    ],
    "link": "https://www.eurorad.org/case/13388",
    "time": "08.04.2016"
  },
  "13414": {
    "case_id": 13414,
    "title": "A case of COP misdiagnosed as cannon ball pulmonary metastasis on the basis of radiological appearance",
    "section": "Chest imaging",
    "age": "51",
    "gender": "female",
    "diagnosis": "Cryptogenic organizing pneumonia (COP)",
    "history": "51-year-old female presented with fever and shortness of breath. Haematological work up shows raised total leukocyte count (TLC) of 14.9. C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) were 17.39 mg/dl and 38 mm/1st hour respectively. All other lab tests were normal.",
    "image_finding": "The chest radiograph shows multiple large rounded soft tissue density masses/nodules scattered in both lungs. (Fig. 2a) Computed Tomography (CT) was advised for further workup. CT chest showed multiple rounded variable-sized soft tissue density lesions scattered in bilateral lungs fields, few of these were showing central low attenuation. The largest one in the left lung apex appeared more solid showing spiculated margins. Multiple enlarged mediastinal lymph nodes at right paratracheal, subcarinal and prevascular location. No evidence of peripheral consolidation on either side. No evidence of pleural effusion or pneumothorax bilaterally. (Fig. 1)",
    "discussion": "Multinodular disease of the lung is a common characteristic of metastatic lung disease, associated in particular with renal, breast, thyroid and gastrointestinal tract malignancies. Numerous non-malignant diseases may also present with a similar radiological picture such as cryptogenic organizing pneumonia (COP), tuberculosis, aspergillosis and Wegener's granulomatosis. [1] Researchers have tried to reach a specific diagnosis based on morphological characteristics and anatomic localization of the nodules using HRCT of lung but definite diagnosis always requires biopsy. [2] This patient was initially diagnosed as a case of pulmonary metastasis on radiological appearance. On the basis of the findings, the patient underwent an extensive investigation attempting to locate a primary tumour. After an unsuccessful workup, the patient was referred for biopsy, which revealed features of organizing pneumonia without any evidence of malignancy. Cryptogenic organizing pneumonia (COP) is a pulmonary disorder characterized by plugs of granulation tissue in bronchioles, alveolar ducts and alveoli. It may be cryptogenic or may be associated with viral infection, toxic fume inhalation, connective tissue disease, drug administration, bone marrow and heart-lung transplantation. [3] On High resolution CT (HRCT) usual features of COP are patchy consolidation with a predominantly subpleural and/or peribronchial distribution. Large pulmonary nodules/masses are found to be rare CT features of COP. This case illustrates that the clinical, roentgenographic, and CT findings of COP are nonspecific and in some cases can be confused with those of metastatic tumour in the lungs. The clinical symptoms and pulmonary lesions dramatically resolved as the patient received steroid therapy. Follow-up radiograph revealed residual fibrosis without lung nodules. Whatever the aetiology, early diagnosis may have prevented the patient from having rapidly progressive COP that is a deadly form of the disease and can occur in a small percentage of patients. [4] In conclusion, not every patient showing cannonball lesions in lung should be directly labelled as a case of disseminated malignancy and timely image-guided biopsy can prevent unnecessary delay in diagnosis and management.",
    "differential_diagnosis": "Cryptogenic, organizing, pneumonia, (COP), Pulmonary, metastasis, Wegeners, granulomatosis, Tuberculosis, Aspergillosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013414/000001.jpg?itok=HfdfGkNo",
            "caption": "Multiple rounded variable-sized soft tissue density lesions scattered in bilateral lungs fields, few of these were showing central low attenuation. The largest one in the left lung apex appears more solid showing spiculated margins."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013414/000002.jpg?itok=GAdpT4J4",
            "caption": "Initial radiograph shows multiple large rounded soft tissue density nodules scattered in both lungs. 4 months follow up radiograph after starting steroid therapy shows almost complete resolution of the nodules with some residual fibrotic changes."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT",
      "Conventional radiography"
    ],
    "link": "https://www.eurorad.org/case/13414",
    "time": "27.03.2016"
  },
  "13418": {
    "case_id": 13418,
    "title": "\u201cLadies don\u2019t cough\u201d: Lady Windermere syndrome",
    "section": "Chest imaging",
    "age": "57",
    "gender": "female",
    "diagnosis": "Chronic respiratory infection by Mycobacterium avium intracellulare.",
    "history": "A 57-year-old woman was sent to the hospital due to chronic progressive shortness of breath for the past 12 months. The patient had neither smoking habits nor a relevant previous history. General physical examination was unremarkable. Blood biochemical investigations were normal.",
    "image_finding": "Chest radiogram showed small, ill-defined opacities in the middle and right upper lobe. Air bronchogram was depicted in the middle lobe (Fig. 1).Thoracic enhanced computed tomography (CT) presented cylindrical bronchiectasis and partial volume loss in the middle lobe (Fig. 2). This focal area of bronchiectasis was filled with mucous impaction. Posterior segment of the right upper lobe showed bronchial wall thickening, and multiple small nodules and branching centrilobular nodules in keeping with tree-in-bud pattern (Fig. 3, 4). No mediastinal or hilar adenophathies were shown.Bronchoalveolar lavage was performed revealing acid fast bacilli, proven to be Mycobacterium avium intracellulare by DNA probe analysis.",
    "discussion": "In the reported case, the non-specific and scarce chronic respiratory symptomatology with no previous history of lung disease along with the tree-in-bud pattern, places as first differential diagnosis the hypothesis of respiratory infection. Furthermore, CT features of bronchiolitis, due to the direct signs of centrilobular nodules and tree-in-bud pattern are seen [1, 2]. Additionally the patient is an immunocompetent middle-aged woman in whom the only CT findings were a focal area of bronchiectasis and multiple small centrilobular nodules with tree-in-bud appearance in the right lung. So, facing such a clinical picture, the radiologist must remember that non-tuberculous mycobacterial (NTM) pulmonary infection is the main important differential diagnosis. NTM agents are ubiquitous organisms from reservoirs in the environment that became more recognized in the last ten years as an important cause of chronic human pulmonary infection [3-9]. The manifestations of pulmonary NTM infection are variable and include consolidation, cavitation, fibrosis, nodules, bronchiectasis and adenopathy [6].The non-classic form described here is typically found in immunocompetent elderly white women with no predisposing factors. It usually presents in an indolent fashion with a chronic cough, with constitutional symptoms being uncommon [3-9]. On CT bronchiolitis features with small centrilobular nodules or tree-in-bud opacities with cylindrical bronchiectasis are seen. Usually the middle lobe and the lingula are the most commonly affected regions but any segment can be affected. [3, 4, 6, 7]. These features were termed in the literature as the so-called Lady Windermere syndrome regarding the hypothesis that these patients may voluntarily suppress their cough, reduce clearance of secretions from the middle lobe and lingular segments which have long and narrow bronchi with relatively acute angulations from the parent bronchi, thus predisposing NTM infection [3, 6, 9].Regarding CT findings there are similarities between the appearances of NTM and Mycobacterium tuberculosis, nonetheless the most common findings in active tuberculosis are nodules, consolidation, cavitation and interlobular septal thickening [7]. In the reported case, the suitable diagnosis according to chronic clinical symptoms plus the radiological findings was NTM infection, confirmed by the presence of acid fast bacilli, proven to be Mycobacterium avium intracellulare pulmonary infection.",
    "differential_diagnosis": "Chronic, respiratory, infection, by, Mycobacterium, avium, intracellulare., Non-tuberculous, mycobacterial, pulmonary, infection, Tuberculous, mycobacterial, pulmonary, infection",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013418/000001.jpg?itok=_inhoxXu",
            "caption": "Frontal radiogram shows small, ill-defined opacities in the middle and upper lobe. Air bronchogram is depicted in the right middle lobe."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013418/000002.jpg?itok=RZoOPepS",
            "caption": "CT axial image shows cylindrical bronchiectasis and partial volume loss in the middle lobe."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013418/000003.jpg?itok=cif2HJ-U",
            "caption": "Axial CT image in the posterior segment of the right upper lobe shows bronchial wall thickening and multiple small nodules."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013418/000004.jpg?itok=x6v_FNvW",
            "caption": "Axial CT showing in detail a) branching centrilobular nodules (arrow) in keeping with tree-in-bud pattern and b) bronchial wall thickening (arrow) and multiple small nodules (arrowhead)."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "Digital radiography",
      "CT-High Resolution"
    ],
    "link": "https://www.eurorad.org/case/13418",
    "time": "15.03.2016"
  },
  "13421": {
    "case_id": 13421,
    "title": "Tracheobronchopathia osteochondroplastic",
    "section": "Chest imaging",
    "age": "62",
    "gender": "male",
    "diagnosis": "Tracheobronchopathia osteochondroplastica",
    "history": "A 62-year-old male patient underwent whole body computed tomography (CT) for staging of colon cancer. The patient reported a mild occasional cough for 1 year, without history of smoking cigarettes or known allergies.",
    "image_finding": "Chest CT revealed diffuse submucosal calcified nodules of the anterolateral walls of the trachea, not including the posterior membrane, without a significant narrowing of the airway lumen (fig 1, 2); the proximal tract of the right main bronchus also showed sporadic nodules of the walls (fig. 1, 2). CT virtual endoscopy accurately showed the preserved airway lumen and the protruding submucosal nodules of the anterolateral tracheal and bronchial walls (fig. 3).",
    "discussion": "Tracheobronchopathia osteochondroplastica (TO) is a rare benign airway disease characterized by multiple osseocartilaginous nodules projecting into the lumen of airway selectively from the anterolateral wall, excluding the posterior membrane [1]. TO usually affects the lower two thirds of the trachea and proximal portions of the primary bronchi, but sometimes the larynx and subglottic trachea are also involved [2].The real incidence of this disease is undefined since TO is often detected incidentally during autopsies, routine bronchoscopies, CT-scans that are performed for other unrelated condition and, rarely, during difficult intubations [3]. The aetiology and pathophysiology of TO are not known, although a recent retrospective study reported chronic inflammation as a possible predisposing factor [2].Clinical manifestations of TO are nonspecific: most patients are asymptomatic or complain of a minor cough. Serious symptoms may develop depending on the extent of airway obstruction, in fact there are cases described in the literature in which TO manifests itself in exertional dyspnoea, recurrent pneumonia, and, on occasion, hemoptysis [4]. However, normally the disease has a slow progression and is considered benign [2].Diagnosis of TO can be made by CT, magnetic resonance imaging (MRI) or bronchoscopy [5].CT allows a primary diagnosis and shows pathognomonic findings of TO, such as irregular thickening and/or calcified nodularities protruding into the tracheobronchial lumen, involving the anterior and lateral wall of tracheobronchus [3, 7]. Moreover, CT accurately reveals the typical sparing of the posterior tracheal membrane, allowing us to distinguish TO from other airway diseases, i.e. tracheobronchial amyloidosis and Wegener granulomatosis, which also usually involve the posterior wall [6].MRI examination of the chest may show thickening of the tracheal walls with intermediate signal intensity, and punctiform low signal intensity suggesting calcifications [4].Bronchoscopy is still considered by many authors \"the gold standard\" for the diagnosis of TO and its typical appearance is of multiple smooth, raised, white, osseocartilaginous nodules located over the anterolateral walls. Since these lesions are typically hard, biopsy of them is difficult and is not essential because the visual appearance alone is enough to make a diagnosis [1].Treatment is usually symptomatically dependent, but in the case of severe obstructions laser ablation and surgical resection are recommended [4].In our case, TO was incidentally found during staging whole body-CT. The patient complained of a mild occasional cough without other respiratory symptoms. He was then successfully treated with a therapy of inhaled corticosteroids.",
    "differential_diagnosis": "Tracheobronchopathia, osteochondroplastica, Amyloidosis, Sarcoidosis, Papillomatosis, Wegener, Granulomatosis, Relapsing, Polychondritis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013421/000001.png?itok=6EnXeuSO",
            "caption": "Cross sectional CT image showing diffuse submucosal calcified nodules of the anterolateral walls of the trachea, excluding the posterior membrane"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013421/000002.png?itok=SzQ2rIAS",
            "caption": "Cross sectional CT image showing diffuse submucosal calcified nodules of the anterolateral walls of the trachea, excluding the posterior membrane"
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013421/000003.png?itok=aeEY6HA1",
            "caption": "Cross sectional CT image showing diffuse submucosal calcified nodules of the anterolateral walls of the trachea, excluding the posterior membrane"
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013421/000004.png?itok=Cq-5o5QU",
            "caption": "Cross sectional CT image showing diffuse submucosal calcified nodules of the anterolateral walls of the trachea, excluding the posterior membrane"
          },
          {
            "number": "Figure 1e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013421/000005.png?itok=I3NjnkZ2",
            "caption": "Cross sectional CT image showing diffuse submucosal calcified nodules of the anterolateral walls of the trachea, excluding the posterior membrane"
          },
          {
            "number": "Figure 1f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013421/000006.png?itok=yz15Nc4h",
            "caption": "Cross sectional CT image showing sporadic submucosal nodules of the proximal tract of  right main bronchus"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013421/000007.png?itok=BQBaWqDl",
            "caption": "MPR image showing the distribution of calcified submucosal nodules involving the trachea and the right main bronchus"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013421/000008.png?itok=80ny0Rsk",
            "caption": "MPR image showing the distribution of calcified submucosal nodules involving the trachea and the right main bronchus"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013421/000009.png?itok=o4HFwFv3",
            "caption": "CT virtual endoscopy image showing the protruding submucosal nodules of the anterolateral tracheal walls and the preserved airway lumen. The posterior membrane does not present any irregularities."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013421/000011.png?itok=hWPBoOaa",
            "caption": "CT virtual endoscopy image showing the sporadic protruding submucosal nodules of the anterolateral walls of the right main bronchus"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Respiratory system"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/13421",
    "time": "28.02.2016"
  },
  "13436": {
    "case_id": 13436,
    "title": "Azygos lobe as an incidental finding",
    "section": "Chest imaging",
    "age": "68",
    "gender": "male",
    "diagnosis": "Incidental finding of azygos lobe",
    "history": "A 68-year-old man presented with a medical history of diabetes mellitus and high blood pressure. He was admitted in November 2015 to the ER as a code stroke, after developing a few hours before an acute episode of left sensorimotor deficit. Apart from the brain CT, he underwent a routine chest radiography.",
    "image_finding": "In the chest radiography the mediastinum and the pleuro-parenchymal space were normal, except for the presence of a calcified pulmonary nodule in the medium lobe. We incidentally noticed the presence of an azygos lobe.",
    "discussion": "The azygos lobe is a congenital variant which has been described in 1% of subjects and in about 0.4% of chest radiographs [1-3]. This variant is the result of a failure in the migration of the posterior cardinal vein, a precursor of the azygos vein, from the thoracic wall to its normal location in the tracheobronchial angle. When this migration does not occur, the azygos vein remains inside the right upper lobe, which expands upwards, surrounding the ectopic vein and leaving a deep lung fissure containing the azygos vein at its caudal region. Given that the vein is initially extrapleural, when it penetrates the apex, both the parietal and visceral pleural layers are carried along and cover both sides of the fissure. The consequence is the entrapment of a portion of the right upper lobe by the azygos vein, which is called \u2018azygos lobe\u2019. As it has no bronchi, veins and arteries of its own, it is not a true pulmonary lobe, but rather an anatomically separated part of the upper lobe [1,2].On the chest radiograph, 4 structures can be noticed in the right upper pulmonary field: 1) the shadow of the azygos vein; 2) the previously mentioned fissure that crosses the apex of the right lung, constituted by the apposition of the two layers of visceral pleura and by the two layers of parietal pleura (these two internal layers are known as mesoazygos); 3) the azygos lobe, which represents the portion of the right upper lobe trapped by the previously mentioned structures; 4) a triangular area in the upper portion of the fissure (trigonum parietale) near the thoracic wall, where the mesoazygos continues with the costal pleura [1] (Figure 2).The azygos lobe is usually an incidental finding on chest x-ray or computed tomography. In the chest radiograph, it is usually well limited by the azygos fissure, represented as a fine, convex line that crosses the apex of the right lung. CT images give a more accurate representation of this lobe and its relations with the mediastinum. Although the azygos lobe is not associated with any morbidity, its presence  may compromise the success of  thoracoscopic operations or sympathectomy and increase the risk of these procedures. Recognition of the anomaly is, therefore, important [3].",
    "differential_diagnosis": "Incidental, finding, of, azygos, lobe, Right, Upper, Lobe, Atelectasis, Enlarged, Paratracheal, Lymph, Nodes, Tortuous, Supraaortic, Vessels",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013436/000001.jpg?itok=KS2ngVaK",
            "caption": "Presence of an azygos lobe."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013436/000002.jpg?itok=C0JPT68r",
            "caption": "Presence of an azygos lobe. Note the trigonum (arrowhead), the fissure (arrows) and the azygos vein (open arrow)."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/13436",
    "time": "06.03.2016"
  },
  "13484": {
    "case_id": 13484,
    "title": "A bloody cough",
    "section": "Chest imaging",
    "age": "39",
    "gender": "male",
    "diagnosis": "Life-threatening haemoptysis caused by systemic arterial pseudoaneurysm secondary to aspergilloma.",
    "history": "A 39-year-old, non-English speaking, Indian, male patient presented with massive haemoptysis. Background history includes: Ex-smoker; Crohn's disease and severe Varicella Pneumonia requiring ventilation, chest drains, a prolonged Intensive Care Unit stay and a slow tracheostomy wean. Physical examination was unremarkable.",
    "image_finding": "Right apical cavity on CXR (Fig. 1). CTs performed in systemic and pulmonary arterial phases demonstrate abnormal right systemic arteries, apical cavitation, but no active bleeding/pseudoaneurysm (Fig. 2).Bronchoscopy identified bleeding in the right upper lobe.Extensive angiography demonstrated abnormal intercostal arteries with shunting into the pulmonary veins. Selective catheterisation and embolisation with 350-500mcg Polyvinyl Alcohol particles was performed (Fig. 3).Costocervical trunk angiography showed hypertrophic, serpiginous vessels extending into the right upper lobe from the right internal mammary artery with pseudoaneurysm and shunting into the pulmonary veins (Fig. 4). Coil embolisation was performed throughout these arteries (Fig. 5).Completion angiography demonstrated no filling of the abnormal vessels, pseudoaneurysm or venous shunting.The patient improved clinically, his haemoptysis resolved and he was discharged within a week. Sputum samples remained negative for acid fast bacilli and QuantiFERON-TB Gold, however, Aspergillus precipitin was isolated.Follow-up imaging demonstrated regression of the apical cavitation (Fig. 6). The patient underwent interval lobectomy. Cause of cavity remains unproven.",
    "discussion": "Massive haemoptysis (300\u2013600mL per day) is a respiratory emergency which has a variety of causes. In 90% of cases, the source is the bronchial circulation [1].However, Non-bronchial systemic arteries can be a significant source of massive haemoptysis, especially in patients with pleural involvement caused by underlying disease. Missing the non-bronchial systemic arteries at angiography may result in recurrent bleeding after successful embolisation of the bronchial artery and many practitioners advocate a concerted search for non-bronchial systemic arterial supply [2].Pre-procedural CT delineates the site of the lesion, and may identify bleeding vessels. Use of multi-planar reconstructions and meticulous planning can greatly reduce the amount of time required to embolise target vessels.Massive haemoptysis results from various causes, which differ greatly between the Western and the non-Western world. In the non-Western world, pulmonary tuberculosis (TB) is the most common underlying cause. Bronchogenic carcinoma and chronic inflammatory lung diseases, e.g. bronchiectasis, cystic fibrosis, or aspergillosis are the more prevalent causes of haemoptysis in Western countries [2].Aspergillus is an opportunistic fungus that exists as moulds and can cause a broad spectrum of pulmonary diseases, usually occurring in patients who have pre-existing cavitary lung disease [3]. Major forms in humans include [4]:- Acute invasive aspergillosis, invades surrounding tissue, more common in the immunocompromised.- Disseminated invasive aspergillosis- Aspergilloma, mass-like collection of fungal hyphae, mixed with mucus and cellular debris, within a pre-existing cavity\u2014the walls of which demonstrate vascular granulation tissue [5].Diagnosis is often made as a result of an incidental finding on a CXR or CT scan performed as part of the workup for an unrelated condition. However, a small percentage of aspergillomata invade into a blood vessel which can result in bleeding. There are classical findings associated with the different manifestations of aspergillus infection; haemoptysis being described as the most common symptom, occurring in up to 54% of patients [6]. This may result in life-threatening haemorrhage, though the amount of blood lost is usually inconsequential.Pulmonary artery pseudoaneurysms secondary to pulmonary tuberculosis are known as Rasmussen aneurysms and usually involve the upper lobes in the setting of reactivation tuberculosis [7].Treatment of haemoptysis is usually supportive with management of ABC and correction of clotting abnormalities. In the case of life-threatening events, it is vitally important to obtain high-quality MDCT angiography to direct interventional treatment allowing detection of abnormal vessels and target for embolization by an Interventional Radiologist.Failing this, or in cases of repeated haemoptysis surgical excision with a lobectomy remains the gold standard [8].",
    "differential_diagnosis": "Life-threatening, haemoptysis, caused, by, systemic, arterial, pseudoaneurysm, secondary, to, aspergilloma., Rassmussen, aneurysm, (due, to, TB), Bronchiectasis, Lung, abscess, Chronic, necrotizing/semi-invasive, Aspergillosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013484/000006.png?itok=82_kkIdx",
            "caption": "CXR showing arterial coils and reduced volume of right apical cavitation."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013484/000007.jpg?itok=5qwYlfnO",
            "caption": "Cavitating lesion right lung apex (black arrow) with multiple small lung nodules and loss of volume bi-apically (white arrows).\nSubsequently confirmed as an aspergilloma in old tuberculosis cavity."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013484/000008.jpg?itok=IxwHqW9h",
            "caption": "(Axial image, vascular windows).\nHypertrophied right systemic (solid white arrows) and bronchial arteries (white arrow, black border) which can be compared to the normal arterial tree on the left side of the chest."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013484/000015.jpg?itok=PrJwceIr",
            "caption": "(Sagittal plane, MIP image)\nHypertrophied bronchial arteries (thin white arrows) and right internal mammary artery (black arrows, white border)."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013484/000011.jpg?itok=ENsdClux",
            "caption": "(Sagittal plane, lung windows)\nApical mycetoma (solid black arrow), Emphysematous changes (white arrows, black border)."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013484/000017.jpg?itok=yPtVcG7Y",
            "caption": "DSA. Catheter in origin of right internal mammary artery (solid black arrow).\nAngiogram shows hypertrophic, serpiginous systemic arterial  branches (black arrow, white border) and rapid shunting into the pulmonary veins (white arrows, black border)."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013484/000018.jpg?itok=1TxwNjGQ",
            "caption": "DSA. Same run, moments later showing venous filling (black arrows, white border) and persistent filling in pseudoaneurysm (white arrow, black border)\n[Catheter in origin of right internal mammary artery]"
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013484/000020.jpg?itok=tzXeazLn",
            "caption": "Catheter in origin of intercostal artery (solid black arrow). Demonstrates hypertrophic, serpiginous arteries (black arrow, white border)."
          },
          {
            "number": "Figure 5b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013484/000019.jpg?itok=6KD7eU1b",
            "caption": "Catheter in origin of intercostal artery (solid black arrow). Demonstrates hypertrophic, serpiginous arteries (black arrow, white border) and rapid shunting into the pulmonary veins (white arrows, black border)."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013484/000021.jpg?itok=AIOArNA-",
            "caption": "DSA. Catheter in origin of right internal mammary artery (white arrow, black border). Multiple coils along internal mammary arteries (solid white arrows). No flow beyond proximal coils (solid black arrows)."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Interventional vascular",
      "Arteries / Aorta",
      "Thorax"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT-Angiography",
      "Catheter arteriography"
    ],
    "link": "https://www.eurorad.org/case/13484",
    "time": "14.06.2016"
  },
  "13494": {
    "case_id": 13494,
    "title": "Long term bronchoneumoniae that turned out to be a pulmonary alveolar proteinosis",
    "section": "Chest imaging",
    "age": "44",
    "gender": "female",
    "diagnosis": "Pulmonary alveolar proteinosis",
    "history": "A 44-year-old female patient with fever and dry cough, diagnosed as bronchopneumonia by her general practitioner, which did not improve with antibiotics within a month.",
    "image_finding": "The patient first underwent a frontal and lateral chest X-ray on which bilateral widespread opacities with a tendency to converge were seen (Fig. 1). As the symptoms persisted, one month later the patient underwent a chest CT, which revealed extensive bilateral sharply marginated areas of ground glass opacities associated with smooth thickening of interlobular septal lines, a pattern which is known as \"crazy paving\" (Fig. 2). A bronchoalveolar lavage was then performed, which proved it to be a pulmonary alveolar proteinosis.",
    "discussion": "Pulmonary alveolar proteinosis is a rare lung disease which consists of an accumulation of surfactant-like lipoproteinaceous material. It typically affects middle-aged men and is strongly associated with tobacco. It can be idiopathic (90%), secondary to other diseases such as haematological malignancies or chemotherapy, or congenital [1]. Their symptoms are usually respiratory and not specific, and they may range from dyspnoea or chest pain to respiratory failure, although it may also be asymptomatic. On CT, the \"crazy paving\" pattern is typical though not pathognomonic of this entity, as it can also be seen in other alveolar diseases such as pulmonary haemorrhage, bronchioloalveolar carcinoma or pulmonary oedema, and a bronchoalveolar lavage or a lung biopsy, which reveals foamy macrophages with PAS+ proteinaceus material, is needed to confirm the diagnosis [2]. The bronchoalveolar lavage is also used as a treatment, as it improves the symptoms of this disease and usually also its radiological features, since it produces a decrease in the density of the ground glass opacities. The prognosis of this entity is usually good even though it tends to relapse and multiple bronchoalveolar lavages may be required [1].",
    "differential_diagnosis": "Pulmonary, alveolar, proteinosis, Acute, respiratory, distress, syndrome, Cardiogenic, oedema, Pulmonary, infectious, disease, Bronchioloalveolar, carcinoma, Pulmonary, haemorrhage, Sarcoidosis, Acute, interstitial, pneumonia, Cryptogenic, organizing, pneumonia",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013494/000001.png?itok=AIsNMUCh",
            "caption": "Chest X-ray (frontal and lateral projections) show extensive diffuse opacities. There is no pleural effusion."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013494/000002.png?itok=vngpzZRr",
            "caption": "Chest CT (axial (a,b,c and d) and coronal sections (d)) shows widespread geographic ground glass opacities accompanied by smooth thickening of the interlobular septal lines, the \"crazy paving\" pattern."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013494/000003.png?itok=PlaR-b-f",
            "caption": "Chest CT (axial (a,b,c and d) and coronal sections (d)) shows widespread geographic ground glass opacities accompanied by smooth thickening of the interlobular septal lines, the \"crazy paving\" pattern."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013494/000004.png?itok=WU4wY3LF",
            "caption": "Chest CT (axial (a,b,c and d) and coronal sections (d)) shows widespread geographic ground glass opacities accompanied by smooth thickening of the interlobular septal lines, the \"crazy paving\" pattern."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013494/000006.png?itok=41MKcNqa",
            "caption": "Chest CT (axial (a,b,c and d) and coronal sections (d)) shows widespread geographic ground glass opacities accompanied by smooth thickening of the interlobular septal lines, the \"crazy paving\" pattern."
          },
          {
            "number": "Figure 2e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013494/000005.png?itok=VwbMT6nm",
            "caption": "Chest CT (axial (a,b,c and d) and coronal sections (d)) shows widespread geographic ground glass opacities accompanied by smooth thickening of the interlobular septal lines, the \"crazy paving\" pattern."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT",
      "Conventional radiography"
    ],
    "link": "https://www.eurorad.org/case/13494",
    "time": "16.04.2016"
  },
  "13495": {
    "case_id": 13495,
    "title": "Apical asymmetric new-appearance opacity: a pancoast tum",
    "section": "Chest imaging",
    "age": "75",
    "gender": "male",
    "diagnosis": "Pancoast tumour",
    "history": "A 75-year-old male long-term smoker with one month history of several disorientation episodes underwent a brain CT, which was normal, and later a chest X-ray. No other relevant symptoms related to any other system were reported.",
    "image_finding": "The abnormality on this chest radiograph may be easily missed as it is located in one of the areas known as \u201cblind spots\u201d: There is an opacity in the right lung apex, and also an absence of the second rib (Fig. 1).Based on these findings, we sought for prior imaging studies in order to confirm that the lesion was new, as it happened to be in this case (Fig. 2). Subsequently, a thoracic and abdominal CT was performed, which revealed a right posterior apical mass measuring 5.6 x 5.4 x 4.8 (AP x T x CC) cm. The mass was accompanied by rib destruction and an adjacent soft-tissue mass invading the chest wall. (Figure 3)There were also supraclavicular and paraoesophageal enlarged lymph nodes (Fig. 4).Subsequently, a CT-guided lung biopsy was performed, which revealed squamous lung cancer.",
    "discussion": "Pancoast tumour, also known as superior sulcus tumour, refers to a type of cancer that arises in the lung apex and invades the surrounding soft tissues [1]. Superior sulcus tumours are usually non-small cell lung cancers, and the most common histology encountered in the superior sulcus tumours are squamous cell bronchogenic carcinomas, as it resulted to be in this case [3].Even though the tumour arises from the lung, symptoms are usually, if present, rarely pulmonary (such as cough, dyspnoea, or chest pain). Instead, they are a result of a growth and invasion of the local structures, which may cause the classical Pancoast syndrome, only seen in 25% patients, and which consists of shoulder-arm pain (if they grow and invade the bone), and Horner\u00b4s syndrome (ipsilateral miosis, ptosis and anhidrosis due to invasion of the cervical sympathetic plexus) [1].Chest X-ray is usually the first imaging technique performed in patients with a pancoast tumour. Unfortunately, because of their location in the lung apices, this cancer is usually very difficult to detect, as the tumour may be seen as a subtle soft-tissue mass that may be confused with benign apical pleural thickening if it isn\u00b4t very big. The presence of associated bone destruction may be difficult to ascertain on the basis of radiographs, so in many patients, a thoracic CT is required to confirm the presence of a tumour [2].The main objectives of CT in patients with a superior sulcus tumour are to confirm the presence of a pulmonary mass, to allow accurate staging of the disease, and to guide the biopsy. In the superior sulcus tumour, CT is the best modality for depicting bone abnormalities adjacent to the primary mass, such as rib and vertebral body erosion, information that may influence the surgical approach taken and the extent of the resection [2].The presence of adenopathies is associated with poorer prognosis, and they may occur in up to 20%, as it happened in this case [2].The key to be guided to the final diagnosis on this case was the detection of a new asymmetric apical opacity. The fact that the mass was accompanied by bone destruction led the differential diagnosis to neoplastic causes such as a bone tumour invading the lung or a lung cancer (pancoast tumour) causing bone destruction [4].",
    "differential_diagnosis": "Pancoast, tumour, Extrapleural, fat, Infectious, diseases:, tuberculosis, Empyema, Traumatic, (haematoma), Neoplastic:, arising, from, the, lung, (Pancoast, tumour), or, arising, from, the, bone, (lytic, metastases, or, plasmocytoma)",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013495/000001.png?itok=EYCPVbNV",
            "caption": "Frontal chest X-ray shows an asymmetric right apical opacity and a lack of the second right rib (yellow arrow)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013495/000002.png?itok=lABEa-vO",
            "caption": "Older chest X-ray performed 3 years ago where the right apical opacity and lack of the second rib were not present."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013495/000004.png?itok=gDz5FLFR",
            "caption": "Coronal reconstruction in mediastinal window shows a right supraclavicular adenopathy (pink arrow). Axial section of the mid thorax also in mediastinal window shows a paraoesophageal lymph node (green arrow)."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013495/000005.png?itok=WTjzQXLW",
            "caption": "Axial and coronal reconstructions of the thoracic CT in lung and mediastinal windows show a right apical mass and a destruction of the second rib (yellow arrows)."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/13495",
    "time": "14.05.2016"
  },
  "13514": {
    "case_id": 13514,
    "title": "Pulmonary cystic echinococcosis mimicking metastatic malignancy",
    "section": "Chest imaging",
    "age": "20",
    "gender": "male",
    "diagnosis": "Pulmonary cystic echinococcosis",
    "history": "A 20-year-old male patient presented to us with chief complaints of haemoptysis and hydatidoptysis for 2 weeks, and weight loss during the past month.",
    "image_finding": "Posteroanterior chest radiograph showed multiple nodules involving predominantly the right lung and airspace consolidation in the right upper lobe.Computed tomography followed and demonstrated multiple thick-walled cystic lesions of variable size which were located predominantly at the right lungOne of these lesions (in the left upper lobe) showed an intracystic serpentine structure representing collapsed membranes (serpent sign) in relation with partial expectoration of the cyst fluid and scolices in the bronchioles.The following differential diagnoses were considered based on imaging findings: metastases to the lungs, pulmonary hydatid disease, tuberculosis and multiple pulmonary bacterial abscesses. Patient\u2019s hydatid serology of blood came positive for the anti-echinococcal antibody allowing to confirm the diagnosis of pulmonary echinococcosis.Medical therapy (including oral albendazole) was started.",
    "discussion": "Hydatid cysts are caused by a tapeworm of the genus Echinococcus. Dogs are the definitive host and humans may be infected only accidentally [1].Liver (75%) and lung (25%) are the most commonly involved sites, other organs are involved in 10% of cases [2]. Pulmonary hydatid cysts are multiple in 30% of cases and bilateral in 20% [3].Clinically, hydatid disease is frequently aspecific and many patients may be asymptomatic. The manifestations of cysts depend on their location and size. Symptoms are generally caused by the compression of underlying pulmonary tissue and or complications (rupture or infection).The cyst rupture into the bronchial tree may cause chest pain, haemoptysis or hydatoptysis [4].Typical radiographic findings of uncomplicated pulmonary hydatid disease are single or multiple homogenous round mass with smooth boarders [5, 6]. Some characteristic radiological signs may be present: crescent sign, cumbos sign with an \u201conion peel\u201d appearance, camelotte sign (water lily sign), and Monods sign (mass within a cavity). [7, 8] Post-contrast chest CT scan may demonstrate a thin annular enhancing of the cyst wall if it is unruptured; if a daughter is present or if the main cyst is ruptured the diagnosis may be confirmed.Routine blood tests are generally non-specific [3]. Serological tests are highly sensitive and specific.The percutaneous aspiration of cysts can demonstrate protoscolices, hooklets and/or cyst membranes allowing establishment of the diagnosis; this procedure is too risky because discharge of contents may cause anaphylaxis. The treatment of choice for hydatid cysts is surgical excision or evacuation [9]. Some scolicidal agents (hypertonic saline, hydrogen peroxide\u2026) may be used intraoperatively. Medical therapy includes oral albendazole [10] and mebendazole.",
    "differential_diagnosis": "Pulmonary, cystic, echinococcosis, Sarcoidosis, Lung, metastasis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013514/000002.jpg?itok=OQFWamBU",
            "caption": "Multiple nodules involving predominantly the right lung and airspace consolidation in the right upper lobe."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013514/000003.jpg?itok=rc1aGZH3",
            "caption": "Mediastinal window demonstating that all these nodules were cysts."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013514/000004.jpg?itok=WU1J8AEl",
            "caption": "Mediastinal window demonstating that all these nodules were cysts."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013514/000005.jpg?itok=1Qc5nr-b",
            "caption": "Mediastinal window demonstating that all these nodules were cysts."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013514/000006.jpg?itok=Atg62kRh",
            "caption": "Mediastinal window demonstating that all these nodules were cysts."
          },
          {
            "number": "Figure 2e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013514/000007.jpg?itok=ILFRwtGk",
            "caption": "Mediastinal window demonstating that all these nodules were cysts."
          },
          {
            "number": "Figure 2f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013514/000008.jpg?itok=F1C2Bp5I",
            "caption": "Mediastinal window demonstating that all these nodules were cysts."
          },
          {
            "number": "Figure 2g",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013514/000009.jpg?itok=7Y8bkd5e",
            "caption": "Mediastinal window demonstating that all these nodules were cysts."
          },
          {
            "number": "Figure 2h",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013514/000010.jpg?itok=S-BHuY0h",
            "caption": "Mediastinal window demonstating that all these nodules were cysts."
          },
          {
            "number": "Figure 2i",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013514/000011.jpg?itok=qLDE-mkO",
            "caption": "Mediastinal window demonstating that all these nodules were cysts."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013514/000014.jpg?itok=njqoLUyR",
            "caption": "Lung window: multiple nodular lesions, various in diameter and located predominantly in the right lung."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013514/000015.jpg?itok=WbnTx9hO",
            "caption": "Lung window: multiple nodular lesions, various in diameter and located predominantly in the right lung."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013514/000016.jpg?itok=a8nOaPUG",
            "caption": "Lung window: intracystic serpentine structure (in the left upper lobe) representing collapsed membranes (serpent sign)."
          },
          {
            "number": "Figure 3d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013514/000017.jpg?itok=WIIHo9G4",
            "caption": "Lung window: multiple nodular lesions, various in diameter and located predominantly in the right lung."
          },
          {
            "number": "Figure 3e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013514/000018.jpg?itok=kT7ItSTZ",
            "caption": "Lung window: multiple nodular lesions, various in diameter and located predominantly in the right lung."
          },
          {
            "number": "Figure 3f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013514/000019.jpg?itok=old5qvja",
            "caption": "Lung window: multiple nodular lesions, various in diameter and located predominantly in the right lung."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013514/000020.jpg?itok=B0xm0yMC",
            "caption": "Coronal reformations:\nmultiple nodular lesions, various in diameter and located predominantly in the right lung."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013514/000021.jpg?itok=MvhypKDe",
            "caption": "Coronal reformations:\nmultiple nodular lesions, various in diameter and located predominantly in the right lung."
          },
          {
            "number": "Figure 4c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013514/000022.jpg?itok=9oOft4Ht",
            "caption": "Coronal reformations:\nmultiple nodular lesions, various in diameter and located predominantly in the right lung."
          },
          {
            "number": "Figure 4d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013514/000023.jpg?itok=W-Qju5pu",
            "caption": "Coronal reformations: multiple nodular lesions, various in diameter and located predominantly in the right lung."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/13514",
    "time": "05.05.2016"
  },
  "13544": {
    "case_id": 13544,
    "title": "Boerhaave syndrome \u2013 spontaneous oesophageal perforation",
    "section": "Chest imaging",
    "age": "70",
    "gender": "male",
    "diagnosis": "Spontaneous oesophageal rupture",
    "history": "Sudden clinical deterioration in intensive care unit patient with longstanding pneumonia. The patient had severe chest pain. Lab tests showed signs of infection. Normal ECG. No abdominal pain or vomiting.",
    "image_finding": "A contrast-enhanced CT of the chest, abdomen, and pelvis was performed (Fig. 1-2). The scan showed an oesophageal lesion with large pneumomediastinum. A large fluid collection with air fluid level was seen in the mediastinum (Fig. 1). Bilateral pleural fluid collections with slight enhancement (empyema) were also present. The pleural fluid collections were communicating with the mediastinal fluid, suggestive of mediastinal abscess and bilateral empyemas. Air in the pleural cavity (Fig. 2) confirmed communication with the free air in the mediastinum. The abdomen was unremarkable.",
    "discussion": "Spontaneous oesophageal perforation is a rare, but very serious condition. Predisposing factors include gastroesophageal reflux disease, candidiasis, asthma, and cancer. The Boerhaave syndrome refers to oesophageal perforation following vomiting [1]. Spontaneous ruptures are most commonly located in distal third of the oesophagus. This is probably related to relative thin muscle layer in this area combined with little support from adjacent connective tissue. Signs and symptoms of oesophageal rupture include the Mackler triad with vomiting, severe chest pain and subcutaneous emphysema [2]. Other signs and symptoms are abdominal tenderness and epigastric pain. If left untreated the mortality following oesophageal ruptures exceeds 90%. Treatment should be surgical intervention with either closure of the defect or oesophageal resection [3]. Furthermore, fluid collections in the pleura or mediastinum should be drained and antibiotics should be given to the patient. CT is the method of choice for imaging of oesophageal ruptures [4]. In some cases the defect in the oesophageal wall may be detected. Otherwise the main imaging findings are free air in the mediastinum (pneumomediastinum) and fluid collections in the mediastinum and pleural cavities. Oral water soluble contrast media administered before scanning improve detection of oesophageal ruptures. Chest radiography may show pneumomediastinum and pleural fluid. Oesophagus fluoroscopy can also be used to detect ruptures. However, this procedure is not easy to perform in acutely ill patients.In the present case no oesophageal opacification with contrast media was needed to establish the diagnosis as large amounts of free air were seen in the mediastinum surrounding the distal oesophagus. The patient had poor outcome as he died 3 weeks after the perforation occurred. No surgery was performed. The patient had severe comorbidity with chronic obstructive lung disease. Looking beyond spontaneous ruptures, iatrogenic rupture following endoscopy is another important cause of oesophageal rupture [5].In conclusion, spontaneous oesophageal rupture is a rare condition that can be diagnosed with CT.",
    "differential_diagnosis": "Spontaneous, oesophageal, rupture, Iatrogenic, oesophageal, perforation, Empyema",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013544/000001.jpg?itok=hcX7OLY6",
            "caption": "Contrast-enhanced CT of the chest showing pneumomediastinum around the oesophagus. A large fluid collection with air fluid level is seen transversing the mediastinum. The fluid collection communicates with both pleural cavities."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013544/000002.jpg?itok=eRnFLis8",
            "caption": "Contrast-enhanced CT of the chest showing large fluid collections in the pleural cavities. Air is noted in the pleural cavities."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Mediastinum"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/13544",
    "time": "21.06.2016"
  },
  "13550": {
    "case_id": 13550,
    "title": "wing sarcoma of rib",
    "section": "Chest imaging",
    "age": "12",
    "gender": "male",
    "diagnosis": "Ewing sarcoma of rib",
    "history": "A 12-year-old boy from India presented with right-sided chest pain, intermittent fever and cough with expectoration for the past five months. He had no contact history of tuberculosis. His leukocyte count was 12000/mm3 and ESR (Erythrocyte sedimentation rate) was 70mm/hr at the time of examination.",
    "image_finding": "He was initially seen by a general practitioner who started him with intravenous antibiotics and anti-tubercular therapy suspecting it to be a case of tubercular empyema as it is endemic in India. Chest radiograph showed opacified right hemithorax and rib destruction was not obvious at that time. There was no improvement in the patient's condition after a month of treatment and the patient was referred to our hospital for a CECT thorax.Noncontrast CT scan showed a large heterogeneous soft tissue mass with calcific foci occupying almost the whole right hemithorax associated with pleural effusion. There was lytic destruction of right 3rd rib with bone expansion without any significant periosteal reaction (Fig. 2, 3). The lesion was noted extending to the mediastinum with mediastinal shift to the left. It was abutting the right lateral chest wall without any extrathoracic extension. The mass lesion showed heterogeneous enhancement on contrast-enhanced CT (Fig. 4). Histopathological examination of the mass revealed Ewing sarcoma.",
    "discussion": "Ewing sarcoma (ES) is named after James Stephen Ewing, American pathologist (1866-1943), which he described as diffuse endothelioma or endothelial myeloma. It belongs to the Ewing sarcoma family of tumours (ESFT), which are small round blue cell tumours sharing common microscopic appearances and karyotyping abnormality [non-random t(11;22)(q24;q12) chromosome rearrangement resulting in formation of EWS-ETS fusion gene] [1, 2, 3].Approximately 10% of all primary malignant bone tumours are Ewing sarcomas [4]. ES is the second most common primary malignant tumour of the bone after osteosarcoma in children and adolescents [3]. Ewing tumour is the most common cause of a malignant chest wall mass in children. The typical patient with Ewing sarcoma, notwithstanding the site of origin, presents between 10 to 25 years of age [2, 3, 4]. The male-to-female ratio is 2:1 for patients with primary Ewing sarcoma of the rib [4]. Most common sites affected are femur (21%), ilium (12%\u2013 13%), tibia (8%\u201311%), humerus (10%), fibula (7%\u20139%), ribs (8%), and sacrum (6%). In long bones the most affected site is metadiaphysis (44%), followed by middiaphysis (33%) and metaphysis (15%) [2].Primary Ewing tumour of the rib usually presents with a clinical history of chest pain sometimes associated with a palpable chest wall mass .The rib lesions may show predominantly lytic (82%), mixed lytic sclerotic (9%) or sclerotic (9%) patterns [4, 5]. Thirty five percent of the affected ribs show an \u201cexpanded\u201d contour. The lateral portion of the rib is most commonly affected [4]. Periosteal reaction in rib lesions is relatively insignificant, as compared with other bones involved by Ewing tumour. Ewing sarcoma of the rib penetrates the bone cortex rapidly with resultant formation of a soft tissue mass. The intrathoracic component is larger than the extrathoracic component and intraosseous involvement. The intrathoracic component sometimes obscures subtle bone changes on chest radiograph and can be mistaken for empyema when fever and pleural effusion are present. Computed tomography simplifies the diagnosis in such cases and can show precise extent, relationship to the adjacent structures, intraspinal extension and metastatic spread to the lungs and mediastinal lymph nodes [2, 4, 5, 6]. Treatment includes a combination of neoadjuvant chemotherapy followed by en bloc resection of rib and radiotherapy. The five year disease-free survival rate is now approximately 75% [2, 5].TEACHING POINTWhenever a young patient presents with pleural effusion, especially in tuberculosis endemic countries like India, it is worthwhile to perform histopathological examination before starting the patient on antituberculosis treatment.",
    "differential_diagnosis": "Ewing, sarcoma, of, rib, Osteosarcoma, Chondrosarcoma, Tuberculous, empyema, with, chest, wall, involvement, Thoracic, actinomycosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013550/000009.jpg?itok=51SSj2Ff",
            "caption": "Right third rib destruction (posterior and lateral segment)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013550/000030.jpg?itok=OgLlo68D",
            "caption": "Note the heterogeneous enhancement of  the mass (m) with mediastinal extension."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013550/000019.jpg?itok=0s23vlvc",
            "caption": "Note the heterogeneous enhancement of the mass with mediastinal extension."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013550/000031.jpg?itok=xMg_KFOh",
            "caption": "Right pleural effusion (*)"
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013550/000021.jpg?itok=qtA0p5G2",
            "caption": "Coronal image showing a large heterogenously enhancing mass occupying almost the whole right hemithorax."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013550/000024.jpg?itok=SbW6O4qw",
            "caption": "Scanogram shows opacified right hemithorax with tracheal shift to left (long arrow) and destruction of right third rib (short arrow)."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013550/000025.jpg?itok=29nxRC0O",
            "caption": "Lytic bone destruction of right third rib (yellow arrow) with large heterogenous intrathoracic mass causing mediastinal shift to lthe eft (red arrow)."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013550/000026.jpg?itok=u3-dh9yr",
            "caption": "Rib is expanded with cortical breach of inner margin.\n \nOuter cortex is normal (arrow) without any extrathoracic extension."
          },
          {
            "number": "Figure 4c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013550/000027.jpg?itok=DzRBx0tT",
            "caption": "Note the calcific focus (arrow) within the mass."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013550/000028.jpg?itok=DBq-KY_n",
            "caption": "Right third rib expansion and destruction involving the posterior segment (arrow)."
          },
          {
            "number": "Figure 5b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013550/000029.jpg?itok=833xNN5I",
            "caption": "Destruction of lateral segment of right third rib (arrow). Outer cortex is apparently intact without any extrathoracic soft tissue component."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Bones",
      "Thoracic wall",
      "Thorax"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/13550",
    "time": "22.04.2016"
  },
  "13554": {
    "case_id": 13554,
    "title": "Atypical manifestations of sarcoidosis: A case report",
    "section": "Chest imaging",
    "age": "61",
    "gender": "female",
    "diagnosis": "Sarcoidosis",
    "history": "We are reporting a case of a 61-year-old female patient who presented with weight loss and fatigue for 6 months. She had palpable cervical nodes.",
    "image_finding": "She underwent PET-CT on 26-01-2016 which documented metabolically active extensive pulmonary pleural nodularity with an avid mass in the left upper lobe. There were supraclavicular, mediastinal, paraoesophageal and upper abdominal lymph nodes as well.Based upon these findings she underwent CT guided biopsy of left apical lung mass.",
    "discussion": "Sarcoidosis is a multisystem inflammatory disease which is characterized by chronic non-granulomatous inflammation. The most common sites of involvement are lungs and mediastinal lymph nodes. The most common sites of lymphadenopathy are mediastinal lymph nodes with symmetrical involvement of the right paratracheal and bilateral hilar nodes. It may involve lymph nodes at atypical sites which could be mistaken for other potential causes of lymph node enlargement like lymphoma and tuberculosis. Pulmonary involvement is seen as nodules with perilymphatic distribution. Ill-defined pulmonary opacities are less common [1, 2]. Atypical pulmonary involvement may mimic primary lung cancer. Gold standard for diagnosis is histopathology.Our case had both typical and atypical imaging features [Fig. 1, 2, 3]. Later it was histopathologically proven as sarcoidosis. There was non-caseating granulomatous inflammation without necrosis. Ziehl-Neelsen and GMS stains and cultures for mycobacteria were negative. She was given steroid treatment. Post biopsy scans documented complete metabolic response with partial morphologic response [Fig. 4, 5, 6].FDG-PET CT has an emerging role in the evaluation of sarcoidosis as there is increased FDG uptake by inflammatory cells. Simultaneous acquisition of morphological and functional data can identify occult disease sites which are not detected by other imaging techniques. Similarly, FDG PET-CT aids in monitoring treatment response. This is especially useful when the disease remains morphologically stable. In these cases response can still be assessed based on FDG uptake. FDG PET-CT is especially useful to assess active and fibrotic components of the disease [3].In conclusion, sarcoidosis should always be kept in the differential list in patients having mediastinal lymph adenopathy with pulmonary involvement even with atypical sites of nodal involvement.",
    "differential_diagnosis": "Sarcoidosis, Lung, cancer, with, metastatic, lymph, adenopathy, Lymphoma, Tuberculosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013554/000004.png?itok=iYh9e7yu",
            "caption": "Previously noted significantly avid mediastinal lymphadenopathy has reduced in size, without any significant FDG uptake on current examination."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013554/000005.png?itok=gq872gNd",
            "caption": "Left supraclavicular lymph node (A, B) and bulky periportal lymph adenopathy (C, D) has also significantly decreased without significant FDG uptake within residual subcentimetre lymph nodes."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013554/000006.png?itok=aSAYa_-V",
            "caption": "Previously noted spiculated opacity in left upper lobe has significantly reduced in size, this currently has a thickness of around 11 mm as compared to 21 mm, with completely resolved metabolic uptake within this mass-like lesion."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013554/000007.png?itok=z8u0GLtV",
            "caption": "Atypical metabolically active left supraclavicular (A, B) and portal hepatis lymph nodes (C, D)."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013554/000008.png?itok=jbTm4xtx",
            "caption": "Typical sites of lymphadenopathy involving mediastinal and bilateral hilar lymph nodes."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013554/000009.png?itok=ELY_yVHh",
            "caption": "Metabolically active spiculated opacity in the left upper lobe posterior segment with multiple pulmonary nodules."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lymph nodes",
      "Abdomen",
      "Lung"
    ],
    "imaging_technique": [
      "PET-CT"
    ],
    "link": "https://www.eurorad.org/case/13554",
    "time": "16.06.2016"
  },
  "13576": {
    "case_id": 13576,
    "title": "Incidentally detected Kartagener&#039;s syndrome",
    "section": "Chest imaging",
    "age": "13",
    "gender": "male",
    "diagnosis": "Kartagener's syndrome",
    "history": "A 13-year-old boy was referred for ultrasonography of the abdomen for abdominal pain. He didn't have any significant medical or surgical history.",
    "image_finding": "Ultrasonography of the abdomen revealed situs inversus. The rest of the scan was normal. However, no cause for abdominal pain was found. Computed tomography of the abdomen and thorax confirmed situs inversus totalis along with features of bronchiectasis in bilateral lower lobes and left middle lobe. The normal pulmonary anatomy was reversed suggesting situs inversus thoracalis with the right lung having two lobes (bi-lobar) and the left lung having three lobes (tri-lobar). Centrilobular nodules with tree-in-bud pattern were noted in bilateral lower lobes, left upper and middle lobes. CT scan of paranasal sinuses revealed mucosal thickening of all sinuses. Semen analysis could not be done due to patient's age.",
    "discussion": "Kartagener\u2019s syndrome (KS) is a subset of primary ciliary dyskinesia (PCD) characterized by the clinical triad of situs inversus, sinusitis and bronchiectasis. This triad was first recognized as a distinct congenital syndrome in 1933 by Manes Kartagener, a Zurich pulmonologist. It is an autosomal recessive disorder. Incidence is about 1 in 30, 000 live births. It accounts for one-tenth of the cases of bronchiectasis and about one-sixth of the cases of situs inversus. About 50% of the people affected with PCD have Kartagener\u2019s syndrome. Male patients with this syndrome have infertility because of immotile spermatozoa. Afzelius (1960) was the first to recognize the relationship between KS and male infertility and attribute it to defective ciliary ultrastructure [1, 2, 3, 4].Ultrastructural defects (electron microscopy) in cilia include 1) complete or partial absence of dynein arms: inner arms, outer arms or both 2) radial spoke defect 3) microtubular transposition. This ultimately leads to impaired ciliary beating and mucociliary clearance [4, 5].The clinical picture includes chronic sinusitis and chronic otitis media, bronchiectasis, infertility in both men and women, increased incidence of ectopic pregnancy in women. The most common respiratory pathogens are Haemophilus influenzae, Streptococcus pneumoniae, Staphylococcus aureus and Pseudomonas. At times patients with KS are diagnosed when they are evaluated for infertility [1, 3, 4].Radiological features include those of situs inversus, bronchiectasis, sinusitis. Bronchiectactic changes are much milder than in cystic fibrosis [6]. In addition CT can demonstrate consolidation, mucocele (impacted mucus in bronchiole), tree-in-bud pattern or centrilobular nodules (due to endobronchial spread of infection), mosaic perfusion, scarring due to recurrent infection. It is important to note that up to 20% of patients with situs inversus can have KS [7]. Since our patient had the triad of situs inversus, sinusitis and bronchiectasis, KS was diagnosed. A confirmation of the diagnosis of PCD relies on electron microscopic examination of nasal and bronchial cilia for ultrastructural defects and abnormal ciliary beating which couldn't be done in our case. Nasal nitric oxide measurement and saccharin test are rapid and reliable screening methods [3].Treatment includes antibiotics, bronchodilators, mucolytics, and chest physiotherapy, influenza and pneumococcal immunisation. Surgical treatment includes placement of tympanostomy tubes, endoscopic sinus surgery, lobectomy and pneumonectomy for localised lung damage with recurrent haemoptysis [1, 3, 4].Although there is no specific treatment, failure to diagnose this may lead to unnecessary repeated admissions, investigations and inappropriate treatment. Late diagnosis with established bronchiectasis worsens the overall prognosis, even with the best of treatment modalities. Hence an early diagnosis is warranted [1, 3].",
    "differential_diagnosis": "Kartagener's, syndrome, Cystic, fibrosis, Young, syndrome",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013576/000001.jpg?itok=52hddV3X",
            "caption": "Cardiac apex, descending aorta on the right side. (dextrocardia)"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013576/000002.jpg?itok=lvRPy_47",
            "caption": "Situs inversus abdominalis: note the total transposition of abdominal viscera: liver, IVC on the left side; spleen, gastric fundus, aorta on the right side (i.e. mirror image of internal organs normal positioning)."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013576/000003.jpg?itok=u5CCVyth",
            "caption": "Situs inversus totalis"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013576/000010.jpg?itok=wVH6rv0c",
            "caption": "Axial CT (mediastinal window): Note right-sided aortic arch (arrow)\n(situs inversus thoracalis)"
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013576/000011.jpg?itok=29guJPk6",
            "caption": "Axial CT (mediastinal window): Descending aorta (AO) on the right and inferior vena cava (IVC) on the left with dextrocardia (situs inversus thoracalis)."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013576/000004.jpg?itok=atrYK-Kb",
            "caption": "Axial CT (lung window) showing left middle lobe minimal bronchiectasis."
          },
          {
            "number": "Figure 3d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013576/000005.jpg?itok=hwVWJ61e",
            "caption": "Axial CT (lung window): Bilateral lower lobe mild bronchiectasis. Cardiac apex pointing to the right."
          },
          {
            "number": "Figure 3e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013576/000006.jpg?itok=fz7_Um4I",
            "caption": "Axial MIP (maximum intensity projection) CT scan showing centrilobular nodules with tree-in-bud pattern in the left upper lobe."
          },
          {
            "number": "Figure 3f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013576/000007.jpg?itok=X4ORvecH",
            "caption": "Axial MIP (maximum intensity projection) CT scan showing centrilobular nodules with tree-in-bud pattern in bilateral lower lobes."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013576/000008.jpg?itok=At3_XDr_",
            "caption": "Bilateral maxillary sinuses, inferior turbinates mucosal thickening."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013576/000009.jpg?itok=skk8x3x1",
            "caption": "Bilateral ethmoid sinuses mucosal thickening."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Anatomy",
      "Abdomen",
      "Liver",
      "Arteries / Aorta",
      "Lung",
      "Ear / Nose / Throat"
    ],
    "imaging_technique": [
      "CT",
      "CT-High Resolution",
      "Conventional radiography"
    ],
    "link": "https://www.eurorad.org/case/13576",
    "time": "19.04.2016"
  },
  "13579": {
    "case_id": 13579,
    "title": "Pulmonary sarcoidosis",
    "section": "Chest imaging",
    "age": "52",
    "gender": "female",
    "diagnosis": "Sarcoidosis",
    "history": "A 52-year-old female patient presented with breathlessness on exertion for 3 months. She also complained of dry cough for a month which did not respond to antibiotics. There was no history of haemoptysis, cough with expectoration or chest pain.",
    "image_finding": "Radiograph of chest (Fig. 1) revealed reticulo-nodular pattern with infiltrates in right perihilar region and left mid zone. Few nodular opacities are also seen in left upper zone and adjacent to left costo-phrenic angle. Further evaluation with plain and post-contrast enhanced HRCT scan of the chest was performed.The findings included:- Multiple enlarged, homogeneous mildly enhancing nodes in the mediastinum in pretracheal, right paratracheal, prevascular, bilateral hilar and subcarinal locations (Fig. 2).- Non-enhancing, ill-defined soft tissue masses in bilateral perihilar areas extending to the peripheral lung (Fig. 3).- Diffuse thickening of peribronchovascular interstitium along with sharp well-defined nodules (Fig. 5, 7).- Multiple well-defined nodules in subpleural, fissural location and along the interlobar interstitium (Fig. 5, 6, 7).- Sarcoid cluster - consisting of cluster of multiple micro nodules was also seen in the right lower lobe. (Fig. 8)- Multiple hypoenhancing lesions in both lobes of the liver (Fig. 4).",
    "discussion": "- Sarcoidosis is a chronic, immune-mediated multi-system inflammatory disorder of unknown aetiology characterized by non-caseous epitheloid granulomas most commonly involving the lung and mediastinal/hilar lymph nodes which thus accounts for most of the mortality and morbidity associated with this condition [1].- The patient may be asymptomatic and sarcoidosis may be suspected incidentally on routine chest radiography when bilateral hilar and right paratracheal fullness due to nodal enlargement is noted.Patients may present with respiratory complaints such as cough, dyspnoea, chest pain, haemoptysis or non-specific symptoms like fever, fatigue, weight loss.- The most common finding in sarcoidosis is that of enlarged intrathoracic lymphadenopathy and it typically manifests as bilateral symmetric hilar adenopathy with right paratracheal adenopathy; occurring in almost 85% of patients [2]. The nodes show homogeneous enhancement without necrosis differentiating it from tuberculosis/malignancy. Occasionally calcification may be seen in these nodes which may be amorphous, punctate or egg-shell type [2].- High-resolution CT (HRCT) is the imaging modality of choice for detecting minute parenchymal details in pulmonary sarcoidosis. It helps in distinguishing active inflammatory changes of nodules, ground glass and alveolar opacities from honeycomb-like cysts, bullae, broad and coarse septal bands, architectural distortion, volume loss, and traction bronchiectasis which indicate irreversible fibrosis in patients with sarcoidosis [1]. - CT features of pulmonary sarcoidosis include interlobular septal thickening, reticulonodular infiltrates and mass-like consolidations. The non-caseating granulomas seen in pulmonary sarcoidosis have a propensity for forming along lymphatics of interstitial tissues in peribronchial, perivascular, subpleural spaces and along fissures. The nodules are sharply defined, small and show upper and middle lobe predominance. Nodular irregular thickening of peribronchovascular interstitium is also seen. Sarcoid cluster is a cluster of multiple micronodules seen along lymphatics in peripheral lung.Fibrotic changes are characterised by architectural distortion, volume loss, tractional bronchiectasis, coalescent fibrotic perihilar or parenchymal masses. Fibrocystic changes of bullae, honeycomb cysts indicate advanced stage of sarcoidosis.- The Siltzbach classification system (Radiological classification of Intrathorvacic changes) [3]stage 0, normal appearance at chest radiographystage I lymphadenopathy onlystage II lymphadenopathy and parenchymal lung diseasestage III parenchymal lung disease onlystage IV with pulmonary fibrosisDiagnosis is by biopsy from enlarged mediastinal adenopathy or lung lesions which shows non-caseating granulomas. Angiotensin converting enzyme (ACE) is elevated and correlates with disease activity. The CD4:CD8 ratio in the blood serum is commonly decreased [2]. Treatment is with corticosteroids.",
    "differential_diagnosis": "Sarcoidosis, Tuberculosis, Silicosis, Pneumoconiosis, Lymphoma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013579/000001.png?itok=UMkCPZWS",
            "caption": "Reticulo-nodular pattern is seen in right perihilar region and left mid zone (blue arrows). \nFew nodular opacities are also seen in left upper zone and adjacent to left costo-phrenic angle (circle)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013579/000002.png?itok=qiyVFkt2",
            "caption": "Multiple enlarged homogeneous mildly  enhancing mediastinal lymph nodes are seen in left paratracheal (green arrows) and prevascular regions (blue arrows)."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013579/000003.png?itok=OMiMse18",
            "caption": "Multiple enlarged homogeneous mildly  enhancing \nMediastinal lymph nodes are seen in left paratracheal (green arrows) region."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013579/000004.png?itok=VM9TPs6R",
            "caption": "Multiple enlarged homogeneous mildly  enhancing mediastinal lymph nodes are seen in subcarinal (orange arrow) and bilateral hilar regions (yellow arrows). Note right perihilar mass radiating to periphery (star)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013579/000005.png?itok=enZgRDvM",
            "caption": "Conglomerate bilateral perihilar masses are seen extending along peribronchovascular interstitium radiating to periphery (star).\nNote enlarged subcarinal (orange arrow) and bilateral hilar regions (yellow arrows)."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013579/000006.png?itok=dOeV_scy",
            "caption": "Conglomerate bilateral perihilar masses are seen extending along peribronchovascular interstitium radiating to periphery (star).\nNote enlarged right paratracheal (green arrows), subcarinal (orange arrow) and bilateral hilar regions (yellow arrows)"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013579/000007.png?itok=aByC_tnk",
            "caption": "Multiple small 5-7 mm sized hypoenhancing lesions are seen in right lobe of liver (red arrows). No spleen lesions were seen."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013579/000008.png?itok=13dWW1ny",
            "caption": "Multiple small 5-7 mm sized hypoenhancing lesions are seen in right lobe of liver (red arrows). No spleen lesions were seen."
          },
          {
            "number": "Figure 4c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013579/000009.png?itok=wX9Logkx",
            "caption": "Multiple small 5-7 mm sized hypoenhancing lesions are seen in right lobe of liver (red arrows). No spleen lesions were seen."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013579/000010.png?itok=-528zHVz",
            "caption": "Conglomerate perihilar masses (star) extending along  the peribronchovascular interstitium. Note the bronchi traversing through these masses without their obliteration. Mulitple well-defined nodules are seen along the peribronchovascular interstitium (green arrows) and subpleural areas (blue arrow)."
          },
          {
            "number": "Figure 5b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013579/000011.png?itok=Y1fKNiGj",
            "caption": "Mulitple well-defined nodules are seen along the peribronchovascular interstitium (green arrows) and subpleural areas (blue arrow)."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013579/000012.png?itok=x0Ij_GZz",
            "caption": "Multiple well-defined, small, rounded nodules are seen predominantly in the upper lobes.\nThe nodules are seen along the fissures (yellow arrow), in subpleural location (blue arrow) suggestive of perilymphatic distribution."
          },
          {
            "number": "Figure 6b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013579/000013.png?itok=U_SyWC8g",
            "caption": "Multiple well defined, small, rounded nodules are seen predominantly in the upper lobes.\nThe nodules are seen along the fissures (yellow arrow), in subpleural location (blue arrow) suggestive of perilymphatic distribution."
          }
        ]
      },
      {
        "number": "Figure 7",
        "subfigures": [
          {
            "number": "Figure 7a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013579/000014.png?itok=abinhMiC",
            "caption": "Multiple well-defined, small, rounded nodules are seen predominantly in the upper and middle lobes. The nodules are seen in subpleural location (blue arrows) and peribronchovascular interstitum (green arrows) suggestive of perilymphatic distribution."
          },
          {
            "number": "Figure 7b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013579/000015.png?itok=A2NooPev",
            "caption": "Multiple nodules are seen in subpleural location (blue arrows) and peribronchovascular interstitum (green arrows) suggestive of perilymphatic distribution. Also note large bulla in apicoposterior segment of left upper lobe."
          },
          {
            "number": "Figure 7c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013579/000016.png?itok=lID_7Jz4",
            "caption": "Multiple well-defined, sharply defined, small, rounded nodules are seen predominantly in the upper and middle lobes. The nodules are seen along the fissures (yellow arrow)."
          }
        ]
      },
      {
        "number": "Figure 8",
        "subfigures": [
          {
            "number": "Figure 8",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013579/000017.png?itok=156OzedB",
            "caption": "Sarcoid cluster consists of  a cluster of multiple micronodules seen in the peripheral lung (blue arrow)."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/13579",
    "time": "12.05.2016"
  },
  "13589": {
    "case_id": 13589,
    "title": "A case of malignant solitary fibrous tumour of the mediastinal ple",
    "section": "Chest imaging",
    "age": "52",
    "gender": "male",
    "diagnosis": "Malignant solitary fibrous tumour of mediastinal pleura",
    "history": "A 52-year-old male patient complained of dysphagia and mild chest pain for 8 months. Blood laboratory tests were unremarkable. Since the oesophagogastroscopy didn\u2019t reveal any mucosal abnormalities the patient underwent chest computed tomography (CT).",
    "image_finding": "Chest CT revealed a well circumscribed, round, mild heterogeneous enhancing mass located in the middle part of the mediastinum (Fig. 1, 2), with left dislocation of the oesophagus (Fig. 2c). The lesion presented a peripheral calcification (Fig. 1e, 1f, 2e). Following the diagnostic hypothesis of oesophageal GIST the patient underwent surgical resection of the mass: right posterolateral thoracotomy revealed a large encapsulated mass measuring 10 x 9 cm (Fig. 3) with a pedicle of connection with the mediastinal pleura. Histological images (not available to view) showed spindle cells within a background of collagen stroma; histological and immunohistochemical analysis revealed positive staining for CD34 and a high mitotic rate (5/10 HPF) with nuclear atypia, suggesting the diagnosis of malignant solitary fibrous tumour of the pleura.",
    "discussion": "Solitary fibrous tumours (SFT) are rare neoplasms of mesenchymal origin and they may be benign or malignant: about the 15\u201320% of SFT are malignant, and even benign SFT present indeterminate malignant potential [1, 2]. SFT generally occur during the fifth and sixth decades of life, without significant sex predilection. In most of cases SFT arise from the pleura and may be sessile or pedunculated [1]; extra pleural sites of involvement have been reported: intrathoracic, i.e. lung, mediastinum and pericardium, and extrathoracic, i.e. spine, kidney and liver. SFT are often asymptomatic or manifest with thoracic pain, cough and dyspnoea [3]. SFT are often incidentally found in radiologic imaging performed for unrelated conditions. The morphologic characteristics of these lesions on CT are not specific and depend on tumour size; small SFT appear homogeneous, well-defined, showing an obtuse angle with the pleural surface [4]. Larger lesions are heterogeneous, may present calcification and may not exhibit CT features suggestive of belonging to the pleura [4]. SFT enhance homogeneously or heterogeneously after intravenous injection of contrast medium, depending on their size [4]. Normally pleural SFT are located peripherally, adjacent to the chest wall or within a fissure, with only few cases of mediastinal pleural SFT reported in the literature [3]. In our case the atypical mediastinal pleural origin and the large size of the tumour, together with the patient\u2019s dysphagia caused the radiological misdiagnosis of oesophageal GIST.At MRI, SFT are normally isointense on T1-weighted images and show a variable intensity of signal on T2-weighted images, a finding that has been described as a black-and-white-mixed pattern; on T2-weighted images the large lesions may reveal areas of necrosis and haemorrhage that show high signal intensity [1].Surgical resection is the treatment of choice of SFT [5]. Moreover, due to the non-specific imaging characteristics of SFT, histological and immunohistochemical analysis are essential for the definitive diagnosis. In fact, the 70\u201380% of SFT stains for CD34 [1].The malignant potential of SFT is defined by imaging features, pathologic findings and immunohistochemical analysis [5]. The imaging findings suggestive of malignancy are: a diameter greater than 10 cm, interval increase in size, infiltration of adjacent structures, extensive necrosis and haemorrhage and pleural effusion [1]. In the setting of pathologic findings, hypercellularity, pleomorphism, necrosis and a mitotic index of >4/HPF are suggestive of malignancy. Our case revealed a high mitotic index (5/HPF), which is the most important pathologic parameter suggestive of malignancy [5].",
    "differential_diagnosis": "Malignant, solitary, fibrous, tumour, of, mediastinal, pleura, Bronchogenic, cyst, Oesophageal, GIST/leiomyoma, Malignant, pleural, mesothelioma, Neurogenic, tumour",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013589/000001.jpg?itok=ueDbGYOL",
            "caption": "Axial chest CT image shows a well-circumscribed round enhancing solid mass located in the middle part of the mediastinum."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013589/000002.jpg?itok=mgPcUU4s",
            "caption": "Axial chest CT image shows a well-circumscribed round enhancing solid mass located in the middle part of the mediastinum."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013589/000003.jpg?itok=qDPQpqKG",
            "caption": "Axial chest CT image shows a well-circumscribed round enhancing solid mass located in the middle part of the mediastinum."
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013589/000004.jpg?itok=5R0NhCt0",
            "caption": "Axial chest CT image shows a well-circumscribed round enhancing solid mass located in the middle part of the mediastinum."
          },
          {
            "number": "Figure 1e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013589/000009.jpg?itok=ln7-mg7P",
            "caption": "Axial chest CT image shows a well-circumscribed round enhancing solid mass located in the middle part of the mediastinum, with eccentric calcification (arrow)."
          },
          {
            "number": "Figure 1f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013589/000006.jpg?itok=WLCm27Aw",
            "caption": "Axial chest CT image shows a well-circumscribed round enhancing solid mass located in the middle part of the mediastinum, with eccentric calcification (arrow)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013589/000010.jpg?itok=gUiAVlra",
            "caption": "Coronal chest CT image shows a well-circumscribed round mild heterogeneous enhancing solid mass located in the middle part of the mediastinum."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013589/000011.jpg?itok=mJtJNm26",
            "caption": "Coronal chest CT image shows a well-circumscribed round mild heterogeneous enhancing solid mass located in the middle part of the mediastinum."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013589/000012.jpg?itok=pIL3fbGS",
            "caption": "Coronal chest CT image shows a well-circumscribed round mild heterogeneous enhancing solid mass located in the middle part of the mediastinum, with left dislocation of the oesophagus (arrows)."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013589/000013.jpg?itok=KBZWCsf9",
            "caption": "Coronal chest CT image shows a well-circumscribed round mild heterogeneous enhancing solid mass located in the middle part of the mediastinum."
          },
          {
            "number": "Figure 2e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013589/000014.jpg?itok=D5s-F-IR",
            "caption": "Coronal chest CT image shows a well-circumscribed round enhancing solid mass located in the middle part of the mediastinum, with eccentric calcification (arrow)."
          },
          {
            "number": "Figure 2f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013589/000015.jpg?itok=M_SITpG6",
            "caption": "Coronal chest CT image shows a well-circumscribed round mild heterogeneous enhancing solid mass located in the middle part of the mediastinum."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013589/000016.jpg?itok=-AK2gFZy",
            "caption": "After surgical removal, the well-circumscribed, encapsulated and round appearence of the tumour is confirmed."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013589/000017.jpg?itok=5GsEYKQ9",
            "caption": "After surgical removal, the well-circumscribed, encapsulated and round appearence of the tumour is confirmed."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Mediastinum"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/13589",
    "time": "19.04.2016"
  },
  "13619": {
    "case_id": 13619,
    "title": "Classic simple silicosis with bacterial bronchopneumoni",
    "section": "Chest imaging",
    "age": "55",
    "gender": "male",
    "diagnosis": "Classic simple silicosis with bacterial bronchopneumonia",
    "history": "A 55-year-old male patient who had worked as a stonemason for 18 years was admitted to the emergency department for acute onset of dyspnoea and fever (39\u00b0C). Blood tests revealed an elevation of CPR and leucocytosis. Following the radiographic suspicion of diffuse interstitial lung disease, chest computed tomography (CT) was performed.",
    "image_finding": "Chest CT showed diffuse multiple small lung nodules with perilymphatic distribution, predominantly located in the upper lobes, and multiple patchy confluent areas of ground glass and airspace consolidations of the right lower lobe, with associated thickening of the interlobular septa (Fig. 1, 2, 3). Mediastinal window revealed enlarged mediastinal and hilar lymph nodes with eccentric calcifications (Fig. 4). The tuberculin skin test was negative. According with the patient\u2019s occupational anamnesis the diagnostic suspicion of silicosis with associated bronchopneumonia was expressed. Bronchoalveolar lavage (BAL) revealed positive culture for Streptococcus pneumoniae, excluded tuberculosis and showed alveolar macrophages containing dust particles, typical of silicosis. Antibiotic (amoxicillin) therapy was performed, with good clinical outcome. Follow-up chest CT, performed after 20 days, showed a significant reduction of parenchymal consolidations and of thickening of interlobular septa and confirmed the multiple small lung nodules and the enlarged mediastinal and hilar lymph nodes, suggestive of classic simple silicosis (Fig. 5).",
    "discussion": "Silicosis is an occupational respiratory disease caused by inhalation of crystalline silica that determines a fibrotic response in the lung parenchyma. Occupations associated are mining, quarrying, and tunnelling [1]. The risk of developing silicosis is related to the period of exposure to crystalline silica and genetic factors, and removing the source of silica exposure is important to prevent the disease\u2019s progression [1, 2].Silicosis occurs in three forms, acute, which is progressive and may cause respiratory failure, classic, which could be asymptomatic or manifest with cough and dyspnoea, and accelerated, characterized by a rapid progression [1].The diagnosis of silicosis is based on occupational anamnesis and radiological findings.Although chest radiograph is considered the most important diagnostic tool, CT is more sensitive and specific in detection of parenchymal abnormalities [3]. In acute silicosis CT shows perihilar bilateral centrilobular nodular ground-glass opacities and multifocal patchy consolidation with occasional \u201ccrazy paving\u201d pattern [4].Classic silicosis is classified on the basis of radiological findings as simple or complicated.Simple silicosis is characterized on CT by multiple small nodules, sometimes calcified, with perilymphatic distribution and main involvement of upper lobes. Hilar and mediastinal lymph node enlargement, usually with peripheral calcifications (\u201ceggshell pattern\u201d) is typical. Complicated silicosis presents focal soft-tissue masses, with irregular margins, indicative of fibrosis, surrounded by areas of emphysematous changes. Because of the mass-like appearance, a problem of differential diagnosis with lung cancer may occur; the imaging features suggesting lung cancer are unilaterality of the mass, absence of calcification and rapid growth rate, while complicated silicosis reveals bilateral and symmetrical masses, sometimes with calcifications, and presents slow progression [5].Accelerated silicosis shows radiological characteristics of both acute and classic silicosis [4].Patients with silicosis have an increased risk of developing pulmonary tuberculosis and other mycobacteria-related diseases, maybe because of modified immune response determined by silica. The diagnosis of superimposed tuberculosis could be difficult in the early stage of the infection, because of its radiological pattern very similar to silicosis. In case of clinical suspicion in a patient with known silicosis, a sputum culture and chest radiograph must be performed, and if both investigations don\u2019t rule out the infection, bronchoscopy with BAL and eventual biopsy are necessary. CT may be useful in the diagnosis of silicotuberculosis, showing centrilobular nodules with a \"tree in bud\" pattern and a rapid progression of parenchymal abnormalities [4, 6].",
    "differential_diagnosis": "Classic, simple, silicosis, with, bacterial, bronchopneumonia, Sarcoidosis, Tuberculosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013619/000001.jpg?itok=VD_XDDxT",
            "caption": "Chest CT axial image shows diffuse multiple small perilymphatic lung nodules, predominantly located in the upper lobes."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013619/000002.jpg?itok=-Up1DPSM",
            "caption": "Chest CT axial image shows diffuse multiple small perilymphatic lung nodules, predominantly located in the upper lobes."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013619/000003.jpg?itok=XSygVM6-",
            "caption": "Chest CT axial image shows diffuse multiple small perilymphatic lung nodules, predominantly located in the upper lobes."
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013619/000004.jpg?itok=Q8Y1OUzU",
            "caption": "Chest CT axial image shows multiple patchy confluent areas of ground glass and airspace consolidation of the right lower lobe, with associated thickening of the interlobular septa."
          },
          {
            "number": "Figure 1e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013619/000005.jpg?itok=LeKwmWG_",
            "caption": "Chest CT axial image shows multiple patchy confluent areas of ground glass and airspace consolidation of the right lower lobe, with associated thickening of the interlobular septa."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013619/000006.png?itok=2_t49tWi",
            "caption": "Coronal MIP image shows the bilateral multiple perilymphatic nodules and the consolidation of the right lower lobe."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013619/000007.png?itok=eXfiwXx6",
            "caption": "Coronal MIP image shows the bilateral multiple perilymphatic nodules and the consolidation of the right lower lobe with associated thickening of interlobular septa."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013619/000008.png?itok=pa_v0_L2",
            "caption": "Coronal MIP image shows the enlarged mediastinal and hilar lymph nodes with peripheral calcifications."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013619/000009.png?itok=hNfCFaeW",
            "caption": "Coronal MIP image shows the enlarged mediastinal and hilar lymph nodes with peripheral calcifications."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013619/000010.png?itok=wDCeGPwQ",
            "caption": "Coronal MIP image shows the enlarged mediastinal and hilar lymph nodes with peripheral calcifications."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013619/000011.png?itok=4znueCHB",
            "caption": "Coronal MIP image shows a significant reduction of parenchymal consolidations and confirms the multiple bilateral small nodules."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013619/000012.png?itok=ZXy5u2Jd",
            "caption": "Coronal MIP image shows a significant reduction of parenchymal consolidations and confirms the multiple bilateral small nodules."
          },
          {
            "number": "Figure 4c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013619/000013.png?itok=gwWaLOUn",
            "caption": "Coronal MIP image confirms the enlarged mediastinal and hilar lymph nodes."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013619/000014.png?itok=vi5eLI1o",
            "caption": "Axial MIP image reveals multiple small nodules located also in the spleural surface, showing perilymphatic distribution."
          },
          {
            "number": "Figure 5b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013619/000015.png?itok=zyLCdH0C",
            "caption": "Axial MIP image reveals multiple small nodules located also in the spleural surface, showing perilymphatic distribution."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/13619",
    "time": "05.05.2016"
  },
  "13653": {
    "case_id": 13653,
    "title": "Mounier-Kuhn syndrome",
    "section": "Chest imaging",
    "age": "60",
    "gender": "female",
    "diagnosis": "Mounier-Kuhn syndrome",
    "history": "A 60-year-old female patient presented with symptoms of cough and breathlessness of three days duration. A provisional diagnosis of asthma of several years' duration followed. She had never been a smoker. Examination noted normal vital signs and inspiratory crepitations in the right interscapular area. The results of blood analysis were within normal limits.",
    "image_finding": "A chest radiograph (Fig. 1) and a helical CT scan were performed which showed tracheomegaly. Computed tomography revealed abnormally dilated trachea and bilateral main stem bronchus, with a transversal diameter of trachea of 32 mm, the diameter of the right and left main bronchus being 20 mm and 18 mm respectively. There were irregularity of the tracheal wall, multiple diverticulae/sacculations (diverticula were evident mainly in the posterior tracheal wall) with a few cystic bronchiectasis in the right lower lobe, some of which contained mucoid material (Fig. 2, 3). The coronal reformatted images and the post processed thick minimal intensity images (MinIP) were particularly useful in demonstrating dilated tracheobronchial tree with absence of the cavities at the lung periphery (Fig. 4). Flexible bronchoscopy noted dilated trachea and main bronchi with few tracheal protrusions/diverticula and generalised collapse on expiration with a dilated thin-walled bronchial tree.",
    "discussion": "Tracheobronchomegaly was first described by Mounier-Kuhn in 1932. Its cause is unknown although it is caused by atrophy of the elastic and smooth-muscle fibres of the tracheal and main bronchial walls with resulting defective mucociliary clearance leading to recurrent infection and bronchiectasis. It is more common in middle age men (40-50 years), especially African Americans. Most of the cases are sporadic, but familial cases have been described with a possible recessive inheritance. Secondary tracheobronchomegaly may also occur as a result of Ehlers-Danlos syndrome, Marfan syndrome, cutis laxa in children, Kenney-Caffe syndrome, connective diseases, severe upper lobe fibrosis as in sarcoidosis, cystic fibrosis and chronic airway inflammation [1-5].The clinical presentations can vary from asymptomatic patients to respiratory failure. The majority of the patients have nonspecific symptoms and are usually diagnosed as having chronic bronchitis or bronchiectasis. Pulmonary function testing may show reduced flow rates, increase in dead space, and increased tidal volume [1, 2, 5].Mounier-Kuhn syndrome (MKS) has 3 subtypes. In type 1, there is a minimal symmetric dilation of the trachea and the main bronchi. In type 2 is more obvious bizarre enlargement which may include sacculations in the major bronchi. Type 3 is characterized by extension of dilation and diverticula to the distal bronchi [1, 3]. Diagnosis is generally made radiographically by chest radiography, however, it can be easily overlooked on radiographs. CT scan remain the mainstay modality for diagnosing the disease. It helps in accurate measurement of tracheobronchial tree and associated diverticulosis (1/3 patients). The diagnosis is made when the transverse diameter of trachea is greater than 3.0 cm and that of right and left main bronchi is more than 2.4 cm and 2.3 cm, respectively. In females, it can be considered to be present when transverse and sagittal diameters of the trachea exceed 21 and 23 mm, respectively, and the diameters of the right and left main bronchi exceed 19.8 and 17.4 mm, respectively. With MinIP images one can get a wholesome idea of tracheobronchial tree. Bronchoscopy is useful to confirm the diagnosis when CT images are not conclusive. On bronchoscopic imaging the trachea and major bronchi distend with deep inspiration and collapse on expiration [1, 3, 4]. There is no specific treatment for MKS. Asymptomatic patients usually require no treatment. Smoking cessation is beneficial. Symptomatic patients can be managed by bronchodilators, antibiotics, and chest physiotherapy and postural drainage. Surgery (resection or stenting) has a minimal role in treatment [1, 4, 5].",
    "differential_diagnosis": "Mounier-Kuhn, syndrome, Recurrent, respiratory, tract, infection, and, bronchiectasis, Williams-Campbell, syndrome, Tracheomalacia",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013653/000001.jpg?itok=PiG_gzTw",
            "caption": "Chest X-ray PA and lateral view showed tracheomegaly (arrows)"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013653/000002.jpg?itok=7oyfI3bv",
            "caption": "Contrast-enhanced transverse CT scan obtained at different levels with mediastinal/lung window setting showed dilated trachea and small diverticula (yellow arrow) and a few cystic bronchiectasis in the right lower lobe (red arrow)"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013653/000003.jpg?itok=MManFRyh",
            "caption": "Coronal and sagittal reformatted images with lung window setting: tracheomegaly with irregularity of the tracheal wall, multiple sacculations and with cystic bronchiectasis (arrow) in the right lower lobe"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013653/000004.jpg?itok=BUJAh_w4",
            "caption": "The post-processed thick minimal intensity images (MinIP) were particularly useful in demonstrating dilatation and irregularity of tracheobronchial tree with absence of the cavities at the lung periphery."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013653/000005.jpg?itok=Ce0hAYkw",
            "caption": "3D VR coronal reformatted image"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax",
      "Lung"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/13653",
    "time": "06.05.2016"
  },
  "13657": {
    "case_id": 13657,
    "title": "Morgagni hernia containing omental fat: differential diagnosis with prominent epicardial fat p",
    "section": "Chest imaging",
    "age": "50",
    "gender": "male",
    "diagnosis": "Morgagni hernia containing omental fat",
    "history": "A 50-year-old male patient underwent chest CT for the suspicion of a pulmonary nodule detected on chest radiograph. Another finding on lateral chest radiograph was a triangular opacity in the low retrosternal space, suspected to be prominent epicardial fat pad. The patient did not present with any symptoms.",
    "image_finding": "Chest CT (computed tomography) did not show any pulmonary abnormalities. The retrosternal opacity seen on chest radiograph (Fig. 1) corresponded to prominent soft tissue with fat density, which obliterated the right cardio-phrenic angle (Fig. 2). At first, the finding was considered to be prominent epicardial fat pad, but, after careful evaluation, an opening in the anterior portion of the right hemidiaphragm was seen, with continuity between the right cardio-phrenic fat and the intra-abdominal fat (Fig. 3). Furthermore, the prominent fat tissue mildly displaced the lateral wall of the right atrium (Fig. 2c). Sagittal-CT images clearly showed fine linear densities within the fat tissue which cross the diaphragmatic opening and reach the anterior mediastinum, representing omental vessels (Fig. 3b). The diagnosis of Morgagni hernia containing omental fat tissue was made.",
    "discussion": "The \"epicardial fat pad\" corresponds to adipose tissue located in the cardio-phrenic space which is the most basal mediastinal region and is delimited by the base of the heart, diaphragm, and chest wall [1]. A prominent epicardial fat pad may be idiopathic, but is more frequently seen in overweight patients and in certain clinical conditions, i. e. Cushing syndrome and prolonged steroid therapy. A prominent epicardial fat pad leads to an opacity of the cardio-phrenic space on chest radiograph and is quite easily diagnosed as such. In case of diagnostic doubts, CT or MRI (magnetic resonance imaging) may confirm the diagnosis or show other abnormalities of the cardio-phrenic space, i.e. cystic lesions, solid lesions and fat-containing lesions like a Morgagni hernia [1].Morgagni hernia was first described in 1769 and is characterised by herniation of abdominal viscera into the thorax through the foramen of Morgagni, which is located immediately adjacent to the xiphoid process of the sternum and arises from the failure of closure of the septum transversarium of diaphragm with the seventh costochondral arch. Some authors refer to this type of defect occurring on the right as \u201cMorgagni\u2019s gap\u201d and the one that is located on the left as \u201cLarrey\u2019s gap\u201d [2]. Morgagni hernia represents only 2-3% of congenital diaphragmatic hernias. Herniation of abdominal viscera (colon, omentum, liver, and, less frequently, small bowel or stomach) occur over time through a pre-existing diaphragmatic defect [3]. This abnormality may be asymptomatic or manifests with non-specific symptoms and, in severe cases, with bowel ostruction [4]. In patients with Morgagni hernia chest radiographs may lead to an opacity at the cardio-phrenic angle on p.a. projection and of the retrosternal space on lateral projections. CT-findings are useful to differentiate a Morgagni hernia containing omental fat from a prominent epicardial fat pad: in case of Morgagni hernia the fat tissue of the cardio-phrenic angle may displace the lateral wall of the heart, while the epicardial fat pad does not lead to a mass-effect thus does not displace the adjacent structures. Furthermore, in case of a Morgagni hernia CT is able to demonstrate the defect of the anterior portion of the right hemidiaphragm and the omental vessels that pass through this defect.",
    "differential_diagnosis": "Morgagni, hernia, containing, omental, fat, Prominent, epicardial, fat, pad, Fat-containing, mediastinal, lesion, Cystic, mediastinal, lesion, Solid, mediastinal, lesion",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013657/000001.jpg?itok=fx8OaUbt",
            "caption": "Chest lateral scout view shows retrosternal triangular opacity."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013657/000003.png?itok=L6nZJmJ0",
            "caption": "Chest coronal image shows an opening in the anterior portion of the right hemidiaphragm with continuity between the mediastinal and the intra-abdominal fat."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013657/000004.png?itok=5ENXBs7V",
            "caption": "MIP sagittal image shows an opening in the anterior portion of the right hemidiaphragm and omental blood vessels that cross the diaphragmatic breach within the fat tissue."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013657/000007.jpg?itok=qI8qIxRs",
            "caption": "CT axial image shows prominent soft tissue with fat density obliterating the right cardio-phrenic angle."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013657/000006.jpg?itok=cXtQi5HR",
            "caption": "CT axial image shows prominent soft tissue with fat density obliterating the right cardio-phrenic angle."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013657/000008.jpg?itok=WzxGZSWe",
            "caption": "CT axial image shows prominent soft tissue with fat density obliterating the right cardio-phrenic angle and mildly displacing the lateral wall of the right atrium."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Mediastinum"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/13657",
    "time": "05.05.2016"
  },
  "13669": {
    "case_id": 13669,
    "title": "Intrathoracic extramedullary haematopoiesis and skeletal involvement in a case of thalassaemia intermedi",
    "section": "Chest imaging",
    "age": "25",
    "gender": "male",
    "diagnosis": "Intrathoracic extramedullary haematopoiesis associated with skeletal involvement in thalassaemia intermedia",
    "history": "A 25-year-old boy affected by thalassemia intermedia underwent regular follow-up. The patient was asymptomatic, regularly received transfusions and was positive for HCV. A routine chest radiograph was performed.",
    "image_finding": "Chest radiograph revealed a peripheral right basal opacity abutting the costal arches and bilateral well-defined opacities overlying the spine (Fig. 1). A chest CT (computed tomography) was ordered for further characterization, which showed multiple bilateral well-marginated paravertebral and pericostal soft tissue masses demonstrating mild enhancement after intravenous injection of contrast medium (Fig. 2). A moderate amount of soft tissue diffusely surrounded the sternum (Fig. 2b, 2c, 4b). A diffuse structural remodelling of ribs, vertebral bodies, sternum and scapulae was also seen, consisting of rib widening, destruction of medullary trabeculae with trabecular thinning and multiple cortical interruptions, especially in the costal arches adjacent to the soft tissue masses (Fig. 3, 4). The diagnosis of extramedullary haematopoiesis and skeletal abnormalities related to bone marrow expansion was made.",
    "discussion": "Thalassemia is a chronic, inherited, microcytic anaemia characterized by a defective haemoglobin synthesis associated with ineffective erythropoiesis, leading to bone marrow hyperplasia and extramedullary haematopoiesis, which represents the proliferation of hematopoietic cells outside of the bone marrow [1]. Extramedullary haematopoiesis (EMH) usually involves liver, spleen and lymph nodes, but other possible locations are thorax and kidneys. Uncommon locations are skin, central nervous system and adrenal gland [3].Bone marrow hyperplasia leads to skeletal changes characterized by expansion of the medulla, cortical thinning and resorption of trabecular bone, with loss of bone density that causes a greater risk of fracture [1, 2]; these bone anomalies manifest with a typical widening of the ribs. Secondary cortical breaks may occur because of the expanded bone marrow and could also be attributed to the presence of adjacent foci of erythropoietic tissue. In fact, the presence of masses of EMH adjacent to bone and cortical bone disruption are strongly related [4]. Our patient suffered from thalassaemia intermedia and presented diffuse skeletal anomalies with multiple cortical interruptions that were associated with the adjacent masses of intrathoracic extramedullary haematopoiesis.Intrathoracic EMH is characterized by paraosseous masses adjacent to the vertebrae (frequently bilaterally), ribs (commonly multiple), or both, and may also manifest with interstitial lung changes and haemothorax, either alone or in combination. The presence of paraosseous mass is more frequent in thalassaemia than in other causes of intrathoracic EMH [5]. Chest radiograph reveals smooth or lobulated paraspinal or rib masses. On CT images, paraspinal EMH may manifest with isolated or multiple mediastinal masses. Occasionally these can be continuous with abdominal paraspinal masses. The lesions may present mild enhancement, which may be heterogeneous in long-standing lesions representing iron deposition and fat infiltration [3]. Magnetic resonance imaging is an accurate technique in characterization of intrathoracic EMH, showing with great detail both the topography and extent of the masses; in T1 and T2 weighted images, active lesions show intermediate signal intensity, while inactive lesions may reveal high signal intensity in both sequences because of fatty infiltration or low signal intensity secondary to iron deposition [6].EMH may be asymptomatic or present with symptoms related to the mass-effect of the lesions [5].The diagnosis of EMH is more straightforward when the lesions are multifocal or bilateral, or present iron deposition or fatty replacement, while in EMH manifesting as a single mass, differentiation form neurogenic or mesenchymal tumour may be challenging and may require biopsy [6].",
    "differential_diagnosis": "Intrathoracic, extramedullary, haematopoiesis, associated, with, skeletal, involvement, in, thalassaemia, intermedia, Neurogenic, tumour, (for, EMH), Mesenchymal, tumour, (for, EMH), Lymphadenopathy, (for, EMH), Metabolic, bone, diseases, (for, skeletal, abnormalities), Multiple, myeloma, (for, skeletal, abnormalities)",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013669/000001.jpg?itok=rz9DSzGK",
            "caption": "Chest radiograph shows bilateral well-defined opacities overlying the spine (yellow arrows) and right basal peripheral opacity abutting the costal arches (green arrow)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013669/000002.jpg?itok=E43LwZDK",
            "caption": "Chest axial image shows bilateral paravertebral well-marginated soft tissue masses, demonstrating mild enhancement after intravenous injection of contrast medium; diffuse decreased density of bones with structural remodelling is also seen."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013669/000007.jpg?itok=e7-IL-xY",
            "caption": "Chest axial image shows bilateral paravertebral well-marginated soft tissue masses and soft tissue in parasternal location (arrow); diffuse  decreased density of bones with structural remodelling is also seen."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013669/000008.jpg?itok=OKMkcqI8",
            "caption": "Chest axial image shows bilateral paravertebral well-marginated soft tissue masses and soft tissue in parasternal location (arrow); diffuse  decreased density of bones with structural remodelling is also seen."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013669/000005.jpg?itok=7Xnv37D4",
            "caption": "Chest axial image shows bilateral paravertebral and right pericostal well-marginated masses, demonstrating mild enhancement after intravenous injection of contrast medium; diffuse  decreased density of bones with structural remodelling is also seen."
          },
          {
            "number": "Figure 2e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013669/000006.jpg?itok=H3dYuBVJ",
            "caption": "Chest axial image shows bilateral paravertebral and left pericostal well-marginated masses, demonstrating mild enhancement after intravenous injection of contrast medium; diffuse  decreased density of bones with structural remodelling is also seen."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013669/000009.png?itok=ovI20uLm",
            "caption": "Chest axial image shows diffuse structural remodelling of bones with destruction of trabeculae and multiple cortical interruptions; ribs appear widened (arrow)."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013669/000010.png?itok=3OyGHGrs",
            "caption": "Chest axial image shows diffuse structural remodelling of vertebral bodies with trabecular thinning."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013669/000011.png?itok=GGakmybe",
            "caption": "Chest sagittal image shows diffuse structural remodelling of vertebral bodies and sternum, that reveals trabecular thinning and multiple cortical interruptions; a moderate amount of soft tissue is seen in parasternal location."
          },
          {
            "number": "Figure 3d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013669/000012.png?itok=8J7JXxCn",
            "caption": "Chest sagittal image shows diffuse structural remodelling of scapula with trabecular thinning."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013669/000013.png?itok=UTNbfg_t",
            "caption": "Chest CT axial image shows the rib's cortical interruption (arrow) next to the soft tissue mass."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013669/000015.png?itok=taM_DP8_",
            "caption": "Chest CT sagittal image shows multiple cortical interruptions of the sternum (arrows), which appears surrounded by soft tissue."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Haematologic"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/13669",
    "time": "13.06.2016"
  },
  "13687": {
    "case_id": 13687,
    "title": "Chronic eosinophilic pneumonia with crazy paving pattern",
    "section": "Chest imaging",
    "age": "65",
    "gender": "male",
    "diagnosis": "Chronic eosinophilic pneumonia with crazy paving pattern",
    "history": "A 65-year-old male patient was evaluated for a 3 months history of cough, fatigue and mild dyspnoea. The patient was a non-smoker and did not report drugs consumption. Blood tests revealed moderate peripheral eosinophilia. A chest-computed tomography (CT) was performed.",
    "image_finding": "Chest CT revealed in the right upper lobe scattered subpleural areas of increased lung attenuation (ground-glass opacity) with superimposed interlobular septal thickening and intralobular lines, configuring a \u201ccrazy paving pattern\u201d (Fig. 1, 2). There were no pleural effusion nor a mediastinal lymphadenopathy. The diagnostic suspicion of chronic eosinophilic pneumonia (CEP) was expressed. The patient underwent bronchoscopy with analysis of the bronchio-alveolar lavage, revealing 40% eosinophils on differential cell count with an absence of infectious pathogens. Transbronchial biopsy showed a histological pattern consisting of thickened alveolar septa, with a remarkable accumulation of eosinophils and lymphocytes. These findings confirmed the diagnostic suspicion of CEP.Following corticosteroid therapy, the patient\u2019s symptom regressed and follow-up CT showed complete resolution of lung parenchymal abnormalities (Fig. 3).",
    "discussion": "Chronic eosinophilic pneumonia (CEP), together with simple pulmonary eosinophilia (Loeffler syndrome), acute eosinophilic pneumonia and idiopathic hypereosinophilic syndrome, belongs to eosinophilic lung diseases of unknown cause, consisting of a group of pulmonary disorders associated with peripheral or tissue eosinophilia [1]. Eosinophilic lung diseases of known cause include allergic bronchopulmonary aspergillosis, bronchocentric granulomatosis, parasitic infections, drug reactions, or vasculitis [1].CEP was first described by Carrington in 1969 as a chronic form of Loeffler\u2019s syndrome, which is a self-limiting disease characterized by areas of parenchymal consolidation that disappear within several days. The exact prevalence of CEP is unknown, however, it represents a rare disorder that often involves middle-aged patients and occurs more frequently in women [2, 3].Clinical evaluation, laboratory tests and radiological appearance are synergetic in the diagnosis of CEP, which is based on the following criteria:1) respiratory symptoms, such as dyspnoea and non-productive cough, often non-specific and developing insidiously with a duration of more than 2 weeks before the diagnosis is made; CEP may also manifest itself with general symptoms such as asthaenia, low-grade fever and weight loss [3];2) blood eosinophilia, that may be mild, moderate, or severe,  and alveolar eosinophilia, with BAL analysis typically revealing a very high percentage of eosinophils [1, 3];3) radiological appearance consisting in peripheral pulmonary infiltrates, mainly involving the upper lobes. Chest radiographs may depict peripheral lung consolidations, but CT is a more sensible technique in evaluation of lung abnormalities. CT images usually show non-segmental areas of parenchymal consolidations with peripheral distribution and sometimes ground glass opacities with reticulation. Other radiological finding may be band-like opacities and, in 10% of cases, pleural effusion [1] The crazy paving pattern, which is recognized to be a manifestation of several pulmonary diseases, has been rarely described associated to CEP [4, 5];4) exclusion of known causes of eosinophilic disease [1, 3].Histology is usually not necessary for the definitive diagnosis and typically reveals interstitial and alveolar inflammation with a predominance of eosinophils.CEP presents a good prognosis with regression after corticosteroid therapy; in fact, some authors have indicated the prompt response to steroid treatment to be a diagnostic criterion [3].Our patient\u2019s symptoms and peripheral eosinophilia, together with the radiological pattern consisting in peripheral location of findings and upper lobe involvement, allowed us to suspect CEP, even if the \"crazy paving\" pattern is not common in this disease.",
    "differential_diagnosis": "Chronic, eosinophilic, pneumonia, with, crazy, paving, pattern, Cryptogenic, organizing, pneumonia, Churg-Strauss, syndrome, Loeffler, syndrome",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013687/000001.jpg?itok=7SGD0JLQ",
            "caption": "Axial chest CT image shows peripheral area of crazy paving of the right pulmonary apex."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013687/000002.jpg?itok=2_5nEj43",
            "caption": "Axial chest CT image shows peripheral areas of crazy paving of the right pulmonary apex."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013687/000003.jpg?itok=oZNBXkL6",
            "caption": "Axial chest CT image shows peripheral areas of crazy paving of the right pulmonary upper lobe."
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013687/000004.jpg?itok=Kf9a-Y0O",
            "caption": "Axial chest CT image shows peripheral scattering areas of crazy paving of the right pulmonary upper lobe."
          },
          {
            "number": "Figure 1e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013687/000005.jpg?itok=d1qvzrWL",
            "caption": "Axial chest CT image shows subpleural scattering focal areas of crazy paving of the right pulmonary upper lobe."
          },
          {
            "number": "Figure 1f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013687/000006.jpg?itok=OWGOtPHY",
            "caption": "Axial chest CT image shows a focal paramediastinal area of crazy paving of the right pulmonary upper lobe"
          },
          {
            "number": "Figure 1g",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013687/000007.jpg?itok=MhORcpWp",
            "caption": "Axial chest CT image shows an  anterior subpleural area of crazy paving of the right pulmonary upper lobe"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013687/000009.jpg?itok=fE76UfHk",
            "caption": "Coronal chest CT image shows the anterior subpleural area of crazy paving of the right upper lobe."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013687/000008.jpg?itok=YfCDDN-U",
            "caption": "Coronal chest CT image shows the anterior subpleural area of crazy paving of the right upper lobe."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013687/000010.jpg?itok=xxAEHFgg",
            "caption": "Coronal chest CT image shows the scattered subpleural areas of crazy paving of the right upper lobe."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013687/000011.jpg?itok=ZXc9vv08",
            "caption": "Coronal chest CT image shows the scattered subpleural areas of crazy paving of the right upper lobe."
          },
          {
            "number": "Figure 2e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013687/000012.jpg?itok=r5N1vpal",
            "caption": "Coronal chest CT image shows the scattered subpleural areas of crazy paving of the right upper lobe."
          },
          {
            "number": "Figure 2f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013687/000013.jpg?itok=9fJFr3kM",
            "caption": "Sagittal chest CT image shows the scattered subpleural areas of crazy paving of the right upper lobe."
          },
          {
            "number": "Figure 2g",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013687/000014.jpg?itok=glK8ILNP",
            "caption": "Sagittal chest CT image shows the scattered subpleural areas of crazy paving of the right upper lobe."
          },
          {
            "number": "Figure 2h",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013687/000015.jpg?itok=5HRldYg5",
            "caption": "Sagittal chest CT image shows the scattered subpleural areas of crazy paving of the right upper lobe."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013687/000016.png?itok=rZyfSibV",
            "caption": "Axial chest CT image shows complete resolution of the crazy paving areas."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013687/000017.png?itok=507Adb_a",
            "caption": "Axial chest CT image shows complete resolution of the crazy paving areas."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013687/000018.png?itok=QRGKMeVw",
            "caption": "Axial chest CT image shows complete resolution of the crazy paving areas."
          },
          {
            "number": "Figure 3d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013687/000019.png?itok=gddeYE7K",
            "caption": "Axial chest CT image shows complete resolution of the crazy paving areas."
          },
          {
            "number": "Figure 3e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013687/000021.png?itok=e0IabrjT",
            "caption": "Axial chest CT image shows complete resolution of the crazy paving areas."
          },
          {
            "number": "Figure 3f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013687/000020.png?itok=tlumyat4",
            "caption": "Coronal chest CT image shows complete resolution of the crazy paving areas."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/13687",
    "time": "24.05.2016"
  },
  "13692": {
    "case_id": 13692,
    "title": "Desmoplastic round cell tumour of pleura with liver and spine metastases: Uncommon pathology with grave prognosis",
    "section": "Chest imaging",
    "age": "20",
    "gender": "female",
    "diagnosis": "Desmoplastic small round cell tumour",
    "history": "A 20-year-old female patient was admitted to our hospital with complaints of chest pain, dyspnoea and weight loss for 6 months. X-ray chest revealed opacification of the left hemithorax. On examination dullness was noted in the left side of the chest. CT was advised.",
    "image_finding": "Topogram demonstrated opacification of the left hemithorax with a shift of the mediastinum towards the right side (Fig. 1).CT image morphology showed a heterogeneously enhancing circumferential irregular nodular pleural thickening on the left side, involving the entire pleural surface (Fig. 2a, 2b & 3a, 3b) with ipsilateral pleural effusion and metastases in liver and bone (Fig, 4a & 5). The left diaphragm showed inferior displacement by the mass lesion without obvious trans-diaphragmatic extension. The only manifestation of disease in the abdomen was noted in the form of liver metastases (Fig. 4 & 5), however, no contiguous extension of the lesion was seen.CT-guided biopsy revealed angulated nests of small cells embedded in a vascular fibroblastic stroma and areas of central necrosis. On immuno-histochemistry the cells showed evidence of epithelial, mesenchymal, and neural differentiation with positivity for vimentin and desmin.",
    "discussion": "Background: Desmoplastic small round cell tumour (DSRCT) is an extremely rare malignant neoplasm which is highly aggressive. It was initially reported by Rosai and Gerald in 1989 [1]. The histogenesis or pathogenesis of DSRCT is uncertain, mostly involving the abdominal and/or pelvic peritoneum [2]. It has also been reported in epididymis, ovaries, kidneys, pleura, soft tissues and bones. DSRCT usually occurs in young adults and adolescents in the age group of 16-26 years with male predilection and a male to female ratio of 4:1 [3, 4]. The diagnosis is usually confirmed by histological and immunohistochemistry studies [5].Desmoplastic small round cell tumour (DSRCT) belongs to the group of \u201csmall round blue cell tumours\u201d, which are characterised by sheets of small cells and round nuclei. The primary tumour most commonly arises in the peritoneal cavity, although DSRCT arising from other organs of the body like brain, lung, pleura etc. has been described. [6, 7] It is a very aggressive neoplasm with mean survival of 23 months. [8] CT frequently shows multiple nodular, lobulated, heterogeneous peritoneal soft-tissue mass lesions with a predilection for spread to distant organs (including local, lymphatics and haematogenous modes of spread) without obvious primary organ involvement. On histology these tumours show sharply demarcated, cohesive nests of uniform tumour cells with scanty cytoplasm; surrounded by abundant fibrous stroma. Immunohistochemistry of this peculiar tumour shows co-expression of various markers including epithelial, mesenchymal and neural origin.Genetically DSRCT shows reciprocal translocation specifically between chromosomes 22 and 11, thereby leading to fusion of the Wilms\u2019 tumour gene (WT1) and Ewing\u2019s sarcoma gene (EWS) gene [t(11;22)(p13;q12)]. This type of reciprocal translocation of the EWS gene has also been reported in Ewing\u2019s sarcoma and primitive neuro-ectodermal tumours, but the locus is separate on chromosome 11. CT is the most useful tool for diagnosis and staging of DSRCT and should be the initial imaging test of choice. However, MRI can provide some further characterisation of the lesions of DSRCT (such as the presence of intralesional haemorrhagic necrosis). Fluorodeoxyglucose (FDG)-PET/CT has been shown to identify occult lesions not demonstrated on CT or MRI.Treatment is limited to surgical resection with radiotherapy and chemotherapy. Despite chemotherapy, radiotherapy, and aggressive surgical resection, the overall survival is poor (30-55% at 3 years, less than 15 % at 5 years).Early diagnosis is crucial for disease management.",
    "differential_diagnosis": "Desmoplastic, small, round, cell, tumour, Desmoplastic, small, round, cell, tumour, Ewing's, sarcoma/PNET",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013692/000001.jpg?itok=HBZlS-Ws",
            "caption": "Topographic image of the patient shows opacification of LT hemithorax with evidence of mediastinal shift towards RT side. Part of the lung spared appeared radiolucent on LT side. RT lung appeared clear."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013692/000002.jpg?itok=sF67x2pG",
            "caption": "Axial plain (A) and contrast (B) scan shows heterogeneously enhancing nodular thickening encasing the LT hemithorax forming the rind with shifting of mediastinum towards RT side. Mediastinal fat invasion was noted. Visualized ribs appear normal."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013692/000003.jpg?itok=84VRVEgh",
            "caption": "Axial contrast images at subcarinal (A) and supradiaphragmatic level (B) show heterogeneously enhancing nodular thickening with involvement of mediastinal vascular and diaphragmatic pleura involvement."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013692/000005.jpg?itok=bjjFWZvY",
            "caption": "Coronal reformation demonstrates multiple hypodense lesions in the lower thoracic spine (metastasis) with heterogeneously enhancing nodular thickening on LT side causing collapse of underlying lung parenchyma."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013692/000006.jpg?itok=LwSOS4qQ",
            "caption": "Axial contrast images of upper abdomen (A, B) show multiple liver metastases, hepatomegaly with mild peri-splenic collection. Great vessels appear spared."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Abdomen",
      "Thorax",
      "Bones",
      "Soft tissues / Skin"
    ],
    "imaging_technique": [
      "CT",
      "CT-High Resolution"
    ],
    "link": "https://www.eurorad.org/case/13692",
    "time": "19.06.2016"
  },
  "13696": {
    "case_id": 13696,
    "title": "Idiopathic azygous vein aneurysm",
    "section": "Chest imaging",
    "age": "70",
    "gender": "female",
    "diagnosis": "Idiopathic azygous vein aneurysm",
    "history": "70-year-old female patient presented in the emergency department with sudden onset of chest pain and difficulty breathing. Afebrile. Investigation revealed elevated D-dimer. Pulmonary embolism was suspected and the patient was referred for CT. Pulmonary embolism was ruled out but an incidental finding was noticed in the posterior mediastinum on CT.",
    "image_finding": "Axial contrast-enhanced CT chest in pulmonary arterial phase shows no pulmonary embolism. On axial scan a well-demarcated density was noticed in posterior mediastinum on the right side. On sagittal reconstructions it was found to be a fusiform aneurysm of azygous vein - which was an incidental finding. The presented scanning is in a very early contrast phase (pulmonary arterial phase), therefore did not show any flow in the azygous vein or aneurysm.",
    "discussion": "Background: Azygous vein aneurysm is a rare entity defined as azygous vein diameter exceeding 5 mm. It was first described by Walker in 1963. [2, 5] It's a rare entity resulting from:1. Pressure and volume overload, such as portal hypertension resulting from inferior vena cava occlusion\u2014most common.2. Traumatic pseudo-aneurysms, resulting from blunt injury or catheter insertion into the azygous vein.3. Idiopathic saccular aneurysms, which are assumed to be congenital aneurysms caused by venous malformations. [1, 3]Various pathophysiological hypotheses have been suggested, such as venous hypertrophic process, endothelial phlebosclerosis, congenital weakness or degenerative changes in the venous wall due to connective tissue abnormalities. [1]Clinical perspective:Usually asymptomatic, accidentally detected as mediastinal mass on chest X-rays done for other purposes. Nowadays imaging modalities such as CT and MR have made it possible to diagnose it without invasive procedures such as mediastinoscopic or percutaneous needle biopsy, which carries a high risk of bleeding [2, 3]Imaging perspective:Chest X-ray shows unusual bulge at upper right mediastinal contour, which becomes larger with full expiration/valsalva manoeuvre, implying non-solid character of the mass, which might be hidden on inspiratory films. [1, 3, 4, 5] Chest CT with intravenous contrast showing mild enhancement of the mass in the arterial phase, with marked, homogeneous enhancement during the venous phase confirms the diagnosis [1, 4] Dynamic MRI is especially diagnostic in clarifying the nature and origin of the lesion through detecting connections to adjacent vascular structures. [1, 2, 3]Outcome: Aneurysm may enlarge and compress adjacent structures such as the right main bronchus, right upper lobe bronchus or superior vena cava and therefore should be controlled at regular interval even if asymptomatic. [2, 5] Complications such as formation of a thrombus and pulmonary embolism, chronic pulmonary hypertension, venous rupture are reported especially with floating thrombus. [5]Treatment options are controversial. According to some authors, surgical management such as resection of the azygous vein aneurysm using video-assisted thoracoscopic surgery is necessary to prevent complications. [1, 5] Endovascular treatment has recently been developed and should be considered as an alternative to surgical treatment because of its micro-invasiveness and effectiveness [5]Teaching points:Even though azygous vein aneurysm is a rare entity, it must be included in differential diagnosis of a mediastinal mass to prevent hazardous complications before invasive procedures.",
    "differential_diagnosis": "Idiopathic, azygous, vein, aneurysm, Posterior, mediastinal, mass, Paratracheal, mass:, paraganglioma, Castleman\u2019s, disease, Haemangioma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013696/000001.png?itok=qPYlorb5",
            "caption": "Sagittal reconstruction of contrast-enhanced CT chest in pulmonary arterial phase showing azygous vein aneurysm."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013696/000002.png?itok=np0k17yP",
            "caption": "Sagittal reconstruction of contrast-enhanced CT chest in pulmonary arterial phase showing azygous vein aneurysm."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013696/000003.png?itok=DzMYwhzl",
            "caption": "Sagittal reconstruction of contrast-enhanced CT chest in pulmonary arterial phase showing azygous vein aneurysm."
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013696/000004.png?itok=uiXW2w5T",
            "caption": "Sagittal reconstruction of contrast-enhanced CT chest in pulmonary arterial phase showing azygous vein aneurysm."
          },
          {
            "number": "Figure 1e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013696/000005.png?itok=qUV8tqhh",
            "caption": "Sagittal reconstruction of contrast-enhanced CT chest in pulmonary arterial phase showing azygous vein aneurysm."
          },
          {
            "number": "Figure 1f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013696/000006.png?itok=GxJdL-Po",
            "caption": "Sagittal reconstruction of contrast-enhanced CT chest in pulmonary arterial phase showing azygous vein aneurysm."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013696/000007.png?itok=6dBYvToY",
            "caption": "Axial contrast-enhanced CT chest in pulmonary arterial phase showing azygous vein aneurysm."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013696/000008.png?itok=KnZyHvBk",
            "caption": "Axial contrast-enhanced CT chest in pulmonary arterial phase showing azygous vein aneurysm."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013696/000009.png?itok=igelOo8k",
            "caption": "Axial contrast-enhanced CT chest in pulmonary arterial phase showing azygous vein aneurysm."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013696/000010.png?itok=me5YxXcI",
            "caption": "Axial contrast-enhanced CT chest in pulmonary arterial phase showing azygous vein aneurysm."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Veins / Vena cava"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/13696",
    "time": "30.05.2016"
  },
  "13698": {
    "case_id": 13698,
    "title": "A rare cause of post-obstructive pneumonia: endobronchial fibrolipom",
    "section": "Chest imaging",
    "age": "51",
    "gender": "male",
    "diagnosis": "Endobronchial fibrolipoma of the anterior segmental right upper bronchus.",
    "history": "A 51-year-old man with a history of heavy smoking and metabolic syndrome came to the emergency department of our hospital with high fever and right-sided chest pain for the last few days.",
    "image_finding": "A chest X-ray revealed a consolidation in the anterior segment of the right upper lobe. After antibiotic therapy, the follow-up X-ray showed resolution of the consolidation. Four months later, the patient suffered from another consolidation in the same location. Subsequently, with the diagnosis of recurrent pneumonia, a chest CT was performed. The CT revealed a post-obstructive pneumonia caused by a well-defined fat-density mass into the anterior segmental bronchus of the right upper lobe. A bronchoscopy with biopsy was performed and revealed a total obstruction of this bronchus by a pearly tumour with smooth well-defined surface. The biopsy showed a benign neoplasm made up of proliferation of mature fibroadipose tissue under the normal bronchial epithelium. The diagnosis was endobronchial fibrolipoma. The patient underwent bronchoscopic treatment with rigid bronchoscopy and cryotherapy that allowed cryorecanalization of the endobronchial fibrolipoma and complete reopening of the endoluminal airway.",
    "discussion": "Endobronchial lipomas are rare benign tumours of the bronchial tree, whose incidence ranges from only 0.1 to 0.5% of all lung tumours [1]. Most of them arise in the submucosal layer of the main or segmental bronchus, which shows fat tissue in the wall in histology. They are more common in men, in the sixth decade of life. Obesity and smoking are considered risk factors. Clinically, the patients present with symptoms of bronchial obstruction, such us cough, dyspnoea and recurrent pneumonia [2].A CT study should be performed in order to localize the tumour and its complications, such us post-obstructive pneumonia or atelectasis. They are more often located in the main bronchi or lobar bronchi and despite their benign nature, recurrent obstructive pneumonia may induce nuclear atypia to suggest malignancy in the endobronchial biopsy [3]. Both CT and MRI are helpful in establishing the diagnosis because they can demonstrated the fatty component of the tumour. The T1 and T2 relaxation times and spin density of benign lipomatous tumours are in a range similar to those of normal fat. Since the sensibility and specificity of CT and MRI are similar, it depends on the preferences of the radiologist which technique to choose.The bronchoscopy is the fundamental tool for a definitive histopathologic diagnosis and permits a curative treatment as in our case. Endobronchial fibrolipomas are round, polypoid, yellowish or pearly lesions with smooth borders and they are made up of mature fibroadipose tissue surrounding bronchial glandular structures, without malignant cells. It is important to know that the biopsies obtained by flexible bronchoscopy are often nondiagnostic due to the submucosal growth of the endobronchial fibrolipoma, which is covered by normal epithelium. However, rigid bronchoscopy is almost always diagnostic [3, 4].The endoscopic treatment should be considered as the first therapeutic option, as it avoids both thoracotomy and lung resection. The surgical resection is preferred in peripheral destructive lung disease due to recurrent pneumonia or atelectasis, extrabronchial growth or difficulty of definite diagnosis and possible complicated malignant tumour [4]. Although endobronchial fibrolipomas are a rare cause of bronchial occlusion they must not be disregarded because of an early CT, and endoscopic diagnosis and resection help to prevent irreversible distal lung damage and radical surgery.",
    "differential_diagnosis": "Endobronchial, fibrolipoma, of, the, anterior, segmental, right, upper, bronchus., Malignant, tumour:, bronchogenic, adenocarcinoma, squamous, cell, carcinoma, bronchial, carcinoid, mucoepidermoid, carcinoma, adenoid, cystic, carcinoma., Benign, tumour:, endobronchial, hamartoma, pulmonary, leiomyoma, papilloma., Mucus, plug, Foreign, body, Blood, clot",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013698/000001.jpg?itok=4yDr8fZl",
            "caption": "Chest X-ray (frontal and lateral projections) shows a right hilar opacity with indistinct borders, diagnosed as pneumonia of the right upper lobe."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013698/000002.jpg?itok=bdTo-FGA",
            "caption": "Follow-up chest X-ray shows a normal study, with resolution of the pneumonia in the right upper lobe."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013698/000003.jpg?itok=SOWrinlJ",
            "caption": "Four months later a chest X-ray reveals  a consolidation in the same location as the first time."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013698/000004.jpg?itok=rPXG-VgB",
            "caption": "Chest CT [axial (a and b) and sagittal sections (d)] shows post-obstructive pneumonia caused by a complete occlusion of the anterior segmental bronchus of the right upper lobe due to hypodense mass."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013698/000005.jpg?itok=8ML7hxaU",
            "caption": "Chest CT [axial (a and b) and sagittal sections (d)] shows post-obstructive pneumonia caused by a complete occlusion of the anterior segmental bronchus of the right upper lobe due to hypodense mass."
          },
          {
            "number": "Figure 4c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013698/000006.jpg?itok=wCO-Turt",
            "caption": "Chest CT [axial (a and b) and sagittal sections (d)] shows post-obstructive pneumonia caused by a complete occlusion of the anterior segmental bronchus of the right upper lobe due to hypodense mass."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/13698",
    "time": "16.08.2016"
  },
  "13731": {
    "case_id": 13731,
    "title": "Perforation of right ventricle by pacemaker le",
    "section": "Chest imaging",
    "age": "45",
    "gender": "male",
    "diagnosis": "Perforation of right ventricle by pacemaker lead.Incidental SVC duplication.",
    "history": "A 45-year-old gentleman was referred for an emergency computed tomography (CT) scan immediately after pacemaker insertion. The patient was in shock and vascular injury during cardiac resynchronization therapy (CRT) was suspected.",
    "image_finding": "The CT scan showed pacemaker lead extending through the right ventricular (RV) free wall and epicardial fat pad into the pericardial cavity (Fig. 1). There is evidence of hyperdense pericardial effusion in keeping with haemopericardium due to RV perforation. In addition, a persistent left superior vena cava (SVC) is seen along with right SVC (Fig. 2 and 4). The reconstructed image shows the course of RV lead causing cardiac perforation (Fig. 3)",
    "discussion": "Perforation of right ventricle by pacemaker lead:Cardiac chambers perforation by an endocardial lead is an uncommon, but potentially dangerous, complication of implantation of a pacemaker or a cardioverter defibrillator (ICD) [1].Chest radiograph is an easy and commonly used diagnostic method for detecting pacemaker perforation. On chest radiograph, a diagnosis of pacemaker perforation can be made if the lead is located beyond the confines of the cardiac silhouette. A lateral view of the chest should always be performed as it can localize the position of the pacemaker lead more accurately. Chest X-ray can also detect extracardiac complications such as pleural or pericardial effusion and pneumothorax. Echocardiography (ECHO), a simple and noninvasive test that can be performed easily at the bedside, can also help to assess electrode location and detect presence of the pacemaker lead tip in the pericardium and presence of pericardial effusion. However, both of these diagnostic tests have their limitations and the location of the pacemaker lead tip may not be correctly located. CT scan of the chest is currently regarded as the gold standard in the diagnosis of pacemaker lead perforations. Performing CT scans is standard care in most departments dealing with cardiac implantable electronic devices implants. Chest CT accurately reveals pacemaker lead displacement which can sometimes be missed by chest radiograph or ECHO. In addition, it can confirm the presence of an associated pericardial effusion or pleural effusion. However, caution should be exercised as the position of pacemaker wires may be misinterpreted on CT due to artefacts [2]. To conclude, CT is an extremely useful imaging modality to confirm diagnosis and aid planning of extraction. CT allows ready identification of the course of the lead, relationship to adjacent anatomy and adverse sequelae such as pericardial effusion [3].SVC duplication:A persistent left SVC is an incidental finding in less than 0.5% of the general population. In most cases, the left SVC is a component of a duplicated SVC and left brachiocephalic vein is absent. As an isolated anomaly in the absence of congenital heart disease, a left SVC or left component of a duplicated SVC almost always drains into the coronary sinus. A left-sided SVC is most often not clinically significant, but can cause difficulty in manipulation and stabilisation of ventricular leads as it takes acute angle after coming out of coronary sinus to cross the tricuspid valve, and to reach the RV apex [4].",
    "differential_diagnosis": "Perforation, of, right, ventricle, by, pacemaker, lead.Incidental, SVC, duplication., Haemopericardium, due, to, acute, aortic, syndrome, Cardiac, rupture",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013731/000001.jpg?itok=bb1q6c8-",
            "caption": "Axial image through the ventricles with wide window settings show perforation of the right ventricle free wall by pacemaker lead."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013731/000004.png?itok=TeUybpQG",
            "caption": "Axial image at the level of ascending aorta shows hyperdense fluid in the pericardial sac in keeping with haemopericardium (asterisk). Incidental finding of left-sided SVC (arrow) can be seen."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013731/000005.png?itok=nBtMq1YY",
            "caption": "Oblique reformatted image better demonstrates perforation of right ventricle free wall and epicardial fat (asterisk), and associated hemopericardium (star)."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013731/000007.jpg?itok=maZVjzIa",
            "caption": "Oblique coronal reformatted image shows the incidental left-sided SVC which may cause technical difficulty during pacemaker insertion through it."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Cardiac",
      "Veins / Vena cava"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/13731",
    "time": "19.06.2016"
  },
  "13762": {
    "case_id": 13762,
    "title": "Pleuroparenchymal fibroelastosis",
    "section": "Chest imaging",
    "age": "37",
    "gender": "male",
    "diagnosis": "Pleuroparenchymal fibroelastosis",
    "history": "A 37-year-old man with a history of dyspnea, dry cough and weight loss, significantly worsen in years. Similarly, the restrictive ventilatory defect and impairment of DLco got worse during our observation. Besides, lung CT examinations were carried out at diagnosis and during the follow-up period.",
    "image_finding": "At diagnosis, in upper and middle zones, CT showed focal irregular pleural thickenings, some thickened interlobular septa and bilateral bronchiectasis, the main airways were slightly dilated and distorted. The inferior zones were relatively spared (Fig. 1). After a short follow-up period, due to clinical and functional progressive worsening and impairment of CT findings, a surgical biopsy was performed. On follow-up CT four year later pleural thickenings and subpleural consolidations are markedly increased in extension, and in addition interlobular septa and peribronchovascular bundle are progressively involved in all lung regions, leading to an important architectural distortion (Fig. 2). These lesions involve the upper, middle and lower zones of both lungs, with a predominance of the upper zones (Fig. 3). Additional features include traction bronchiectasis, further luminal enlargement of trachea and bronchi, dilation of oesophagus, and bilateral lung volume loss.The histopathological result documented findings consistent with pleuroparenchymal fibroelastosis (PPFE).",
    "discussion": "PPFE is a disease that was first described in the English literature by Frankel et al. in 2004, and was recently added to the new classification of IIPs as a rare form. PPFE comprises dense established intra-alveolar fibrosis, with the alveolar walls in these areas showing prominent elastosis, and dense fibrous thickening of the visceral subpleura; these changes have a striking upper-zone predominance [1]. Clinically, the patients presented with the most frequently described \u201ctriad\u201d: dyspnoea, dry cough and weight loss. The annual impairment in the respiratory function is marked, and is similar to or more rapid than that observed for chronic fibrosing interstitial pneumonias such as UIP and fibrotic nonspecific interstitial pneumonia. The clinical course of this disease is progressive and almost all patients clinically and functionally deteriorate even over a relatively short follow-up period. Moreover, the prognosis of PPFE patients has been reported to be poor [1].Histophathological findings are thickened visceral pleura and subpleural fibrosis consisting of dense collagen and elastin. Transition from pathological to normal parenchyma is abrupt. Fibroblast foci and lymphocytic inflammation is variably observed [2]. Aetiology is unknown but recurrent infections (in particular by aspergillus species), autoimmune diseases and genetic predisposition seem to be linked. Several case reports of patients who developed PPFE after they underwent bone marrow transplantation have been published [2, 3]. It is interesting to underline that the previous medical history of our patient was unremarkable, and no risk factor for PPFE was identified. Moreover, during the last year of observation, the patient developed dyspnoea on exertion and eventually at rest, due to progressive worsening of respiratory failure with CO2 retention. Currently, he is on treatment with high flow nasal cannula oxygen therapy (HFNCO), and is listed for lung transplantation.HRCT studies of PPFE show subpleural reticular opacities initially favouring the upper zones with pleural fibrosis and linear or wedge-shaped extensions down secondary lobular septa. The mid- and lower zones are initially spared but are progressively enveloped with time. Additional features include volume loss, traction bronchiectasis and honeycomb, moreover pneumothorax (uni- or bilateral) and pneumomediastinum may be present [3, 4]. Finally, there are no established therapeutic options available for PPFE except for supportive care and lung transplantation.",
    "differential_diagnosis": "Pleuroparenchymal, fibroelastosis, Chronic, hypersensitivity, pneumonia, Asbestosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013762/000001.jpg?itok=oET67dTl",
            "caption": "Axial image at upper lung level: some focal irregular pleural thickenings, some thickened interlobular septa and a bronchiectasis are showed in right lung."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013762/000004.jpg?itok=JAJwYyRD",
            "caption": "Axial image at middle lung level: bilaterally some focal irregular pleural thickenings are shown."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013762/000009.jpg?itok=Zk2V5rM7",
            "caption": "Axial image at lower lung level: the inferior zones are relatively spared."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013762/000006.jpg?itok=1X8IqQwP",
            "caption": "Axial image at upper lung level: pleural thickenings and subpleural consolidations are markedly increased in extension, and interlobular septa and peribronchovascular bundle are progressively involved."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013762/000007.jpg?itok=v42b-8Ip",
            "caption": "Axial image at middle lung level: an important and diffuse architectural distortion is evident."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013762/000008.jpg?itok=F3yebXEa",
            "caption": "Axial image at lower lung level: bilaterally, an architectural distortion is evident."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013762/000010.jpg?itok=th3WsCls",
            "caption": "Coronal image: the lesions involve the upper, middle and lower zones of both lungs, with a predominance of the upper zones.\nSee also fig. b and fig. c"
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013762/000011.jpg?itok=zDBapqO6",
            "caption": "Sagittal image of right lung."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013762/000012.jpg?itok=hyxioJVl",
            "caption": "Sagittal image of left lung."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/13762",
    "time": "22.06.2016"
  },
  "13791": {
    "case_id": 13791,
    "title": "Mediastinal liposarcoma of thymic origin",
    "section": "Chest imaging",
    "age": "45",
    "gender": "female",
    "diagnosis": "Primary mediastinal liposarcoma (thymic)",
    "history": "A 45-year-old female patient presented with dyspnoea, non-productive cough, chest discomfort and weight loss (5 kg) for the past five months. These symptoms were insidious in onset and gradually progressive. There was no history of dysphagia, wheezing, haemoptysis, fever or tuberculosis. She had no family history of malignancy and was a non-smoker.",
    "image_finding": "On routine evaluation with a chest radiograph (not shown), she was found to have a mass lesion in the left hemithorax and was referred for a contrast-enhanced CT of the thorax. The CT revealed an opacity in the left lung upper and mid-zone, which did not project above the clavicle. The descending thoracic aorta could be clearly seen through it suggesting an anterior mediastinal mass (Fig. 1).Non-contrast CT (Fig. 2) showed a large well-marginated soft tissue density lesion of approximate size 12\u00d79\u00d78 cm in anterior mediastinum containing areas of fat attenuation (HU -70 to -100). No evidence of calcification or haemorrhage was noted. The lesion abutted the arch of the aorta, left pulmonary artery and anterolateral chest wall without any definite invasion of mediastinal structures. The soft tissue component showed heterogeneous enhancement (Fig. 3). There was associated pericardial effusion. Screening CT of the brain and abdomen revealed no evidence of metastasis. CT-guided FNAC revealed mixed type (well-differentiated and myxoid) liposarcoma of thymic origin.",
    "discussion": "Liposarcomas are most common soft tissue sarcomas in adults constituting about 15-20% of all sarcomas. They usually have their origin in the extremities or the retroperitoneum. However they can also be found in other locations like abdomen, vulva, buttocks and mediastinum. Primary mediastinal liposarcomas are very rare accounting for less than 1% of all mediastinal tumours and 9% of all primary mediastinal sarcomas [1, 2, 3, 4].Mediastinal liposarcomas are commonly found in posterior mediastinum and are rare in anterior mediastinum. Mediastinal liposarcoma containing thymic tissue have also been found and termed as thymic liposarcoma [1, 3, 5].Around 15% of cases can be asymptomatic and detected incidentally on chest imaging. But they can exhibit clinical symptoms due to their larger size and direct invasion of the adjacent structures like pericardium and superior vena cava. The most common symptoms are dypnoea, tachypnoea, wheezing and chest pain. They can also present with signs of superior vena caval obstruction [3, 5, 6].They originate from the primitive mesenchymal cells or the adipose tissues of thymus. Histologically, they are classified into five subtypes: well-differentiated, dedifferentiated, myxoid, round cell and pleomorphic. The well-differentiated subtypes are low grade in nature, rarely metastasize and have a better prognosis. The pleomorphic and dedifferentiated subtypes have a poor prognosis [3, 4].On conventional chest radiographs, mediastinal liposarcomas are seen as widened mediastinum with possible deviation of trachea and vessels. The appearance of mediastinal liposarcoma on CT varies from a predominantly fat-containing mass to a solid mass. On MRI, fatty tissue with high signal intensity is seen in T1-weighted imaging and diminished signal intensity in T2-weighted imaging. Marked heterogeneous internal structure is seen in the pleomorphic subtype [3, 5, 6].The preferred treatment is surgical excision. However, in more advanced and infiltrating tumours, partial excision or debulking of the tumour may be useful in relieving the compressive effect. Radiotherapy and chemotherapy can also be used as an adjunct. The five year survival rate is about 38%. Recurrence is common in deep-seated liposarcomas and usually manifests within the first 6 months with a recurrence rate of 40%; probably due to incomplete excision at the time of primary surgery. Therefore, careful long-term follow up is necessary. [1, 3, 5-7]Masses that can mimic these lesions include: thymolipomas, teratomas, germ cell tumours, lymphomas, herniated peritoneal fat and diaphragmatic hernias [5, 7]Teaching PointThough mediastinal liposarcoma is rare, it should be kept in the differential diagnosis of fat-containing mediastinal lesions.",
    "differential_diagnosis": "Primary, mediastinal, liposarcoma, (thymic), Thymolipoma, Mediastinal, lipoma, Mediastinal, teratoma, Fibromyxolipoma, Angiolipoma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013791/000001.jpg?itok=wfU3VA3v",
            "caption": "CT shows an opacity in the left hemithorax which does not project above the clavicle (cervicothoracic sign). The descending thoracic aorta (arrows) can be seen through it, suggesting it to be an anterior mediastinal mass."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013791/000002.jpg?itok=8AiSYxNQ",
            "caption": "Axial NCCT shows a large well-marginated soft tissue density lesion of approximate size 12\u00d79\u00d78 cm in anterior mediastinum displacing the trachea to the right (T). Note the fatty components (HU -70 to - 100) (*)"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013791/000003.jpg?itok=BsFE2pZk",
            "caption": "The lesion abuts the anterior chest wall. Fat attenuation areas are marked (*)."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013791/000004.jpg?itok=Tk3YqEjn",
            "caption": "Pericardial effusion (e)"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013791/000005.jpg?itok=_6SUQkaP",
            "caption": "Axial CECT Thorax shows heterogeneously enhancing soft tissue density mass in the anterior mediastinum with areas of fat (*) displacing the trachea (T) slightly to the right."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013791/000006.jpg?itok=Iwp4WRug",
            "caption": "The mass lesion abuts the arch of the aorta and the anterolateral chest wall. Asterisks indicate areas of fat. No mediastinal invasion is noted."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013791/000007.jpg?itok=-eiIpAbl",
            "caption": "Anterior mediastinal mass abutting the left pulmonary artery (LPA) and anterior chest wall."
          },
          {
            "number": "Figure 3d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013791/000008.jpg?itok=rAWP750E",
            "caption": "Coronal CECT showing  the mass lesion and pericardial effusion (e). Fat components (*). Visualised part of the liver is normal."
          },
          {
            "number": "Figure 3e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013791/000009.jpg?itok=kSMhb5m5",
            "caption": "Coronal CECT showing  the mass lesion and pericardial effusion (e). Fat components (*). Mild displacement of trachea (T) to the right is noted."
          },
          {
            "number": "Figure 3f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013791/000010.jpg?itok=LLq94RDB",
            "caption": "Sagittal CECT showing the location of the mass (anterior mediastinum) and pericardial effusion (e)"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Mediastinum",
      "Thorax",
      "Lung"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/13791",
    "time": "19.06.2016"
  },
  "13793": {
    "case_id": 13793,
    "title": "Dendriform pulmonary ossification in a case of usual interstitial pneumoni",
    "section": "Chest imaging",
    "age": "66",
    "gender": "male",
    "diagnosis": "Dendriform pulmonary ossification in a case of usual interstitial pneumonia",
    "history": "A 66-year-old male patient was evaluated for known IPF (idiopathic pulmonary fibrosis), diagnosed 1 year ago. Pulmonary function testing demonstrated restrictive disease with forced expiratory volume in 1 second of 60% of predicted value, vital capacity of 58% and diffusing capacity for carbon monoxyde of 38%.",
    "image_finding": "Chest CT showed the typical pattern of UIP, revealing subpleural reticulation, cystic honeycombing with predominant basal and subpleural distribution and bronchiectasis (Fig. 1, 2). Other findings were fine irregularities of the pleural surfaces suggesting interface sign (Fig. 2b). After evaluation through mediastinal window multiple calcifications with predominant branching and reticular appearance were noted within the fibrotic areas, with predominance in the right lung (Fig. 3); other tiny calcifications with subpleural predominance were also present (Fig. 3e, 3g). In accordance with the literature, a further evaluation was made through \"osteoporosis\" window (width 818, level 273), that confirmed the calcific nature of the findings (Fig. 4). The diagnosis of dendriform pulmonary ossification in the setting of a known UIP pattern was made.",
    "discussion": "Dendriform Pulmonary ossification (DPO) is the less common form of diffuse pulmonary ossification, a rare condition that includes also the more frequent nodular pattern, usually affects men between 40 and 60 years, and is characterized by the presence of mature heterotopic bone in the lung parenchyma [1, 2].DPO is characterized by branching mature bone within the interstitium, maybe related to chronic tissue injury resulting in enzyme activation and induction of osteogenic factors [3]. The presence of diffuse pulmonary ossification itself is not related to any symptoms, and the clinical features lead to the eventual associated respiratory diseases. In fact, although DPO may be idiopathic, it also may be present in many respiratory diseases, such as COPD, adult respiratory distress syndrome and OP; however, the main association described in the literature is idiopathic pulmonary fibrosis (IPF) [4].IPF represents the clinical syndrome associated with the morphologic pattern of UIP, that is characterized on chest CT by reduction of lung volumes, subpleural reticular opacities, macrocystic honeycombing, and traction bronchiectasis, the extent of which increases from the apex to the bases of the lungs [5]. DPO appear on chest radiograph like fine, branching reticular opacities, usually peripheral and basal. When associated to fibrosis, on chest CT DPO consists of dense reticular and nodular opacities within the area of fibrosis. Moreover, Kim et al suggested the importance of the use of an \"osteoporosis\" window, to recognize true calcification from high attenuation \u201cpseudocalcification\u201d [1].Mandeloff proposed that 9% of patients with pulmonary fibrosis present DPO, which is related to the chronicity and/or severity of the disease [1]. Other authors suggested that the presence of DPO may be considered to be a helpful factor in distinguishing between Usual Interstitial Pneumonia (UIP) and Non-Specific Interstitial Pneumonia (NSIP), because the first one may have DPO as opposed to the second one [6]. However, because of its rarity, DPO is not considered to be a diagnostic criterium for UIP diagnosis.In our case, the patient already had the diagnosis of UIP on the basis of radiological features, and the presence of DPO was an additional finding on follow-up chest CT. In particular, the presence of reticular abnormalities, honeycombing with basal and subpleural distribution (associated with bronchiectasis),  and the absence of features listed as inconsistent with UIP pattern had allowed the diagnosis of UIP without need of biopsy, in agreement with the diagnostic criteria proposed by American Thoracic Society [7].",
    "differential_diagnosis": "Dendriform, pulmonary, ossification, in, a, case, of, usual, interstitial, pneumonia, Pulmonary, alveolar, microlithiasis, (PAM), Metastatatic, pulmonary, malignancy, Non-malignant, metastatic, pulmonary, calcification, (renal, failure, hyperparathyroidism), Occupational, lung, disease, Granulomatous, disease",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013793/000014.png?itok=rDaYX6UQ",
            "caption": "Chest CT image shows bilateral subpleural reticulation and right subpleural areas of honeycombing and focal left subpleural area of honeycombing. Fine irregularities of pleural surfaces suggesting \"interface sign\" are also seen (arrows)."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013793/000005.png?itok=88JNwIZT",
            "caption": "Chest CT image shows bilateral subpleural reticulation and bilateral subpleural honeycombing."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013793/000012.png?itok=jukX8mY4",
            "caption": "Chest CT image shows bilateral subpleural reticulation and  honeycombing, both more evident than the more cranial sections, suggesting apico-basal gradient. Bronchiectasis are also present (arrows)."
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013793/000009.png?itok=HrEPbdvy",
            "caption": "Chest CT image shows bilateral basal extensive honeycombing."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013793/000019.png?itok=Gs0f-CFB",
            "caption": "Chest CT coronal image clearly shows the apico-basal gradient of honeycombing areas, presenting with main subpleural distribution."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013793/000015.png?itok=fWPFNKTn",
            "caption": "Chest CT MinIP image clearly shows bilateral basal bronchiectasis within honeycombing areas."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013793/000016.png?itok=QfaXXhEO",
            "caption": "Chest CT MinIP image clearly shows bilateral basal bronchiectasis within honeycombing areas."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013793/000020.jpg?itok=vgoNDg0R",
            "caption": "Axial chest CT MIP image shows subpleural calcifications with branching and reticular appearance in the right lung. Other similar calcifications, less extensive, are present in the left lung."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013793/000021.jpg?itok=up69GJd4",
            "caption": "Axial chest CT MIP image shows subpleural calcifications with branching and reticular appearance in the right lung. Other similar calcifications, less extensive, are present in the left lung."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013793/000022.jpg?itok=O6TwP64t",
            "caption": "Axial chest CT MIP image shows subpleural calcifications with branching and reticular appearance in the right lung. Other similar calcifications, less extensive, are present in the left lung."
          },
          {
            "number": "Figure 3d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013793/000023.jpg?itok=IYHlwhdl",
            "caption": "Axial chest CT MIP image shows bilateral calcifications with branching and reticular appearance."
          },
          {
            "number": "Figure 3e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013793/000024.jpg?itok=vZI3SIeP",
            "caption": "Axial chest CT MIP image shows bilateral subpleural tiny calcifications."
          },
          {
            "number": "Figure 3f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013793/000025.jpg?itok=_gQDS273",
            "caption": "Coronal chest CT MIP image shows subpleural calcifications with branching and reticular appearance with predominance in the right lung."
          },
          {
            "number": "Figure 3g",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013793/000026.jpg?itok=E6IhzD7P",
            "caption": "Coronal chest CT MIP image reveals subpleural calcifications with branching and reticular appearance, showing predominance in the right lung. Other subpleural tiny calcifications are also present."
          },
          {
            "number": "Figure 3h",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013793/000027.jpg?itok=b1Nmuje7",
            "caption": "Sagittal chest CT MIP image shows subpleural calcifications with branching and reticular appearance in the right lung."
          },
          {
            "number": "Figure 3i",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013793/000028.jpg?itok=Ms2L9-mF",
            "caption": "Sagittal oblique chest CT MIP image shows subpleural calcifications with branching and reticular appearance in the right lung."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013793/000029.jpg?itok=zzpWdmJf",
            "caption": "Axial chest CT MIP image confirms subpleural calcifications with branching and reticular appearance in the right lung. Other similar calcifications, less extensive, are present in the left lung."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013793/000030.jpg?itok=JYJrSQqp",
            "caption": "Axial chest CT MIP image confirms subpleural calcifications with branching and reticular appearance in the right lung. Other similar calcifications, less extensive, are present in the left lung."
          },
          {
            "number": "Figure 4c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013793/000031.jpg?itok=I8JPcdpm",
            "caption": "Axial chest CT MIP image confirms subpleural calcifications with branching and reticular appearance in the right lung. Other similar calcifications, less extensive, are present in the left lung."
          },
          {
            "number": "Figure 4d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013793/000032.jpg?itok=31aJwPte",
            "caption": "Axial chest CT MIP image shows bilateral calcifications with branching and reticular appearance."
          },
          {
            "number": "Figure 4e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013793/000035.jpg?itok=aerfLkG7",
            "caption": "Axial chest CT MIP image confirms bilateral subpleural tiny calcifications."
          },
          {
            "number": "Figure 4f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013793/000034.jpg?itok=xgDeBWWD",
            "caption": "Coronal chest CT MIP image confirms subpleural calcifications with branching and reticular appearance with predominance in the right lung."
          },
          {
            "number": "Figure 4g",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013793/000036.jpg?itok=c83UXjzi",
            "caption": "Coronal chest CT MIP image reveals subpleural calcifications with branching and reticular appearance, showing predominance in the right lung. Other subpleural tiny calcifications are also present."
          },
          {
            "number": "Figure 4h",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013793/000037.jpg?itok=jCQnNAuI",
            "caption": "Sagittal chest CT MIP image confirms subpleural calcifications with branching and reticular appearance in the right lung."
          },
          {
            "number": "Figure 4i",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013793/000038.jpg?itok=FByfLT1K",
            "caption": "Sagittal oblique chest CT MIP image confirms subpleural calcifications with branching and reticular appearance in the right lung."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/13793",
    "time": "15.06.2016"
  },
  "13800": {
    "case_id": 13800,
    "title": "Granulomatous-lymphocytic interstitial lung disease",
    "section": "Chest imaging",
    "age": "26",
    "gender": "male",
    "diagnosis": "Granulomatous-lymphocytic interstitial lung disease",
    "history": "A 27-year-old male patient presented with fever and cough. He was treated with antibiotics with no improvement. The chest CT revealed innumerable bilateral pulmonary nodules, thoracoabdominal lymphadenopathy, and splenomegaly. His work up was negative for a haematological malignancy. He had absent IgM, IgA and low level of IgG2.",
    "image_finding": "The chest radiograph showed subtle bilateral ill-defined ground glass nodules in mid and lower lungs. The chest CT showed innumerable bilateral pulmonary nodules and nodular ground glass opacities scattered throughout both lungs, mediastinal, bilateral hilar, upper abdominal lymphadenopathy, and splenomegaly.",
    "discussion": "Common variable immunodeficiency (CVID) is the most frequent diagnosis in cases of symptomatic primary immunodeficiency in adults with estimated prevalence of 1 in 10, 000 to 30, 000. This condition is characterized by a deficit in the production of all major classes of antibodies. The condition is generally diagnosed in patients with low or absent serum immunoglobulin levels and recurrent infections. Males and females are affected in equal numbers. The onset of symptoms may occur in early or late childhood or adulthood. [1] Although infectious complications of lungs occur quite frequently in patients with CVID, some non-infectious complications such as systemic granulomatosis and lymphoid hyperplasia can also occur in these patients. The term granulomatous-lymphocytic interstitial lung disease (GLILD) has been created to describe these non-infectious, diffuse lung disease complications that develop in CVID patients. They exhibit both granulomatous and lymphoproliferative histologic patterns, consisting of lymphocytic interstitial pneumonia, follicular bronchitis, and lymphoid hyperplasia. The GLILD has been reported to occur in 5-10% of CVID patients. [2] Radiologically, the patient with CVID with recurrent infections usually presents with consolidation, bronchiectasis, atelectasis and air trapping. On the other hand, GLILD has different distinct imaging features than CVID and presents with soft tissue density and ground glass micronodules and thoracoabdominal lymphadenopathy. The nodules have mid and lower zone predominance which is a helpful feature to distinguish this entity from sarcoid. Patients with GLILD also usually have splenomegaly. Bronchiectasis is typically less common in GLILD than in CVID. Low or absent immunoglobulins help in differentiating this condition from lymphoma. [1, 2]There is currently no established guideline for treatment of subgroup of CVID patients afflicted with GLILD. Most commonly, corticosteroids have been used to treat these patients, with general improvement in clinical symptoms as well as resolution of radiological abnormalities, however; relapse is not uncommon following cessation of therapy. Recently, combination chemotherapy with rituximab and azathioprine has been reported to improve pulmonary function and decrease radiographic abnormalities in patients with CVID and GLILD. [3, 4]Non-infectious complication such as GLILD should be strongly suspected in known CVID patients who present with pulmonary soft tissue density or ground glass nodules, thoracoabdominal lymphadenopathy and splenomegaly.",
    "differential_diagnosis": "Granulomatous-lymphocytic, interstitial, lung, disease, Sarcoid, Lymphoma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013800/000001.jpg?itok=Itiuz-sE",
            "caption": "The frontal chest radiograph shows ill-defined subtle ground glass opacities in both mid and lower lungs."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013800/000002.jpg?itok=Y47F80oh",
            "caption": "CT chest at mid lung level shows multiple bilateral solid as well as ground glass nodules."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013800/000003.jpg?itok=_mOhmk3u",
            "caption": "CT chest at lower level shows multiple bilateral solid as well as ground glass nodules."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013800/000004.jpg?itok=pERR8iQ1",
            "caption": "CT chest at mid chest level shows mediastinal lymphadenopathy (arrowheads)."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013800/000005.jpg?itok=eL-J2KEv",
            "caption": "CT chest at slightly lower level than prior figure shows hilar and posterior mediastinal lymphadenopathy."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013800/000006.jpg?itok=Ef0hAzy8",
            "caption": "CT abdomen shows enlarged spleen."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Lymph nodes",
      "Spleen"
    ],
    "imaging_technique": [
      "Digital radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/13800",
    "time": "16.08.2016"
  },
  "13810": {
    "case_id": 13810,
    "title": "Bilateral wandering inferior pulmonary veins",
    "section": "Chest imaging",
    "age": "50",
    "gender": "female",
    "diagnosis": "Bilateral meandering inferior pulmonary veins",
    "history": "50 y/o woman. No medical history of interest. Chest X-ray performed because of a year-long retrosternal intermittent, non-irradiated pain.",
    "image_finding": "- Chest X-ray: Tubular curved opacities over bilateral lower pulmonary zones.- Enhanced chest CT: Both inferior pulmonary veins are enlarged and follow an anomalous, tortuous peripheral course. The lower left pulmonary vein drainage includes part of the lingula. All the pulmonary veins drain into the left atrial appendage, with no abnormalities in location and number of ostia. Neither airway nor arterial tree show any pathology.",
    "discussion": "The typical anatomy (found in 70% of patients) [1] consists of four pulmonary veins, two draining each lung. The right superior pulmonary vein drains the upper and middle lobes; the left superior vein drains the lingula and left upper lobe and both inferior veins drain each lower lobe. They course in the intersegmental septa (unlike the pulmonary arteries) and drain separately into the left atrial appendage, passing anterior and inferior to the pulmonary arteries. Meandering pulmonary vein was first described by Goodman et al (1972) [2]. It consists of an abnormal course of a pulmonary vein, following a peripheral and tortuous route, with a subsequent normal drainage into the left atrial appendage. It doesn't associate any other vascular, cardiac or lung anomalies.It is considered an anatomical variant, included into the group of congenital anomalies of the pulmonary venous drainage [3].There are very few case reports of this entity, and only one [4] describing a bilateral form. It is usually an incidental finding on an imaging test performed for other reasons. Patients remain asymptomatic. In chest X-ray we can see a curved vascular shadow with a peripheral path, which may be confused with the appearance of a Scimitar syndrome when it courses through the right lower lobe, along the right cardiac border [5]. When bilateral, as in our case, we will see this over both hemithoraces.Enhanced CT is the technique that will allow us to make the diagnosis in most of cases. We can see the anomalous vein as a dilated, curved vascular structure with a peripheral course and also demonstrate its normal drainage into the left atrial appendage and the absence of other vascular or parenchymal anomalies.Bilateral meandering inferior pulmonary veins are considered an anatomical variant with no associated complications [6] that doesn't require any follow-up.This is a rarely described entity with the bilateral form being even rarer. In the literature there are a few old case reports lacking high resolution images with up-to date imaging techniques. Familiarity with this rare anatomic variant of inferior pulmonary veins will allow Radiologists to reliably distinguish it from other congenital vascular diseases that might require further investigation with additional imaging.",
    "differential_diagnosis": "Bilateral, meandering, inferior, pulmonary, veins, Scimitar, syndrome, (if, unilateral), Pulmonary, arteriovenous, fistula, Pulmonary, venous, varix, (normally, unilateral), Anomalous, pulmonary, venous, drainage",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013810/000001.jpg?itok=AMrA_3dM",
            "caption": "Posterioanterior view"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013810/000002.jpg?itok=dSU1D3yZ",
            "caption": "Lateral view"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013810/000003.jpg?itok=0KGweM5f",
            "caption": "Axial view"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013810/000004.jpg?itok=IiwaCuoZ",
            "caption": "Axial view"
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013810/000008.jpg?itok=Dn-Hm4vV",
            "caption": "Axial view"
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013810/000009.jpg?itok=ekHz6GB4",
            "caption": "Coronal MinIP"
          },
          {
            "number": "Figure 2e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013810/000005.jpg?itok=4GrlWCCA",
            "caption": "Coronal thick MIP"
          },
          {
            "number": "Figure 2f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013810/000006.jpg?itok=kPrXcKRi",
            "caption": "3D reconstruction of pulmonary venous tree. Anterior view."
          },
          {
            "number": "Figure 2g",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013810/000007.jpg?itok=zT22aESI",
            "caption": "3D reconstruction of pulmonary venous tree. Posterior oblique view"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/13810",
    "time": "21.11.2016"
  },
  "13823": {
    "case_id": 13823,
    "title": "Thoracic endometriosis syndrome: a rare cause of pneumothorax in young women",
    "section": "Chest imaging",
    "age": "29",
    "gender": "female",
    "diagnosis": "Thoracic endometriosis with catamenial pneumothorax",
    "history": "A 29-year-old female smoker came to our emergency department with right thoracic pain and dyspnoea. Auscultation revealed hypophonesis on right hemithorax.The patient did not present fever, cough or other symptoms.",
    "image_finding": "A chest radiography on posteroanterior view was performed (Fig. 1). A large pneumothorax with contralateral mediastinal displacement was observed. Pseudo-nodular extrapulmonar opacities adjacent to the right anterior diaphragm were also noted.Two days later, after the placement of a thoracic tube, a complementary chest CT was ordered (Fig. 2 a-c). In this imaging technique a diminution of the right pneumothorax and the existence of extrapleural lesions attached to the right diaphragm were confirmed.In order to improve the characterization of the extrapulmonary lesions, a thoracic MR was performed after the resolution of the pneumothorax (Fig. 3 a-d). Those extrapulmonary lesions were markedly hyperintense in T1 and fat-suppressed T1 sequences, with an intermediate-high T2 signal.After the complete resolution of the pneumothorax, surgery was performed. Histological analysis confirmed the diagnosis.",
    "discussion": "Endometriosis is defined as the presence of functional endometrial glands and stroma outside the uterine cavity [1]. The true prevalence of this disease is unknown. To make a definitive diagnosis biopsy, surgery or laparoscopy have to be performed. An estimated prevalence of 5-10% in all childbearing women has been described [2]. The most common location of endometriotic implants are the ovaries (76%) and anterior and posterior cul-de-sac (69%). However, these implants can arise in other atypical sites as gastrointestinal system, urinary system and thorax. When endometriotic implants extend to the thoracic cavity, they can produce a thoracic endometriosis syndrome (TES) [3]. TES can associate four different clinical entities: catamenial recurrent pneumothorax (CP), catamenial haemothorax, haemoptysis and pulmonary nodules.CP is defined as spontaneous and recurrent pneumothorax occurring within 72 hours from the onset of menstruation. Although CP is the most common presentation of TES, it is a rare cause of pneumothorax accounting for less than 5% of cases of this disease in young women [4].The most common locations of endometriotic implants in the thoracic cavity are the diaphragmatic surface and the visceral pleura [5], with the right thoracic cavity being involved most frequently. This fact supports the hypothesis of the retrograde menstruation and transdiaphragmatic leakage as a possible pathophysiology of TES.Chest plain film is usually the imaging technique of choice when pneumothorax is suspected. The presence of pneumothorax and ipsilateral extrapleural opacities involving the diaphragm in a young woman within 72 hours from the onset of menstruation are the most common findings of CP. Chest CT can improve the detection of endometriotic implants due to its better spatial resolution. It can also give information about other possible differential diagnoses. MR can be helpful when CP is suspected. Typical endometriotic thoracic implants usually appear as well-defined lesions with high signal intensity on T1, T1 with fat saturation and T2 sequences [6].The standard treatment of CP includes the pharmacologic inhibition of sex hormones with gonadotropin-releasing hormone analogues (GnRH). Since these drugs inhibit ovulation, patients who wish to conceive sometimes refuse to undergo hormone therapy. In some cases, this treatment could not be effective and the surgical removal of endometriotic implants using video-assisted thoracoscopic surgery could be an alternative choice. Nevertheless, a combination of surgical and hormonal therapy may be the preferred approach for treatment and prevention of recurrence of CP [5].",
    "differential_diagnosis": "Thoracic, endometriosis, with, catamenial, pneumothorax, Emphysema, secondary, to, blebs, Lymphangioleiomatosis, Subpleural, abscesses, Langerhans, cell, histiocytosis, Subpleural, metastases",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013823/000004.jpg?itok=-TryrMS4",
            "caption": "Posteroanterior chest radiography. Right pneumothorax with contralateral displacement of the mediastinum was found. Extrapleural opacities attached to the right diaphragm were also observed."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013823/000005.jpg?itok=VNDfV75h",
            "caption": "Axial chest CT. Right pneumothorax and extrapleural nodules attached to the diaphragm were found.\nA right thoracic tube could be also observed."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013823/000006.jpg?itok=xM7KB2d6",
            "caption": "Sagittal chest CT. Right pneumothorax and extrapleural nodules attached to the diaphragm were found.\nA right thoracic tube could be also observed."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013823/000007.jpg?itok=AhhHU42o",
            "caption": "Coronal chest CT. Right pneumothorax and extrapleural nodules attached to the diaphragm were found.\nA right thoracic tube could be also observed."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013823/000008.png?itok=DNHMqxMC",
            "caption": "Coronal T1-weighted fat-suppressed\nsequence. The lesions attached to the right diaphragm were markedly hyperintense."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013823/000009.jpg?itok=WmgVQ8xq",
            "caption": "Axial T1-weighted fat-suppressed\nsequence. The lesions attached to the right diaphragm were markedly hyperintense."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT",
      "MR"
    ],
    "link": "https://www.eurorad.org/case/13823",
    "time": "05.08.2016"
  },
  "13850": {
    "case_id": 13850,
    "title": "Pleuroparenchymal fibroelastosis: a rare idiopathic interstitial pneumoni",
    "section": "Chest imaging",
    "age": "42",
    "gender": "female",
    "diagnosis": "Pleuroparenchymal fibroelastosis",
    "history": "- A 42-year-old female non-smoker presented with dry cough and progressive exertional dyspnoea. Previous medical history included childhood asthma, breast cancer, and pneumothorax treated with drainage and pleurodesis.\n\n- A 26-year-old male non-smoker with worsening of dyspnoea on effort and non-productive cough. Previous medical history included Cattleman's disease, splenectomy and epilepsy.",
    "image_finding": "- Case 1\nThe chest X-ray showed a progressive upper lobe volume loss, shrinkage and distortion of the pulmonary hila and apical pleural thickening (Fig. 1).\n\nThe HRCT showed upper lobe volume loss, architectural distortion, traction bronchiectasis, reticular abnormalities and pleural thickening with subpleural parenchymal consolidations, mainly in the upper lobes (Fig. 2).\n\nLung biopsy had been previously performed, and the pathology showed subpleural parenchymal fibroelastosis.\n\n- Case 2\nThe chest X-ray showed bilateral pleural thickening of apical predominance with reticular interstitial pattern more prominent on the left and upper lobes volume loss (Fig. 3).\n\nThe HRCT showed bilateral pleural thickening with subpleural irregular opacities more prominent in the left apex, architectural distortion, multiple traction bronchiectasis, ground-glass opacities and upper lobes volume loss (Fig. 4).\n\nThe patient underwent bilateral lung transplantation.\n\nMicroscopic examination of the explant showed pleural fibroelastosis in the upper lobes and a pattern of nonspecific interstitial pneumonia in the lower lobes (Fig. 5).",
    "discussion": "Pleuroparenchymal fibroelastosis (PPFE) is a rare condition that consists of fibrosis involving the pleura and subpleural lung parenchyma, predominantly in the upper lobes [1, 2].\nThis entity was first coined in 2004 by Frankel et al. [3], although the same concept designated as idiopathic pulmonary upper lobe fibrosis was proposed in 1992 by Aminati and colleagues [4].\nThe PPFE is now listed as one of the rare idiopathic interstitial pneumonias (IIPs) in the updated classification of IIPs of the American Thoracic Society/European Respiratory Society [1].\nThere are no reliable data on the incidence and prevalence [5].\nLittle is known about its aetiology, and many cases have been regarded as idiopathic [6], however, a considerable number of patients with PPFE have underlying diseases or conditions that might be relevant to its occurrence and development, including radiation, anticancer chemotherapy, bone marrow transplantation, lung transplantation, occupational dust exposure, infections, pneumothorax, autoimmunity, and a possible genetic predisposition [6, 7, 8, 9].\nAge at onset is wide-ranging, from young to old age, with a median age of 57 years [2, 7]. There is no gender predilection [1, 2, 7] and patients are most often non-smokers [7].\nThe main symptoms are nonproductive cough and exertional dyspnoea. Such symptoms appear insidiously. Chest pain due to pneumothorax may be the first symptom [7].\nAlthough surgical lung biopsy or autopsy is essential for the definite diagnosis, imaging findings are also essential as the first step to the final diagnosis.\nAt the early stage of idiopathic PPFE, bilateral apical pleura appear irregularly thickened on the frontal view of chest radiographs. Later, chest radiograph shows marked apical pleural thickening associated with superior hilar retraction. Subsequently, reticular and nodular opacities appear in the bilateral upper lung fields, and hilar opacities are further elevated [5].\nHRCT shows dense pleural and subpleural consolidation with a reticular pattern, predominantly in the upper lobes, traction bronchiectasis, architectural distortion, and upper lobe volume loss [1, 5]. In contrast to such changes in the upper lobes, changes in the middle and lower lobes are minimal. As the disease progresses, the opacities extend to the adjacent lobes [5].\nPPFE is histologically characterized by alveolar collapse with subpleural elastosis and intra-alveolar fibrosis, in addition to the thickening of the pleura mainly in upper lobes [5, 8, 10, 11].\nThe clinical course of this affection is progressive and prognosis is poor, although some cases take years to develop, others rapidly progress to respiratory failure, with no therapeutic options other than lung transplantation available [5].",
    "differential_diagnosis": "Pleuroparenchymal, fibroelastosis, Asbestosis, Connective, tissue, diseases, Advanced, fibrosing, sarcoidosis, Radiation, or, drug, induced, lung, disease, Chronic, hypersensitivity, pneumonitis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013850/000001.png?itok=ZteKFp-F",
            "caption": "Posteroanterior conventional chest x-ray revealed bilateral upper lung volume loss, hilar opacities elevated (red arrow), and apical pleural thickening (yellow arrow)."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013850/000002.png?itok=EUIvnp1i",
            "caption": "Left lateral chest X-ray showed upper lobe volume loss, hilar opacities elevated (red arrow), and apical pleural thickening (yellow arrow)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013850/000003.png?itok=kKZ3Rxse",
            "caption": "Axial HRCT showed upper lobe volume loss, architectural distortion, traction bronchiectasis, reticular abnormalities and apical irregular pleural thickening, with subpleural parenchymal consolidations, mainly in the upper lobes."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013850/000004.png?itok=ULnArE5D",
            "caption": "Coronal HRCT images showed upper lobe volume loss, architectural distortion, traction bronchiectasis, reticular abnormalities and apical irregular pleural thickening."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013850/000005.png?itok=7-bEY9vX",
            "caption": "Posteroanterior conventional chest X-ray showed pleural thickening of apical predominance (yellow arrow) with reticular interstitial pattern more prominent on the left and signs of volume loss in the upper lobes."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013850/000006.png?itok=NJIGHdve",
            "caption": "Left lateral chest X-ray showed pleural thickening of apical predominance and upper lobe volume loss."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013850/000007.png?itok=3Nh6uLS5",
            "caption": "Axial HRCT showed bilateral pleural thickening with subpleural irregular opacities more prominent in left apex, architectural distortion, multiple traction bronchiectasis, ground-glass opacities and upper lobe volume loss."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013850/000008.png?itok=mqLvWHvV",
            "caption": "Coronal HRCT images showed bilateral pleural thickening, architectural distortion, multiple traction bronchiectasis, ground-glass opacities and upper lobe volume loss."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013850/000016.png?itok=fu-9762M",
            "caption": "Histological sample with haematoxylin and eosin showed increase of elastic fibres (blue arrow) and abrupt transition to normal parenchyma (yellow arrow)."
          },
          {
            "number": "Figure 5b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013850/000010.png?itok=JZ_ZAHKG",
            "caption": "Histological sample with haematoxylin and eosin (200x) showed increase of elastic fibres (blue arrow) and abrupt transition to normal parenchyma (yellow arrow)."
          },
          {
            "number": "Figure 5c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013850/000013.png?itok=td_I5ggV",
            "caption": "Histological sample with haematoxylin and eosin stain (400x) showed collapse of alveolar spaces by interstitial material that corresponds to elastic  fibres (green arrow). There is also scant lymphocyte infiltrate (red arrow)."
          },
          {
            "number": "Figure 5d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013850/000017.png?itok=B2dcLlgF",
            "caption": "Van Gieson stain demonstrates abnormal elastic fibres in the thickened interstitium."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax",
      "Lung"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT-High Resolution",
      "Experimental"
    ],
    "link": "https://www.eurorad.org/case/13850",
    "time": "30.06.2016"
  },
  "13855": {
    "case_id": 13855,
    "title": "Severe achalasia with hiatal herni",
    "section": "Chest imaging",
    "age": "94",
    "gender": "female",
    "diagnosis": "Sliding hiatal hernia in end stage achalasia.",
    "history": "The patient suffered from dysphagia and regurgitation and found intake of food increasingly difficult. She was admitted due to severe dehydration and malnutrition. Upon admission her weight was 38kg and her general condition poor. She previously had a percutaneous endoscopic gastrostomy (PEG) tube to secure nutrition.",
    "image_finding": "She was referred to a barium swallow for anatomic evaluation.The examination showed end stage achalasia combined with a large hiatal hernia. There was an abnormal dilatation of oesophagus with air-filled sacculate ballooning (Fig. 1a+b)). The passage of barium contrast was severely delayed due to almost total loss of peristalsis, and a spastic lower oesophageal sphincter (LES) with has a lumen of only 2 mm (Fig. 2b). Additionally, the large hiatal hernia measuring 13x8cm in diameter prevented the passage of barium contrast (Fig. 2a+b). Trendelenburg/Valsalva manoeuvre in supine position showed that most of the hernia was sliding, but it also had an paraesophagal component, making it a Type III hiatal hernia. It comprised 2/3 of the stomach, including the fundus and the majority of the corpus.",
    "discussion": "Achalasia is a motor disease of unknown cause in which there is a loss of peristalsis in the distal oesophagus and a failure of LES relaxation. It is a rare disorder with an prevalence of 10 cases per 100, 000 individuals [1]. Men and women are affected with equal frequency and the disease can occur at any age, however, onset before adolescence is rare. Hiatal hernia refers to herniation of elements of the abdominal cavity through the oesophageal hiatus of the diaphragm. Contrary to achalasia it is a common radiological finding with a reported frequency of 20-50% in the general population. The wide reported frequency is partly dependent on the age of the population studied as the frequency increases with age. [2]Although hiatal hernia is more common, its occurrence and potential implication in achalasia is less well-known. There are few articles on the subject, and no greater study has been published in English the last 15 years. When reviewing the literature, the great majority of the reports on hiatal hernia in achalasia have emphasized its rarity with a prevalence ranging from 1.4%-14% [3-5]. Factors responsible for the rarity are not known.  However, based on the literature published so far the most common symptoms in patients with hiatal hernia and achalasia are dysphagia and/or regurgitation. The sex, age distribution, type and frequency of symptoms, and LES pressures have not been significantly different in patients having hiatal hernia compared to those without hernia. Furthermore, patients with achalasia and hiatal hernia where successfully treated with pneumatic balloon dilatation without complications, suggesting that such treatment can be performed successfully. [2, 6, 7]The patient in this clinical case was treated with pneumatic balloon dilatation.",
    "differential_diagnosis": "Sliding, hiatal, hernia, in, end, stage, achalasia., Oesophageal, diverticula, Oesophageal, cancer, Ventricle, cancer, Oesophageal, stricture",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013855/000005.jpg?itok=adEcXEoa",
            "caption": "Frontal projection\nImage showing achalasia with severe dilatated air-filled sacculate oesophagus and spastic narrow LES."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013855/000006.jpg?itok=MPYQ4cQP",
            "caption": "Lateral projection"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013855/000007.jpg?itok=h_3ipmhM",
            "caption": "Supine frontal projection. This is a Type III hernia because there are elements of both sliding- and paraesophagal hernia."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013855/000008.jpg?itok=j7f2_mZH",
            "caption": "Supine lateral projection"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Oesophagus",
      "Gastrointestinal tract"
    ],
    "imaging_technique": [
      "Conventional radiography"
    ],
    "link": "https://www.eurorad.org/case/13855",
    "time": "10.09.2016"
  },
  "13878": {
    "case_id": 13878,
    "title": "Acute pneumonia evolution",
    "section": "Chest imaging",
    "age": "33",
    "gender": "male",
    "diagnosis": "Acute varicella pneumonia",
    "history": "A previously healthy patient presented with a 2-day history of high fever, skin lesions, non-productive cough, and dyspnoea.Physical examination revealed non-pruritic skin lesions in different stages, bilateral basal lung crackles, and hypotension. Viral pneumonia was suspected and the patient was started on acyclovir treatment.",
    "image_finding": "The emergency room chest X-ray showed a bilateral nodular pattern, consisting of numerous 5 to 10 mm poorly defined nodules that were confluent in some areas (Figs. 1 and 2).Some hours later, the patient experienced respiratory failure and was transferred to the intensive care unit. Portable chest X-ray revealed bilateral interstitial oedema (Fig. 3). PCR testing of the cutaneous exudate was positive for varicella zoster complex.The patient received respiratory support and treatment with intravenous acyclovir and ceftriaxone, with a favourable response. Nine days later, his clinical status had improved, oxygen was not required, and he was discharged from the hospital. On chest plain films, interstitial oedema had resolved but the nodular pattern persisted (Fig. 4). The follow-up chest X-ray at 10 days after discharge showed no changes (Fig. 5).",
    "discussion": "Viral pneumonia in adults can be divided into two groups: atypical pneumonia that affects healthy hosts and viral pneumonia in immunocompromised hosts [1].Varicella-zoster virus (VZV) is the causal agent of chickenpox, the initial manifestation of infection by this pathogen [2]. The incidence of VZV infection in adults has doubled in the last few years (2.3 cases per 400 individuals) [3], with increases in the associated hospitalization and mortality rates [4].Varicella pneumonia, the most serious complication of disseminated VZV, affects healthy adults much more often than children [4, 5]. The incidence of varicella pneumonia in healthy adults ranges from 5% to 50%, depending on the series [6]. The respiratory symptoms (dyspnoea, chest pain, tachypnoea, cyanosis, haemoptysis and fever) usually develop after the typical skin rash, which helps to establish the diagnosis [2, 4]. In some cases these symptoms are severe and lead to respiratory failure with signs of oedema on chest radiography [2, 4, 6\u20138]. In adults, varicella pneumonia tends to develop 10-21 days after the primoinfection during the viremia period [2]. Histologic examination of the lung shows diffuse alveolar damage and scattered fibrotic capsular nodules with central necrosis [1, 5, 9]. The key findings of varicella pneumonia on conventional chest radiography are small scattered nodules in both lungs that may coalesce [1, 5, 6]. CT shows multiple, small, ill- or well-defined nodules (1-10 mm) that may have a ground-glass halo, scattered in both lungs, patchy ground-glass attenuation, and coalescent lesions. Lymphadenopathy and pleural effusion are not commonly seen [1, 5, 10, 11]. The small nodules usually resolve within one week after the skin lesions disappear, but they may persist for months. The lesions may calcify, and multiple, scattered, 2 to 3 mm well-defined calcifications are sometimes seen lifelong on chest radiographs [1, 5, 10, 11] (Fig 7, 8).Antiviral treatment (acyclovir) is used in patients in risk for severe disease and in patients with complications such as varicella pneumonia [2, 3, 7, 8]. Other treatments such as assisted ventilation and corticosteroids may be necessary in respiratory insufficiency [7]. Viral pneumonia is the most common complication of primoinfection with VZV.-\tThe diagnosis is made based on the typical skin rash associated with respiratory symptoms, which may be severe-\tChest radiography shows a diffuse nodular pattern with nodule coalescence-\tOn CT the nodules are associated with a ground-glass halo or patchy ground-glass attenuation",
    "differential_diagnosis": "Acute, varicella, pneumonia, Miliary, tuberculosis, Miliary, metastases, Hypersensitivity, pneumonitis, Sarcoidosis, Langerhans, cell, hystiocytosis, Silicosis, Coal, workers\u2019, pneumoconiosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013878/000002.png?itok=98ipiG0v",
            "caption": "Lateral conventional chest X-ray shows a diffuse nodular pattern."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013878/000005.png?itok=e-PYjJBD",
            "caption": "Anteroposterior portable conventional chest X-ray revealed diffuse interstitial pattern."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013878/000006.png?itok=YgGaTyY0",
            "caption": "Posteroanterior conventional chest X-ray depicts a persistent nodular pattern with no interstitial oedema."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013878/000007.png?itok=roEaz3us",
            "caption": "Posteroanterior conventional chest X-ray with a persistent nodular pattern and no interstitial oedema."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013878/000008.png?itok=GARo07fI",
            "caption": "Posteroanterior conventional chest X-ray with multiple small calcified nodules. Breast prothesis."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013878/000009.png?itok=DiPA4S_H",
            "caption": "MIP and coronal reconstruction with multiple small calcified nodules of chronic varicella pneumonia."
          }
        ]
      },
      {
        "number": "Figure 7",
        "subfigures": [
          {
            "number": "Figure 7",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013878/000010.png?itok=qsjsrXvX",
            "caption": "Posteroanterior conventional chest X-ray shows a diffuse bilateral nodular pattern."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "CT",
      "Conventional radiography"
    ],
    "link": "https://www.eurorad.org/case/13878",
    "time": "11.08.2016"
  },
  "13884": {
    "case_id": 13884,
    "title": "Pulmonary cement embolism",
    "section": "Chest imaging",
    "age": "76",
    "gender": "female",
    "diagnosis": "Pulmonary embolism by cement.",
    "history": "A 76-year-old female patient presented to the emergency department with dyspnoea. Arterial blood gas test showed hypoxaemia. The symptoms did not improve with non-invasive ventilation. The patient had undergone spinal transpedicular osteosynthesis from T10 to S1 48 hours ago.",
    "image_finding": "A dense tubular-branched opacity in the proximity of the right hilum was observed on the chest radiograph. The morphology of this opacity suggested that it was following the path of a vessel (Fig. 1). Given the chest radiograph findings and the patient\u2019s symptoms, a Computed Tomography Pulmonary Angiography (CTPA) was performed immediately, which revealed that bilateral segmental and sub-segmental pulmonary arteries were filled with a high density material (1, 125 Hounsfield Units), compatible with cement (Fig. 2). The CTPA also showed that cement used for the transpedicular osteosynthesis had migrated trough the vertebral venous plexus (Fig. 3). Those CT findings confirmed the diagnosis of pulmonary cement embolism.",
    "discussion": "Pulmonary cement embolism consists of filling of the pulmonary arteries by cement. It occurs in up to 25% of the patients who undergo percutaneous vertebral cementation techniques, usually vertebroplasty and kyphoplasty [1]. More infrequently (4.1% of the cases), it can also originate from a transpedicular osteosynthesis when augmentation of pedicle screws with bone cement is performed [3]. Pulmonary cement embolism is caused by a leakage of cement through the vertebral venous plexus, which migrates through the inferior cava vein, the azygos system and finally reaches the pulmonary circulation (pulmonary arteries). This entity is frequently asymptomatic, but it can present with similar symptoms to those produced by a thrombotic pulmonary embolism, such as dyspnoea, tachypnoea or chest pain and they may appear immediately after the surgery or several months later. [2]On chest X-ray, the cement embolus may be depicted as linear high-density opacities that follow the routes of the pulmonary vessels. On chest CT, the occupation of the pulmonary arteries by a high-density structure compatible with cement makes the diagnosis.Although the treatment and management of a cement pulmonary embolism is controversial, in general terms, it is the same as for an embolism of thrombotic origin: fibrinolysis if there is haemodynamic instability or anticoagulation therapy if there is no instability. The prognosis depends on the right heart function. [1]Faced with a patient with dyspnoea and a previous vertebral cementation procedure, we must keep in mind the possibility of a cement pulmonary embolism [2]. In contrast to other embolic diseases, this entity can be diagnosed with a chest radiograph.",
    "differential_diagnosis": "Pulmonary, embolism, by, cement., Since, the, patient, had, undergone, a, cemented, spinal, procedure, in, the, previous, 48, hours, radiological, findings, were, highly, suggestive, of, pulmonary, thromboembolism, by, cement., There, is, no, differential, diagnosis.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013884/000001.jpg?itok=o2yXErwc",
            "caption": "Anteroposterior chest radiograph showing a tubular-branched opacity denser than calcium located in the proximity of the right hilum (white arrow). Transpedicular osteosynthesis in caudal dorsal spine is also observed (black arrows)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013884/000002.jpg?itok=skkAApVO",
            "caption": "Contiguous axial oblique Computed Tomography Pulmonary Angiography (CTPA)images showing segmental and sub-segmental pulmonary arteries in the anterior segment of both upper lobes occupied by cement (white arrows).  A pleural effusion is also present (asterisks)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013884/000003.jpg?itok=644x5nJi",
            "caption": "Contiguous axial oblique CTPA images showing material related to transpedicular spinal osteosynthesis using cemented screws (arrowheads) at caudal dorsal level. Cement migrates from the vertebral body (black arrow) through the vertebral venous plexus (white arrows)."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Arteries / Aorta",
      "Education"
    ],
    "imaging_technique": [
      "CT-Angiography"
    ],
    "link": "https://www.eurorad.org/case/13884",
    "time": "10.08.2016"
  },
  "13898": {
    "case_id": 13898,
    "title": "Mediastinal hamartomatous vascular malformation causing dysphagi",
    "section": "Chest imaging",
    "age": "47",
    "gender": "female",
    "diagnosis": "Mediastinal hamartomatous venous malformation",
    "history": "47-year-old female presenting with chest discomfort and dysphagia to medicine outpatient department. Gastrointestinal endoscopy was done which did not reveal any mass lesion, however, there was extrinsic compression on oesophagus 30 cm from the central incisors.",
    "image_finding": "Computed Tomography angiography revealed a mixed soft tissue mass with venous collaterals (Fig. 1) in the mediastinum in the prevascular and subcarinal (retro-oesophageal and para-aortic) regions with tiny calcific specks within. Multiple venous collaterals were noted in the mediastinum adjoining these soft tissue masses draining into large venous collateral connecting the left inferior pulmonary vein to the azygous vein (crossing posterior to the descending thoracic aorta) (Fig. 2, 3). It was causing widening of the carina (Fig. 4) indenting the posterior surface of the left atrium (Fig. 5), compressing the oesophagus anteriorly (Fig. 6) and was encasing the descending thoracic aorta (Fig. 5). Multiple grossly dilated venous collaterals were noted in the perigastric and perisplenic regions (Fig. 7) with a large tortuous draining vein communicating with the inferior vena cava superiorly and the portal vein inferiorly (coronary vein). The portal vein was grossly dilated (2.4 cm) at the porta hepatis (Fig. 8).",
    "discussion": "Vascular malformations are congenital abnormalities of vascular embryological development consisting of dysplastic vessels (arterial, venous, capillary, lymphatics or combination of any of these) [1]. They are commonly seen in extremities, head and neck and visceral organs like liver and spleen [2]. Mediastinal vascular malformations are rare and usually asymptomatic but may present with signs and symptoms related to mass effect on adjacent structures [3]. The International Society for the Study of Vascular Anomalies classification system divides vascular anomalies into 2 primary biological categories: vasoproliferative or vascular neoplasms and vascular malformations depending on the endothelial cell turnover [4]. These can be further classified into high flow and low flow malformations. Low flow malformations contain a combination of capillary, venous and lymphatic components whereas high flow malformations contain arterial components in combination with other vascular components [4].A venous malformation is a low flow malformation composed of serpentine structures of slow flowing blood separated by septations which communicates with adjacent veins and is interspersed with hamartomatous stroma [2]. Hamartomatous tissue is a non-neoplastic proliferation of cells and tissue that normally occur in an affected area. Round, ovoid calcified thrombi may be seen within the malformation.Imaging plays an important role in diagnosis and characterisation of these lesions, revealing the anatomical extent and involvement of adjacent structures required for planning the optimal therapeutic option [2]. CT angiography is useful for characterisation of soft tissue masses by revealing the vascularity of the lesion required for preoperative planning with a high degree of spatial resolution [5]. On Magnetic Resonance Imaging, these usually show intermediate signal intensity on T1Weighted images and very high signal intensity on T2 Weighted images with slow enhancement on post-contrast images. Phleboliths may show blooming on gradient echo images.In our case, there was a soft tissue mediastinal mass with multiple venous collaterals communicating with adjacent veins leading to a diagnosis of venous malformation. It is distinct from fibrosing mediastinitis where infiltrative mediastinal mass is seen which is encasing and/or infiltrating the mediastinal structures. Ig G-4 related disease also presents as a diffuse mediastinal mass encasing and compressing the mediastinal structures, however, no venous collaterals are seen. Thus the diagnosis in our case was a mediastinal hamartomatous vascular malformation.Though mediastinal vascular malformations are rare, they should be considered in the differential diagnosis of patients presenting with dysphagia.",
    "differential_diagnosis": "Mediastinal, hamartomatous, venous, malformation, Mediastinal, tumours, Ig, G-4, related, disease, Fibrosing, mediastinitis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013898/000001.jpg?itok=7Ijiy3RF",
            "caption": "CT angiography of chest coronal image showing a mixed soft tissue mass with venous collaterals in mediastinum."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013898/000002.jpg?itok=BmkkI0VM",
            "caption": "CT angiography of chest axial images showing multiple venous collaterals draining into large venous collateral connecting the left inferior pulmonary vein to azygous vein (crossing posterior to the descending thoracic aorta)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013898/000003.jpg?itok=GNcSkNaV",
            "caption": "CT angiography of chest axial images showing multiple venous collaterals draining into large venous collateral connecting the left inferior pulmonary vein to azygous vein (crossing posterior to the descending thoracic aorta)."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013898/000004.jpg?itok=q3SJ5Ufh",
            "caption": "CT angiography of chest coronal image showing mediastinal hamartomatous vascular malformation widening of carina and indentation on the posterior surface of left atrium."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013898/000005.jpg?itok=bcJg-mHM",
            "caption": "CT angiography of chest axial image showing mediastinal hamartomatous vascular malformation encasing descending thoracic aorta and indenting the posterior surface of left atrium."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013898/000006.jpg?itok=fn3G63r-",
            "caption": "CT angiography of chest axial image showing mediastinal hamartomatous vascular malformation compressing the oesophagus anteriorly."
          }
        ]
      },
      {
        "number": "Figure 7",
        "subfigures": [
          {
            "number": "Figure 7",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013898/000007.jpg?itok=Pd-vvJfb",
            "caption": "CT angiography of chest coronal image showing multiple grossly dilated venous channels in perigastric and perisplenic regions."
          }
        ]
      },
      {
        "number": "Figure 8",
        "subfigures": [
          {
            "number": "Figure 8",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013898/000008.jpg?itok=Z2olZUBJ",
            "caption": "CT angiography of chest coronal image showing grossly dilated portal vein at porta hepatis."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Mediastinum"
    ],
    "imaging_technique": [
      "CT-Angiography"
    ],
    "link": "https://www.eurorad.org/case/13898",
    "time": "02.08.2016"
  },
  "13903": {
    "case_id": 13903,
    "title": "Pulmonary infarction: What should I look for?",
    "section": "Chest imaging",
    "age": "50",
    "gender": "male",
    "diagnosis": "Pulmonary infarction (pulmonary thromboembolism)",
    "history": "50-year-old patient who reports a sudden onset of stabbing right thoracic pain without fever, dyspnoea or cough. Previous medical history included ulcerative colitis, bladder cancer and deep venous thrombosis.",
    "image_finding": "X-ray (10 days after the acute episode): A non-specific parenchymal opacity within the right inferior lobe and blurring of the right costophrenic angle (pleural effusion). Note the enlarged inferior pulmonary artery (Palla's sign). (Fig. 1b) Following these findings, the patient started an antibiotic treatment.X-ray (15 days): Increasing pleural effusion with blurring of the right costophrenic angle (Ellis-Daimoseau line) and a slightly enlarged inferior pulmonary artery (Fig. 1c). After these new findings and his previous medical history, a CECT was performed to rule out other pathological conditions.CECT: Pulmonary embolism involving the latero-basal and postero-basal arterial branches of the right lower lobe (Fig. 2). Triangle-shaped consolidation with peripheral air lucencies within it (which are not air bronchograms) and diminished enhancement of lung parenchyma (Fig. 3a, b). Note the absence of arterial vessels within the consolidation (Fig. 3, 4). X-ray (before being discharged):Persistent right lower lobe subtle opacity with a residual linear scar and pleural thickening. No pleural effusion is present (Fig. 5).",
    "discussion": "A- BACKGROUND [1] Pulmonary infarction is due to coagulative ischaemic necrosis. The ischemic damage to the arterial endothelium and alveolar cells causes haemorrhage (early stages) or coagulative necrosis (infarction, later stages). Peripheral emboli rather than central, tend to cause infarction (10\u201330% of patients with pulmonary embolism have pulmonary infarction), this is related to a dual blood supply of the lung: from pulmonary arteries and bronchial arteries. Peripheral blood flow relies mainly on pulmonary arteries, this is the reason why this area suffers the most important ischaemic changes.  B- CLINICAL PERSPECTIVE [1, 2]Infarction and haemorrhage occur at the periphery of the lung. Small haemothorax secondary to pulmonary infarction tend to irritate the pleura and cause pain. Pleuritic chest pain is more frequent in patients with pulmonary infarction than in patients with acute pulmonary embolism who do not have infarction. C- IMAGING PERSPECTIVE [1, 2, 3]X-ray:Unspecific parenchymal opacity. A typical appearance as a wedge-shaped pleurally-based opacity \u2018Hampton hump\u2019 typically abutting the pleura, could be found. Pleural effusion is more common in pulmonary embolism with than without infarction. Chronic pulmonary infarcts can leave residual radiographic changes as linear scars and pleural thickening. ULTRASOUND: Pleurally-based hypoechoic, triangular or round lesion. Early infarcts are often hypoechoic. CT: - Wedge-shaped, broad pleurally-based opacity with a truncated apex and a convex border (\u2018Hampton hump\u2019).- Central lucencies are suggestive of pulmonary infarction, although they could represent aerated non-infarcted lung. Interobserver agreement seems good for central lucencies.- Lower frequency of air bronchograms within the infarcted lung parenchyma.CONTRAST-ENHANCED CT:- Thromboembolism within the pulmonary artery feeding the \"opacity\" could be detected.- The vascular sign (a thickened vessel leading to the apex of the opacities) is difficult to recognize. - Decreased enhancement is related to a diminished perfusion of the lung secondary to the vascular occlusion.MRI: MRI appearance changes according to signal characteristics of the aging blood present in the alveoli (haemorrhage):- <24 h = T1 hypointense and T2 hyperintense.- >24 h to 1 week = Subacute infarction being T1 hyperintense. D- OUTCOME Infarcts should diminish (\u2018melting sign\u2019) with complete resolution or leaving a residual scar or pleural thickening, although this occurs over a period of weeks or months. E- TAKE HOME MESSAGE- Central lucencies are very specific for infarct. - Pleural effusion is a frequent finding.- Wedge-shaped, broad pleurally-based opacity with a truncated apex and a convex border (\u2018Hampton hump\u2019) is typical.",
    "differential_diagnosis": "Pulmonary, infarction, (pulmonary, thromboembolism), Necrotizing, pneumonia, Neoplasm",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013903/000001.jpg?itok=A10nM54Z",
            "caption": "Pulmonary embolism involving the latero-basal and postero-basal arterial branches of the right lower lobe (red arrow)."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013903/000003.jpg?itok=QjHy8OP_",
            "caption": "Filling defect of the latero-basal and postero-basal branches, caused by a thromboembolism (red arrow)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013903/000004.jpg?itok=wb3cKh_u",
            "caption": "Consolidation with diminished enhancement (red arrows) compared to normal enhancement (yellow arrows). Note the abscence of arterial vessels in the right lower lobe compared to normal lung (orange arrow). Bronchogram within well-perfused lung (white arrow)."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013903/000018.jpg?itok=maEns1cr",
            "caption": "Triangle-shaped consolidation which contains multiple internal air lucencies (red arrows). Diminshed enhancement of the consolidation\n(yellow arrows = normal enhancement)."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013903/000005.jpg?itok=XrANCqL4",
            "caption": "Sparing of the anterior basal branch of the inferior lobe and middle lobe artery, with correct enhancement of lung parenchyma (yellow arrows)."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013903/000006.jpg?itok=xdgUhwNb",
            "caption": "On a posterior coronal image, the abscence of blood vessels within the unenhanced parenchyma is seen. Normal enhancement of the superior segment (yellow arrows) compared to diminshed enhancement of posterior and basal segments (red arrows)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013903/000008.jpg?itok=L_gVsLjH",
            "caption": "Internal air\nlucencies (which are not air bronchograms) present within the confluent consolidation (bubbly consolidation)."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013903/000009.jpg?itok=fecDEdPs",
            "caption": "Note the peripheral location of the previously mentioned air\nlucencies within the consolidation."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013903/000015.jpg?itok=iL3Mzfhv",
            "caption": "10 DAYS:\nA non-specific parenchymal opacity within the right inferior lobe (red arrows) and blurring of the right costophrenic angle (pleural effusion)."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013903/000016.jpg?itok=6jhpXaFO",
            "caption": "15 DAY:\nElis-Daimoseau line in the right costophrenic angle (pleural effusion, green arrow). \nSlightly enlarged inferior pulmonary artery (yellow arrow)."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013903/000017.jpg?itok=Uie4l-FM",
            "caption": "Persistent right lower lobe subtle opacity with a residual  linear scar and pleural thickening. Note the normal right costophrenic angle, no pleural effusion."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Trauma",
      "Thorax",
      "eHealth",
      "Contrast agents"
    ],
    "imaging_technique": [
      "CT-Angiography",
      "Digital radiography",
      "CT-High Resolution"
    ],
    "link": "https://www.eurorad.org/case/13903",
    "time": "10.09.2016"
  },
  "13929": {
    "case_id": 13929,
    "title": "Primary pericardial mesotheliom",
    "section": "Chest imaging",
    "age": "81",
    "gender": "male",
    "diagnosis": "Primary pericardial mesothelioma.",
    "history": "An 81-year-old man was admitted in the emergency room for months-long, but recently aggravated, dyspnoea, asthenia, chest pain and palpitations. He had a history of recent weight loss (6 kilograms in the past three months). He was under diagnostic investigation in a different hospital for pericardial effusion.",
    "image_finding": "Chest radiography showed diffuse mediastinal widening. Previous thoracic radiography from 2013 was normal.Thoracic CT revealed heterogeneous enhanced mass occupying the entire pericardial space and surrounding the superior vena cava.",
    "discussion": "Primary pericardial mesothelioma is a rare malignant neoplasm arising from mesothelial cells [1]. It represents the most common of all primary pericardial tumours (50%), but only 0.7% of mesotheliomas [1, 2], which arise more frequently from the pleura (88.8%) and peritoneum (9.6%) [3]. Primary tumours of the pericardium can be benign (teratoma, fibroma, lipoma, angioma) or malignant (mesothelioma, sarcoma) [3, 4]. Secondary tumours are 100-1000 times more common, arising more frequently as lung, breast, melanoma or lymphoma metastasis [5].This tumour can occur at any age, more frequently between 5th-7th decades, with a slight male predominance [2, 5].The cause of this tumour is unknown, and unlike pleural mesothelioma, the link with asbestos exposure is unclear [3]. Factors that may play a role include radiation and recurrent serosal inflammation.Clinical presentation is usually insidious. Common clinical manifestations are constrictive pericarditis, pericardial effusion, cardiac tamponade and heart failure [4].Chest radiography usually demonstrates enlargement of the cardiac silhouette, an abnormal mediastinal contour, or a discrete mediastinal mass [5]. Imaging findings at CT commonly appear as pericardial effusion. Although pericardial effusion is the rule, the pericardial cavity may be obliterated by tumour, as was the case with our patient, showing an infiltrating pericardial mass that is often isoattenuating to hypoattenuating relative to myocardium. Heterogeneous enhancement after administration of intravenous contrast material is routinely demonstrated.Computed tomography also gives details of the relationship with neighbouring structures, invasion of vital structures, and aid in the evaluation the resectability and presence of metastatic disease. Magnetic resonance can also help in characterizing the tumour, demonstrating of myocardial invasion, and assessing the functional impact of the neoplasm on the heart [5]. Positron emission tomography (PET)/CT may be useful for evaluation of distant or loco-regional spread of disease [5]. Criteria to identify a primary pericardial mesothelioma require no tumour present outside the pericardium, with the exception of lymph node metastasis, as was also the case [2]. Lymph node biopsy confirmed the diagnosis in our patient.Complications of pericardial mesothelioma include pericardial effusion, cardiac tamponade, compression of vascular structures or cardiac chambers, encasement of vital structures, diastolic dysfunction, constrictive pericarditis, and invasion of mediastinal structures, regional or distant metastases [5].The prognosis is very poor due to late presentation, frequently presenting as an unresectable tumour, and weak response to radiotherapy and chemotherapy [3]. Survival after diagnosis ranges from 6 weeks to 15 months [4]. In the case of localized disease, surgical resection can be curative.",
    "differential_diagnosis": "Primary, pericardial, mesothelioma., Pericardial, lymphoma, Tuberculous, pericarditis, Inflammatory, myofibroblastic, tumour, Mediasytinal, inflammatory, pseudotumuor",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013929/000001.png?itok=2u4Kpay1",
            "caption": "Enlargement of the cardiac silhouette with a watter bottle configuration, suggesting pericardial effusion."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013929/000002.png?itok=0YRWadjo",
            "caption": "Contrast-enhanced axial CT demonstrating the presence of a hypodense pericardial mass, with heterogeneous enhancement, that encases the great vessels."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013929/000003.png?itok=tR-PhDDr",
            "caption": "Axial CT image shows pericardial mass associated with cardiophrenic lymph nodes. Small bilateral pleural effusion was also present."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013929/000004.png?itok=RFEupatN",
            "caption": "Coronal reformatted contrast-enhanced CT showing the extent of the pericardial mass. A liver cyst is also present."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013929/000005.png?itok=8TTlUYTl",
            "caption": "Coronal reformatted CT image demonstrating multiple enlarged lymph nodes. Liver cyst."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Mediastinum"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/13929",
    "time": "09.08.2016"
  },
  "13935": {
    "case_id": 13935,
    "title": "Sudden thoracic pain and dyspnea in a young adult",
    "section": "Chest imaging",
    "age": "26",
    "gender": "male",
    "diagnosis": "Spontaneous Pneumomediastinum",
    "history": "A 26-year-old male patient was admitted to the emergency department with sudden thoracic and supraclavicular pain and dyspnoea while playing football. During the last week, the patient complained of non-productive cough and rhinorrhea. Cardiac necrosis markers were normal. Chest x-ray, supraclavicular ultrasound and thoracic CT were performed.",
    "image_finding": "The chest radiography was first misinterpreted as normal and a supraclavicular ultrasound ordered because of supraclavicular pain.Supraclavicular ultrasound showed subcutaneous emphysema (Fig. 1) and a CT was then performed showing pneumomediastinum (Fig. 2A), with the air extending to the supraclavicular region, to the retropharyngeal space and surrounding the carotid arteries and jugular veins bilaterally (Fig 2B).Retrospectively, although it was subtle, the chest radiography showed multiple signs of pneumomediastinum which could have been detected earlier if a careful analysis had been made.Bilateral subcutaneous emphysema in the supraclavicular region could be seen (Fig. 3A). In addition, in the mediastinum, detachment of the parietal pleura from the right lateral border of the trachea with air between these two structures could be seen (Fig. 3B). Air outlining the outer contour of the right and left bronchi, a finding known as \"double bronchial wall sign\", was also visible (Fig. 3B).",
    "discussion": "Pneumomediastinum represents the presence of air within the mediastinum, and can be divided in spontaneous and secondary (to trauma, oesophageal or tracheobronchial injury).Mediastinal air may have an intrathoracic (trachea, bronchi, lung, oesophagus) or extrathoracic (peritoneum, head, neck) source. The most common origin of spontaneous and traumatic pneumomediastinum is the lung, and the responsible pathophysiologic mechanism is the Macklin effect which consists of alveolar wall rupture due to elevated alveolar pressures, followed by peri-bronchovascular air dissection into the mediastinum. [1, 2]. The most common presentation of spontaneous pneumomediastinum (SM) is acute retrosternal chest pain. Dyspnoea and subcutaneous emphysema may also be present [3].Chest radiography is the standard diagnostic procedure. There are multiple radiographic signs described, such as [1, 2]:- Double bronchial wall sign: Air outlining bronchial walls.- Continuous diaphragmatic sign: Air posterior to the pericardium.- Subcutaneous emphysema.- Thymic sail sign: In children the thymus may become elevated.On the lateral chest radiograph:- Pneumoprecardium: Air anterior to the heart.- Ring around the artery sign: Air enclosing the pulmonary artery.The distinction between SM and a secondary cause of pneumomediastinum such as esophageal or tracheobronchial rupture can not always be made clinically. Chest radiography should be carefully analysed, as the differentiation is imperative since the first resolves naturally, whereas the last two are often managed surgically [4].The most common site of oesophageal tear is in the left postero-lateral wall of the distal oesophagus, which usually leads to mediastinal air lateral to the aorta and between the parietal pleura and the left hemidiaphragm (Naclerio\u2019s V sign). Moreover, reactive left lower lobe pneumonitis and left pleural effusion may also be found. If needed, the diagnosis may be confirmed with an esophagogram with gastrografin or CT [4].When tracheobronchial injury is suspected, tracheobronchial morphology should be carefully assessed. The fallen lung sign (collapsed lung away from the mediastinum), although rare, is pathognomonic of bronchial fracture [4].The distinction between pneumomediastinum and pneumothorax is usually easily made by the air distribution. However, in the case of a medial pneumothorax, the diagnosis may be difficult, and a contralateral decubitus view may be needed to assess whether the air shifts laterally [1].Pneumopericardium may be suspected when only the pericardial sac itself is visualized.Spontaneous pneumomediastinum is usually a benign condition and treatment consists of rest, analgesia and oxygen administration. Prophylactic antibiotherapy has been recommended in order to prevent mediastinitis. Rarely malignant pneumomediastinum can develop, with elevated pressures impairing venous return to the heart [3].",
    "differential_diagnosis": "Spontaneous, Pneumomediastinum, Medial, pneumothorax, Esophageal, rupture, Tracheobronchial, rupture, Pneumopericardium",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013935/000002.jpg?itok=vv75-FPK",
            "caption": "Supraclavicular ultrasound shows subcutaneous emphysema (white arrow)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013935/000003.jpg?itok=Pb-Fe_AN",
            "caption": "Cervico-thoracic CT shows pneumomediastinum (B-C), with extension to the supraclavicular regions (A)."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013935/000008.png?itok=SLiz3uL9",
            "caption": "CT shows the air extending to the retropharingeal space (black arrow) and surrounding the carotid arteries and jugular veins (blue arrows)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013935/000005.jpg?itok=UpvBcVUO",
            "caption": "Chest plain film shows bilateral supraclavicular subcutaneous emphysema (yellow arrows)."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013935/000007.png?itok=zPNZPrhA",
            "caption": "Enlarged view shows detachment of the parietal pleural from the trachea by air (blue arrow) and air outlining (yellow arrows) the right and left main bronchi (black asterisk) - Double bronchial wall sign."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Mediastinum"
    ],
    "imaging_technique": [
      "CT",
      "Conventional radiography",
      "Ultrasound"
    ],
    "link": "https://www.eurorad.org/case/13935",
    "time": "24.10.2016"
  },
  "13940": {
    "case_id": 13940,
    "title": "Trapped lung",
    "section": "Chest imaging",
    "age": "63",
    "gender": "male",
    "diagnosis": "Trapped lung (pneumothorax ex vacuo)",
    "history": "63-year-old man with past medical history of renal cell carcinoma s/p bilateral nephrectomy on haemodialysis, hypertension, and type II diabetes mellitus presented after a syncopal episode with left flank and rib pain. The patient had decreased breath sounds of the right lung base, crackles of the left lung base.",
    "image_finding": "Presentation chest X-ray showed a large right pleural effusion with compressive atelectasis (Fig. 1); thoracentesis was suggested and performed. Immediately following thoracentesis, the patient's chest X-ray showed development of a hydropneumothorax. The pneumothorax component did not change with inspiration or expiration (Fig. 2). A right-sided chest tube was placed a few days later without successful lung expansion (Fig. 3), although it did resolve the pleural effusion; this chest tube was likely unwarranted as the diagnosis of trapped lung was apparent from the chest X rays immediately following thoracentesis.",
    "discussion": "A. Background: A trapped lung occurs when there is pleural space inflammation resulting in visceral pleural encasement with a fibrous peel preventing the lung from expanding in the chest wall during fluid removal. A negative pressure gradient is created causing a chronic fluid-filled pleural space [2]. The fibrous visceral pleura from chronic inflammation results in separation from the parietal pleura and the space fills with fluid resulting in a hydropneumothorax. When the fluid is removed there is a resulting pneumothorax since the lung cannot expand [1]. B. Clinical Perspective: Clinical presentations of trapped lung include chest pain, dyspnoea on exertion and decreased breath sounds on the affected side. However, patients may be asymptomatic or have minimal dyspnoea with exertion. To diagnose trapped lung, there must be no active pleural inflammatory or malignant process and the lack of expansion must be stable over time [3]. Imaging is needed to make the proper diagnosis and distinguish trapped lung from other process with similar presentations such as lung entrapment which is a complication of active pleural inflammation, malignancy or haemothorax [4]. C. Imaging Perspective: Computed tomography and plain film radiographs can be used to assist in the diagnosis of trapped lung. Trapped lung does not appear larger on expiration than on inspiration in comparison to pneumothorax. The visceral pleural line delineates the scarred lung contour. Visceral pleural peel, pneumothoraces and lobar atelectasis may be visualized on radiography of trapped lung distinguishing it from other entities [2]. Manometry has also been used to assist in the diagnosis of trapped lung [4]. D. Outcome: The therapeutic approach to treating trapped lung depends on the clinical situation. The definitive treatment is surgery including pleurectomy and decortication to remove the fibrosed visceral pleura from the lung to relieve pressure and allow for expansion of the trapped lung [1]. Extended drainage by pleural catheter is another treatment option usually reserved for patients that are symptomatic but are poor surgical candidates [2].E. Take Home Message: Trapped lung should be included in the differential diagnosis of a patient with a radiographically stable pneumothorax after pleural fluid drainage, when lung expansion would be expected. Other clinical entities can initially mimic trapped lung such as lung entrapment and further imaging and other diagnostic tests such as manometry can determine the clinical diagnosis. Making the proper diagnosis initially will help guide management.",
    "differential_diagnosis": "Trapped, lung, (pneumothorax, ex, vacuo), Post-procedural, pneumothorax, Obstructing, bronchogenic, carcinoma, Cryptogenic, organizing, pneumonia, Bronchiolitis, obliterans, organizing, pneumonia",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013940/000001.jpg?itok=ZQ09hU5y",
            "caption": "Posteroanterior radiograph of the chest demonstrates a large right pleural effusion with compressive atelectasis."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013940/000002.jpg?itok=5mX1Lvr2",
            "caption": "Inspiratory posteroanterior radiograph of the chest demonstrates smaller right pleural effusion with pneumothorax."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013940/000003.jpg?itok=LUVLy8Qx",
            "caption": "Expiratory posteroanterior radiograph shows no change of the pneumothorax when compared to inspiratory radiograph. Right pleural effusion is also unchanged from inspiratory radiograph."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013940/000004.jpg?itok=YrX462vk",
            "caption": "Posteroanterior radiograph of the chest shows interval placement of a right chest tube with successful evacuation of right pleural effusion, but no significant expansion of the right lung consistent with trapped lung."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "Conventional radiography"
    ],
    "link": "https://www.eurorad.org/case/13940",
    "time": "05.08.2016"
  },
  "13946": {
    "case_id": 13946,
    "title": "Atypical manifestation of pulmonary sarcoidosis simulating metastatic disease",
    "section": "Chest imaging",
    "age": "20",
    "gender": "male",
    "diagnosis": "Sarcoidosis proven by biopsy.",
    "history": "A 20-year-old gentleman complaining of cough and fever for many weeks. No weight loss.",
    "image_finding": "Chest radiography revealed bilateral lung nodules and hilar lymphadenopathy. Subsequent CT scan was arranged to rule out malignancy. CT images demonstrated marked bilateral hilar and mediastinal lymphadenopathy, multiple bilateral large nodules and ground glass opacities distributed mainly along the peribronchovascular bundles. No evidence of cavitation, pleural disease or fibrosis. The images showed sarcoid galaxy sign which represented conglomerates of small nodules forming larger nodules and surrounded by tiny satellite nodules. Bronchoscopic biopsy was performed and revealed non-caseating granulomas. Special stains for fungi and acid-fast bacilli were negative. No evidence of tumour cells. Morphologically the overall appearances would be in keeping with the clinical diagnosis of sarcoid.",
    "discussion": "Sarcoidosis is an immune-mediated multiorgan disorder of unknown aetiology involving mainly the lung and lymphatic organs. 50% of patients are asymptomatic. The most common clinical symptoms of sarcoidosis are fatigability and respiratory symptoms [1, 4, 14]. The most common imaging feature is bilateral symmetrical hilar and paratracheal lymphadenopathy. Mediastinal lymphadenopathy with no hilar nodes is rare. Lymph node calcification suggests chronic disease and is present in up to 50% of cases [2-4, 7, 9].Other common imaging findings include multiple small nodules along the peribronchovascular bundles, interstitial lung thickening. Fibrosis occurs in 15-20%. Sarcoidosis has a strong predilection for the upper lung parts [11].Atypical imaging features are present in up to 30% and are relatively more common in patients older than 50 years. Features include unilateral or asymmetric lymphadenopathy, necrosis, cavitation, large nodules, ground glass opacities, bronchial wall nodular thickening, pleural disease, honeycombing, miliary shadowing, mosaic attenuation and aspergillomas. However, atypical features are usually associated with the presence of typical imaging findings such as bilateral hilar lymphadenopathy or perilymphatic nodules. On CT, sarcoid galaxy sign is useful in the diagnosis of pulmonary sarcoidosis. This sign describes coalescence of small nodules to form larger nodules, which are surrounded by tiny satellite nodules [8]. It is a non-specific sign and can be seen in pulmonary tuberculosis, lung cancer and progressive massive fibrosis. However, the presence of extensive hilar and mediastinal lymphadenopathies especially when there is calcification, is more suggestive of sarcoidosis [3, 5, 7, 9-12]. Chest X-ray is useful as initial investigation for the diagnosis, staging, and follow-up of sarcoidosis [1-2, 6]. HRCT is more sensitive than X-ray in the detection of lymphadenopathy and lung parenchymal disease [6, 10]. Radionuclide imaging such as gallium-67 and (18)F-fluorodeoxyglucose are useful in detecting extrathoracic involvement, active disease and assessing treatment response [1]. MRI is useful for the diagnosis of cardiac and neurosarcoidosis [6]. The diagnosis is made after clinical radiological evaluation, histologic evidence of non-caseating granulomas and exclusion of other conditions that can have a similar appearance [2, 13-14]. Treatment of sarcoidosis is based on symptoms and functional or imaging evidence of disease progression. Spontaneous resolution is seen in 50%. In symptomatic patients, corticosteroids is the first-line drug followed by methotrexate. TNF\u03b1-antagonists are used in refractory sarcoidosis [15-16].The prognosis of sarcoidosis depends on the organ involved. The disease outcome ranges from a self-limited subclinical process to chronic debilitation and death, with the major complications being fibrosis, mycetoma formation, and corpulmonale [1, 14]. Others can be secondary to cardiac or neural disease.",
    "differential_diagnosis": "Sarcoidosis, proven, by, biopsy., Lymphoma, Metastases, Tuberclosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013946/000004.jpg?itok=NecBqZWk",
            "caption": "Mediastinal and hilar lymphadenopathy. Lung nodules."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013946/000007.jpg?itok=W2mTvdwx",
            "caption": "CT coronal image showed the extent of mediastinal and hilar lymphadenopathy."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013946/000008.jpg?itok=khF8-I3h",
            "caption": "CT coronal image demonstrated bilateral multiple perilymphatic lung nodules."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013946/000010.jpg?itok=Auc3MPat",
            "caption": "Chest x-ray demonstrated bilateral lung nodules and hilar lymphadenopathy."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013946/000011.png?itok=HytcLHY1",
            "caption": "Lung image showed sarcoid galaxy sign which described large nodules surrounded by tiny satellite nodules and ground glass attenuation."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013946/000012.png?itok=DTsO6S0A",
            "caption": "CT image illustrated more nodules and ground glass opacities."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013946/000013.png?itok=D3wVecxI",
            "caption": "CT lung image showed bilateral nodules along the bronchovascular bundles."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/13946",
    "time": "04.10.2016"
  },
  "13963": {
    "case_id": 13963,
    "title": "Knowledge of shadows: Pulmonary alveolar proteinosis",
    "section": "Chest imaging",
    "age": "39",
    "gender": "female",
    "diagnosis": "Primary pulmonary alveolar proteinosis (PAP).",
    "history": "A 39-year-old male patient, known smoker, presented with fever, dry cough, and progressive breathlessness for two months. Initial evaluation confirmed hypoxia, and pulmonary function tests (PFT) were suggestive of a restrictive pattern (Fig. 1).",
    "image_finding": "Plain chest radiography demonstrated bilateral hazy airspace opacities with perihilar infiltrates and diffuse reticulonodular lesions in both lung fields, mostly centrally located (Fig. 2).High resolution computed tomography (HRCT) showed bilateral interstitial confluent pulmonary infiltrates, ground-glass opacities, and smooth thickening of interlobular and intralobular septal lines. The combination of these features is termed \"crazy-paving\" pattern (Fig. 3). The patient was intubated with a double-lumen endotracheal tube for whole lung lavage (WLL). The specimens of fluid contained large amounts of granular acellular eosinophilic proteinaceous material with morphologically abnormal \"foamy\" macrophages engorged with periodic acid-schiff (PAS) positive intracellular inclusions, findings compatible with primary pulmonary alveolar proteinosis (PAP). The procedure was terminated once the effluent had cleared significantly (Fig. 4).Chest radiography and HRCT were performed one week after the WLL. They showed marked decrease in the extent of the opacities noticed in the previous studies (Fig. 5, 6).",
    "discussion": "PAP, also known as pulmonary alveolar phospholipoproteinosis, is a rare disorder of unknown aetiology, first described in 1958 by the physicians Samuel Rosen, Benjamin Castleman, and Averill Liebow, in which lipoproteinaceous material accumulates within alveoli, interfering with gas exchange [1]. Three main categories of PAP have been defined depending on the aetiology: genetic, primary (also called idiopathic), and secondary [2, 3]. Patients are typically aged 20-50 years at diagnosis, more common in males and tobacco smokers [4, 5]. They usually present with progressive dyspnoea and cough. Less common symptoms include fever, chest pain, or haemoptysis [1, 2].Physical examination signs can be unremarkable, but there are inspiratory crackles, cyanosis, and digital clubbing. In uncomplicated cases, chest radiography usually reveals bilateral ill-defined nodular or confluent pattern, suggestive of pulmonary oedema but without other findings of left-sided heart failure [1]. HRCT shows patchy, ground-glass opacities with septal thickening, a pattern commonly referred to as \u201ccrazy-paving\u201d [5]. PFT can be normal but typically show a restrictive ventilatory defect with a disproportionate and severe reduction of the carbon monoxide diffusing capacity [5, 6]. The impairment of gas exchange is secondary to filling of the alveoli with proteinaceous material leading to ventilation and perfusion mismatch.Clinical and radiological findings suggest the diagnosis of PAP in suspected cases, while findings on examination of a bronchoalveolar lavage specimen can establish the diagnosis. The lavage fluid has an opaque and milky appearance. It contains large alveolar macrophages filled with PAS positive material and increased numbers of lymphocytes [7]. On light-microscopy, the normal alveolar architecture is generally preserved unless there is infection. Immunohistochemical staining reveals abundant accumulation of surfactant protein [8].Therapy for all types of PAP remains WLL, although for the primary form of the disorder, successful lung transplantation has been reported [9]. Idiopathic PAP has been treated successfully since the early 1960 by WLL, and this procedure remains the standard of care today [10]. Secondary PAP treatment involves WLL and underlying condition therapy. TEACHING POINTS:1. Abnormal processing of surfactant by macrophages with amorphous proteinaceous material deposition in the alveoli.2. Subacute presentation with a gradual onset of symptoms.3. Imaging findings \u2022\tChest radiography: Symmetric and bilateral alveolar opacities \u2022\tHRCT: \u201cCrazy-paving\u201d pattern4. WLL: First line of treatment.",
    "differential_diagnosis": "Primary, pulmonary, alveolar, proteinosis, (PAP)., Cardiogenic, pulmonary, oedema., Hypersensitivity, pneumonitis, Non-small, cell, lung, cancer, Pneumocystis, jirovecii, pneumonia, Sarcoidosis, Small, cell, lung, cancer",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013963/000002.jpg?itok=3lBtRNOZ",
            "caption": "Pulmonary function tests showed restrictive pattern."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013963/000003.jpg?itok=J6CEQJoe",
            "caption": "Posteroanterior conventional chest X-ray revealed symmetric, bilateral alveolar opacities, without air bronchogram, showing a perihilar and basal distribution."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013963/000004.jpg?itok=_MDDIPoH",
            "caption": "Left lateral conventional chest X-ray revealed symmetric, bilateral alveolar opacities, without air bronchogram, showing a perihilar and basal distribution."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013963/000006.jpg?itok=65igchMj",
            "caption": "Axial HRCT showed reticulations superimposing on ground-glass opacities forming a \u201ccrazy-paving\u201d pattern with a geographic distribution: juxtaposition of healthy and sick zones."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013963/000007.jpg?itok=X1Ajdhfi",
            "caption": "Axial HRCT, coronal reconstruction, showed reticulations superimposing on ground-glass opacities forming a \u201ccrazy-paving\u201d pattern with a geographic distribution: juxtaposition of healthy and sick zones."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013963/000008.jpg?itok=f6Wsv5f0",
            "caption": "Photograph of WLL demonstrating an opaque, milky-appearing fluid with sediments."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013963/000009.jpg?itok=5qXauUKZ",
            "caption": "Posteroanterior conventional chest X-ray after one week of WLL showed improvement of the infiltrative process."
          },
          {
            "number": "Figure 5b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013963/000010.jpg?itok=DxgyXXhZ",
            "caption": "Left lateral conventional chest X-ray after one week of WLL showed improvement of the infiltrative process."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013963/000011.jpg?itok=XY1hlI7o",
            "caption": "Axial HRCT after one week of WLL showed marked decrease in the extent of the opacities."
          },
          {
            "number": "Figure 6b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013963/000012.jpg?itok=FvJVLjux",
            "caption": "Axial HRCT, coronal reconstruction, after one week of WLL showed marked decrease in the extent of the opacities."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Thorax"
    ],
    "imaging_technique": [
      "Experimental",
      "Conventional radiography",
      "CT-High Resolution"
    ],
    "link": "https://www.eurorad.org/case/13963",
    "time": "13.09.2016"
  },
  "13991": {
    "case_id": 13991,
    "title": "Spontaneous oesophageal perforation",
    "section": "Chest imaging",
    "age": "84",
    "gender": "female",
    "diagnosis": "Spontaneous oesophageal perforation",
    "history": "An 84-year-old woman presented with a sudden onset of dyspnoea and epigastric and left-sided pleuritic chest pain after suffering from diarrhoea and vomiting for the past days. An examination revealed decreased sounds in the left hemithorax, tachypnoea and tachycardia. ABG shows hypoxaemia (75mmHg), hypocapnia (31mmHg), and low bicarbonate (18.8mmol/L). Blood test: Leukocytosis 16.000, CRP 54 and Lactate 4.2",
    "image_finding": "Frontal chest radiograph (Fig. 1) showed moderate left pleural effusion with underlying atelectasis/consolidation of the left lower lung zone. Multiple areas of hyperlucency project over the left midline. Subcutaneous emphysema is seen in the soft tissues of the left lower neck. Contrast-enhanced CT (Fig. 2, 3) depicted extensive free gas throughout the neck and chest. Significant pneumomediastinum was seen extending along the soft tissue planes of the neck and upper chest, producing surgical emphysema. There was a moderately-sized, left-sided pneumothorax as well as a bilateral pleural effusion (Fig. 2). Oral contrast medium was seen within the oesophagus and free contrast medium was seen exiting the distal third of the oesophagus and entering the mediastinum (Fig. 3). The patient underwent a thoracotomy with repair of the oesophagus. Postoperatively the patient made a slow but full clinical recovery.",
    "discussion": "Boerhaave's syndrome or postemetic rupture of the oesophagus represents a special instance of barogenic trauma to the oesophagus leading to a challenging clinical syndrome [1]. Vomiting represents the most frequent underlying cause. Nevertheless, a myriad of circumstances have been reported such as straining, weight-lifting, severe coughing, childbirth, blunt trauma, seizures, Cushing's ulcers, seasickness and asthma. A rapid rise in intraluminal pressure with sudden distension of the distal oesophagus causes the ''barogenic rupture''.Boerhaave's syndrome classical presentation consists of vomiting, chest pain and subcutaneous emphysema [2]. Physical examination is not reliable as typical subcutaneous crepitation emphysema is only present in 27% of cases and Meckler triad in 30-50%. An accurate clinical history is therefore mandatory: excessive food/alcohol intake, vomiting and sudden severe chest pain are highly suggestive. When the diagnosis is made in the first 12 hours, mortality rate is about 30-40%; if it takes more than 48h, it rises to 90%. Regardless of its cause a fulminant mediastinal inflammatory response may result from extrusion of bacteria and enzyme-rich salivary, gastric and biliary excretions. Furthermore, circulation of these noxious stimuli throughout the mediastinum and pleural spaces may be exacerbated by the negative intrathoracic pressure that results from the mechanics of ventilation. This results in extensive fluid transit across the excoriated mediastinal and pleural surfaces leading to systemic hypovolaemia, hypoperfusion, systemic inflammation, sepsis and multisystem organ dysfunction, the respiratory system typically resulting affected in the first place. When left untreated this injury has a mortality approaching 100% [1].Chest radiograph is the initial imaging procedure and the simple erect X-ray delivers the most information [3]. Approximately 80% of cases reveal a left pneumothorax plus an effusion. Noteworthy is the fact that a negative or normal chest radiograph doesn't exclude the diagnosis. Computed tomography (CT) shows oesophageal wall oedema and thickening, extraoesophageal air, perioesophageal fluid with or without gas bubbles, mediastinal widening, and air and fluid in the pleural spaces, retroperitoneum or lesser sac [4]. A high index of suspicion must be maintained in patients presenting within one hour of perforation as surgical emphysema (which represents a pathognomonic finding ) might not be evident at the time [3]. Contrast oesophagography using barium represents the most reliable test to confirm a perforation and is mandatory for complete and accurate evaluation. Management consists on limiting further mediastinal contamination with cessation of oral intake, antibiotic therapy and nasogastric decompression. The majority of cases require urgent surgical intervention.",
    "differential_diagnosis": "Spontaneous, oesophageal, perforation, Esophageal, rupture, of, other, cause, Mallory-Weiss, tear, Aortic, dissection, Pulmonary, embolism, Peptic, ulcer, disease, Acute, pancreatitis, Myocardial, infarction, Pneumothorax",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013991/000001.png?itok=iThzgnsi",
            "caption": "Left pleural effusion with underlying atelectasis / consolidation. \n\nAreas of hyperlucency project over the left of the midline, findings compatible with pneumothorax / pneumomediastinum. \n\nSubcutaneous emphysema is seen in the soft tissues of the left lower neck."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013991/000004.png?itok=wAe8733W",
            "caption": "Oral contrast medium was seen within the oesophagus and free contrast medium was seen exiting the distal third of the oesophagus and entering the mediastinum."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013991/000009.png?itok=pZoEblWP",
            "caption": "Pneumomediastinum (green arrow) close to the site of rupture."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013991/000006.png?itok=SpyxZoBX",
            "caption": "Extensive free gas throughout the neck and chest (red arrows). Significant pneumomediastinum (green arrows) was seen to extend along the soft tissue planes of the neck and upper chest producing surgical emphysema."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013991/000007.png?itok=QwGtdR9N",
            "caption": "Pneumomediastinum (green arrows). Pneumothorax (orange arrow) was also evident."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000013991/000005.png?itok=qlYivZ7N",
            "caption": "Mediastinal window better depicts the loculated pleural effusion corresponding to empyema. Compressive atelectasis of the lingual and left lower lobe and small right pleural effusion associated with mild right lung base atelectasis are also noted."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Mediastinum"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/13991",
    "time": "28.02.2017"
  },
  "14030": {
    "case_id": 14030,
    "title": "Chronic Exogenous Lipoid Pneumoni",
    "section": "Chest imaging",
    "age": "60",
    "gender": "male",
    "diagnosis": "Chronic exogenous lipoid pneumonia. Left lung metastasis. Left-sided hydrothorax.",
    "history": "A 60-year-old patient was admitted to our hospital with complaints of dyspnoea and general weakness. In 2007 - laryngeal carcinoma, resection of the larynx, tracheostomy and radiation therapy. In 2013 - laryngectomy, radiation and chemotherapy. In 2015 - atypical resection of the left lung's lower lobe due to a solitary metastasis.",
    "image_finding": "According to the chest x-ray (CXR), there were defined signs of left-sided hydrothorax, a suspected nodule in the left upper lobe (LUL) and lung consolidation in the right lower lobe (RLL) (Fig. 1).Multi-slice computed tomography (MSCT) was performed with working hypothesis of pneumonia in the RLL, left-sided hydrothorax and metastases in the LUL. The following changes were identified: lung consolidation were determined in the basal segments and in the middle lobe of the right lung with indistinct irregular margins, surrounded by uneven patches of ground-glass opacity (Fig. 2). Density in these areas was about -50 HU. The volume of the RLL was reduced, segmental bronchi located close together (Fig. 3). In the left lower lobe (LLL) lung consolidation with fat density was observed (Fig. 4). Left-sided hydrothorax and pulmonary nodules was also determined in LUL (Fig. 5).",
    "discussion": "Lipoid pneumonia (LP) is a rare condition characterized by the accumulation of fat in the alveoli. The reaction in the lung parenchyma is similar to the reaction to a foreign body [1, 2]. LP can be exogenous - inhalation or aspiration of various fatty substances or endogenous - when depositing in the alveolar macrophages of endogenous cholesterol or other lipids which are allocated from necrotic cells [3]. Exogenous LP can be acute (rare) or chronic (more often). LP develops with prolonged using of laxatives and fat-containing nasal drops, after prolonged infusions of mineral oils in the tracheostomy or in cases of professional contact with the oil-containing aerosols [2, 3].Symptoms of LP are nonspecific. In acute exogenous LP they are coughing, shortness of breath, and low-grade fever, that disappear against the background of symptomatic therapy. Chronic LP is often asymptomatic and detected incidentally on X-ray [4].CXR findings of LP are very diverse and nonspecific. Radiological appearance includes lung parenchymal opacities and consolidations and less commonly pneumatoceles, pneumothorax, pleural effusions, and pneumomediastinum [4].MSCT shows lung consolidation predominantly in the LLL with or without fat-like low attenuation or ground-glass opacities with associated thickening of interlobular septa with a crazy-paving pattern. Lung tissue fibrosis is determined around pathological changes in chronic form. Sometimes the solid lesions without fat density may mimic severe lung diseases like primary lung cancer [3, 4]. The differential diagnosis is carried out with a variety of tumours of the lung, bacterial or viral pneumonia, pulmonary alveolar proteinosis, or hamartomas [4]. In this case, the patient's tracheostomy was lubricated by mineral oil in 2007 a few times - it is probable that fat reached the lungs via this path. Clinical presentation and CXR findings are not specific, but MSCT show typical manifestation of chronic LP: lung consolidation with fat density, indistinct irregular margins surrounded by uneven patches of ground-glass opacity and predominace in the LLL.The basis of diagnosis is cytology (bronchoalveolar wash) or histological examination (biopsy of lung tissue) [5].At present there is no proven way to treat LP [4]. It is necessary to stop further flow of fatty substances in the respiratory tract in all cases. Pathological changes are resolved independently over time in most cases in acute LP [1]. Chronic LP is asymptomatic, usually it does not prescribe additional treatment. In severe cases, some authors use repeated bronchoscopic segmental lavage therapy [5].",
    "differential_diagnosis": "Chronic, exogenous, lipoid, pneumonia., Left, lung, metastasis., Left-sided, hydrothorax., Adenocarcinoma, (ex., bronchioalveolar, carcinoma), Cryptogenic, organising, pneumonia, Chronic, eosinophilic, pneumonia",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014030/000001.jpg?itok=qKWQQnmZ",
            "caption": "Lung consolidation in the basal segments and in the middle lobe of right lung with irregular margins."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014030/000002.jpg?itok=1dJxaLkT",
            "caption": "The volume of the RLL was reduced, segmental bronchi close together."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014030/000003.jpg?itok=J_-UhLiS",
            "caption": "Lung consolidation on the left lower lobe with fat density. Left-sided hydrothorax."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014030/000004.jpg?itok=O-wtX4MV",
            "caption": "Pulmonary nodules in the left lung and left-sided hydrothorax. Staplers in the left lower lobe (after surgery)."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014030/000005.jpg?itok=q2ozXndG",
            "caption": "Signs of left-sided hydrothorax, lung consolidation in RLL and suspected mass in the LUL."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT",
      "Conventional radiography"
    ],
    "link": "https://www.eurorad.org/case/14030",
    "time": "16.11.2016"
  },
  "14038": {
    "case_id": 14038,
    "title": "Inflammatory myofibroblastic tum",
    "section": "Chest imaging",
    "age": "62",
    "gender": "male",
    "diagnosis": "Inflammatory myofibroblastic tumour",
    "history": "A 62-year-old man presented with breathing difficulty, dyspnoea and a squeezing sensation of the chest. There was no haemoptysis. Physical examination showed no abnormalities There was a history of asbestos exposure in the 1970s. His further medical history was unremarkable, whereas when his brother died he was diagnosed with lung cancer.",
    "image_finding": "Chest radiograph shows a well-circumscribed coin lesion in the right upper lobe which was not present on a chest radiograph taken two years previously (Fig. 1). A Computed Tomography (CT) without contrast confirmed a solitary well-circumscribed nodule (20 x 19 x 19 millimetre) without intralesional calcifications and a CT density of 35 Hounsfield Units (Fig. 2). A subsequent FDG-PET-CT was performed showing a nodule in the right upper lobe, which was intensely FDG-avid (SUV:10) (Fig. 3). There were no other pulmonary lesions nor evidence of mediastinal or axillary lymphadenopathy. A transbronchial biopsy was done but the sample was insufficient for definitive diagnosis. The mass was surgically removed and histopathological examination revealed an inflammatory myofibroblastic pseudotumour (Fig. 4).",
    "discussion": "Inflammatory myofibroblastic tumour (IMT) is believed to represent a benign neoplastic lesion with intermittent malignancy[1]. IMT has been reported in different sites of the body including the abdominopelvic region, lung, heart and central nervous system. It can virtually be found in any anatomical region but pulmonary location is the most frequent [2]. IMT comprises 0.04% to 0.7% of all the lung neoplasms but in children IMT is the most common primary lung lesion accounting for 50% of all the benign lesions [3]. The pathogenesis is still debated. It is believed to result from an organized cellular growth in association with a pulmonary infection, viral or foreign antigen-antibody reaction which is no longer identifiable at the time of diagnosis [4].Most patients are diagnosed when in their childhood or young adulthood, half of them are younger than 40. The male-female distribution is equal. Often patients are asymptomatic, although persistent cough, pulmonary infections or thoracic discomfort may be present. General symptoms such as weight loss, fever and fatigue are also reported [5]. Histologically IMT is considered a benign lesion consisting of myofibroblastic spindle cells with a prominent inflammatory infiltrate composed of plasma cells and lymphocytes. The lesion can range from 1 cm to 20 cm.There\u2019s an overlap of clinical and histological features with immunoglobulin (IgG)-4\u2013related disorders [6].Radiography often shows a co-incidental-finding of a pulmonary solitary nodule or mass, which is usually well-circumscribed. Localisation in lower lobes is most common. Heterogeneous enhancement is seen and pleural effusion can be present. Calcifications, haemorrhage and necrosis are rare. CT is used for local and distant staging. MRI is useful to visualize the relationship to adjacent structures. A low or intermediate signal intensity is seen on T2-weighted images.A pseudotumour has similar increased uptake of Fluorodeoxyglucose (18F) as a malignant lesion, therefore FDG-PET has no or a limited role in the diagnosis but may be useful to detect multifocality [6, 7].The main differential diagnosis is lung cancer.The optimal treatment is surgical excision which is crucial for diagnosis. Histopathologic examination of the resected specimen is the only reliable method to confirm the exact diagnosis as differentiation between cancer and pseudotumour solely on clinical and imaging findings is not possible. In case of incomplete resection or non-operable patients, radiotherapy is an alternative treatment [8]. Recurrence is seen in 2% to 25% of the cases and in less than 5% metastasis are found [9].",
    "differential_diagnosis": "Inflammatory, myofibroblastic, tumour, Lung, cancer, Hamartoma, Lymphoma, Chondroma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014038/000001.jpg?itok=7te5dUPZ",
            "caption": "Posteroanterior chest radiograph.\nStandard radiography shows a well-circumscribed nodule (arrow) in the right upper lobe."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014038/000002.jpg?itok=LhRrzVLm",
            "caption": "Lateral chest radiograph.\nStandard radiography shows a well-circumscribed nodule (arrow) in the right upper lobe."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014038/000003.jpg?itok=8TKswJUl",
            "caption": "Axial image (mediastinal window).\nA well-circumscribed solid nodule (arrow) in the right upper lobe is confirmed.  There is no contact with the chest wall. No other lesions were visualized."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014038/000004.jpg?itok=l4VzhsP0",
            "caption": "Axial image (lung window).\nA well-circumscribed solid nodule (arrow) in the right upper lobe is confirmed.  There is no contact with the chest wall. No other lesions were visualized."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014038/000005.jpg?itok=sR6WKpnh",
            "caption": "Sagittal reformatted image (lung window).\nA well-circumscribed solid nodule (arrow) in the right upper lobe is confirmed.  There is no contact with the chest wall. No other lesions were visualized."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014038/000006.jpg?itok=5L6X367Z",
            "caption": "Coronal reformatted image (lung window).\nA well-circumscribed solid nodule (arrow) in the right upper lobe is confirmed.  There is no contact with the chest wall. No other lesions were visualized."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014038/000007.jpg?itok=cDd2rYet",
            "caption": "Axial image.\nNote an intensely FDG-avid solitary retrohilar nodule (arrow) within the right upper lobe."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014038/000008.jpg?itok=JJ3cPhDp",
            "caption": "Sagittal image.\nNote an intensely FDG-avid solitary retrohilar nodule (arrow) within the right upper lobe."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014038/000009.jpg?itok=chYkti0R",
            "caption": "Histopathology of the resected specimen (Haematoxylin and eosin , 200 x magnification). Note abundant inflammatory cells, including many plasmocytes (star), against a myofibroblastic background . IgG4 negative immunohistochemical staining (not shown) ."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT",
      "PET-CT",
      "Percutaneous"
    ],
    "link": "https://www.eurorad.org/case/14038",
    "time": "29.09.2016"
  },
  "14055": {
    "case_id": 14055,
    "title": "Proteinosis alveolar: radiologic and pathologic findings",
    "section": "Chest imaging",
    "age": "20",
    "gender": "male",
    "diagnosis": "Alveolar proteinosis.",
    "history": "An asymptomatic 20-year-old man being investigated following cervical trauma was found to have an incidental pulmonary abnormality.",
    "image_finding": "Plain chest radiograph shows bilateral, symmetric and perihilar ground-glass opacities predominant in upper and middle lung fields (Fig 1).In concordance with the chest radiograph, computed tomography revealed patchy areas of ground glass opacities with superimposed thickening of interlobular and intralobular lines (crazy paving) (Fig. 2). It extended through both lungs with a predominant perihilar and upper lobe distribution, where it tended to consolidate (Fig 3).",
    "discussion": "Pulmonary alveolar proteinosis (PAP) is an uncommon diffuse lung disease, characterized by the accumulation of surfactant in the distal airways, due to a dysfunction of alveolar macrophages. In some cases it is related to a secondary cause (immunodeficiency disorders, cancer, etc.), but the majority are idiopathic [1].From the clinical point of view, the typical case is an asymptomatic patient between his/her 20s and 40s, but there is no correlation between radiologic findings and clinical presentation. Symptoms such as cough and dyspnoea can be present.Computed tomography (CT) usually shows parenchymal involvement that consists of ground-glass opacities associated with superimposed interlobular and even intralobular lines [2]. This pattern, known as 'crazy paving', in PAP tends to be bilateral, perihilar and symmetric. However, many other illnesses can mimic this type of presentation [3] and we must bear in mind some details regarding the differential diagnoses:-Pneumocystis jiroveci pneumonia should be suspected in severely immunocompromised patients. In early stages, plain chest radiograph can be unremarkable even with a pathologic CT. In a few days it can turn into a consolidation.-Acute respiratory distress syndrome presents as an acute onset and is usually associated with intense trauma, sepsis or other aggressive factor.-Cardiogenic pulmonary oedema has lower field distribution and acute onset of typical signs and symptoms of cardiac affection.-Alveolar haemorrhage syndromes are usually associated with a clinical context of coagulopathies, collagen or inflammatory diseases as vasculitis or lupus.-Hounsfield units between -35 and -75 suggest lipoid pneumonia (medical history of oil ingestion?). Some studies suggest that ill-defined centrilobular nodules, lower extension and presence of consolidation points to lipoid pneumonia rather than PAP [4].-Hypersensitivity pneumonitis due to pulmonary toxicity when using some drugs can express as a crazy paving pattern.-Bronchioloalveolar carcinoma appears in older patients than those who suffer from PAP (generally in older than 50). Bronchorrhea is infrequent but indicative.-Cryptogenic organizing pneumonia has a subacute onset which consists of non-productive cough and dyspnea. Characteristically responds to treatment with corticoids. Bronchiectasis and thickening of bronchial walls of affected areas are common.Due to non-specificity of the radiologic findings, bronchoscopy must be performed in order to confirm diagnosis. In our case, tissue obtained by transbronchial biopsy was insufficient, but showed granular PAS positive eosinophilic proteinaceous material. The bronchoalveolar lavage fluid showed abundant large acellular material (Fig. 4).These findings in the clinical and radiological context suggest the diagnosis of alveolar proteinosis.",
    "differential_diagnosis": "Alveolar, proteinosis., Pneumocystis, jiroveci, pneumonia, Acute, respiratory, distress, syndrome, Pulmonary, hemorrhage, syndromes, Lipoid, pneumonia, Mucinous, Bronquioloalveolar, carcinoma, Non, Specific, Intersticial, Pneumonia, Organizing, pneumonia, Sarcoidosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014055/000001.jpg?itok=eh9w9FYz",
            "caption": "Posteroanterior chest X-ray showing bilateral, symmetric and perihilar ground-glass opacities predominant in upper and middle lung fields."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014055/000002.jpg?itok=IDximwow",
            "caption": "CT shows a bilateral, perihilar and symmetric \u2018crazy paving\u2019 pattern: nodular ground glass opacities with superimposed thickening of interlobular septa bilateral."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014055/000003.jpg?itok=FySoThoM",
            "caption": "CT shows a bilateral, perihilar and symmetric \u2018crazy paving\u2019 pattern: nodular ground glass opacities with superimposed thickening of interlobular septa bilateral."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014055/000005.jpg?itok=RJMeeOtP",
            "caption": "CT shows a bilateral, perihilar and symmetric \u2018crazy paving\u2019 pattern: nodular ground glass opacities with superimposed thickening of interlobular septa bilateral."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014055/000006.jpg?itok=zQsmz6L4",
            "caption": "CT shows a bilateral, perihilar and symmetric \u2018crazy paving\u2019 pattern: nodular ground glass opacities with superimposed thickening of interlobular septa bilateral."
          },
          {
            "number": "Figure 2e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014055/000007.jpg?itok=c9gwMOpE",
            "caption": "CT shows a bilateral, perihilar and symmetric \u2018crazy paving\u2019 pattern: nodular ground glass opacities with superimposed thickening of interlobular septa bilateral."
          },
          {
            "number": "Figure 2f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014055/000008.jpg?itok=YXchuxy-",
            "caption": "CT shows a bilateral, perihilar and symmetric \u2018crazy paving\u2019 pattern: nodular ground glass opacities with superimposed thickening of interlobular septa bilateral."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014055/000009.jpg?itok=zYPJ_Yp_",
            "caption": "Coronal slices ilustrate better    perihilar and symmetric distribution."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014055/000010.jpg?itok=Niswlut_",
            "caption": "Coronal slices ilustrate better    perihilar and symmetric distribution."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014055/000011.jpg?itok=h3ydehF0",
            "caption": "Coronal slices ilustrate better    perihilar and symmetric distribution."
          },
          {
            "number": "Figure 3d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014055/000012.jpg?itok=e3aUd-7Y",
            "caption": "Coronal slices ilustrate better    perihilar and symmetric distribution."
          },
          {
            "number": "Figure 3e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014055/000013.jpg?itok=9MCNGRBB",
            "caption": "Coronal slices ilustrate better    perihilar and symmetric distribution."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014055/000014.jpg?itok=MH9Z3dPI",
            "caption": "Transbronchial biopsy (Hematoxylin and eosin stain). Tissue obtained by transbronchial byopsy was insufficient, but we can see eosinophilic proteinaceus material"
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014055/000017.jpg?itok=4QECeWS_",
            "caption": "Dense clumps of eosinophilic material are present within the proteinaceous material."
          },
          {
            "number": "Figure 4c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014055/000016.jpg?itok=Uv7cNLx0",
            "caption": "The proteinaceous material stains with the PAS stain."
          },
          {
            "number": "Figure 4d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014055/000015.jpg?itok=nK3ZzJxS",
            "caption": "The bronchoalveolar lavage (papanicolaou stain) showed abundant large acellular extracelular material. The grocott stain was negative."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Thorax"
    ],
    "imaging_technique": [
      "CT",
      "Experimental",
      "Conventional radiography"
    ],
    "link": "https://www.eurorad.org/case/14055",
    "time": "04.01.2017"
  },
  "14071": {
    "case_id": 14071,
    "title": "Rare case of echinococcosis with negative histology and cytology",
    "section": "Chest imaging",
    "age": "25",
    "gender": "male",
    "diagnosis": "Echinococcosis.",
    "history": "A 25-year old male patient from Syria had a long hospitalisation due to fever and haemoptysis with unknown aetiology, chest pain and dyspnoea.",
    "image_finding": "The contrast-enhanced CT of the lungs and upper abdomen showed a cystic lesion in the upper lobe of the left lung with fluid and air bubbles. It also showed atelectasis and pleural fluid in the left hemithorax and mediastinal shift to the right (Figs. 1 and 2). In the axial plane the CT showed a waterlily-sign (Fig. 3); a detachment of the endocyst membrane which results in floating membranes within the pericyst; a classic appearance of echinococcosis cyst. Serological tests for hydatidosis were not significantly elevated.Histology and cytology samples with ultrasound-guided core-needles from different areas of the cyst (and later ELISA-test) were taken and had negative results, thus a diagnosis of the patient could not be given. The patient therefore underwent a long series of tests (TB, staphylococcus etc.) without positive findings. Due to the patient\u2019s condition getting worse he underwent surgery and the pathology exposed an echinococcal cyst.",
    "discussion": "Human echinococcosis (HE) is a rare condition caused by the larval stage of the tapeworm from the genus Echinococcus. There are two species of echinococcus; The E. granulosus which causes cystic echinococcosis or hydatidosis and E. multilocularis which causes alveolar echinococcosis [1].The typical life cycle of echinococcus starts as the adult worms reside in the intestine of a main host such as wolves, foxes and dogs. The released eggs are then ingested by intermediate hosts such as goats, sheep and horses where they hatch in the small intestine. Here, the larvae penetrate through the gut wall and follow the bloodstream. Eggs are also released into the environment where they can survive for at least one year [2]. Transmission to humans happens faecal-orally. Predisposing factors such as pets, drinking water and spoiled food can cause transmission to humans which spreads to the bloodstream and the organs. This way, humans can develop life-threatening illnesses. However, the parasite is not contagious from one human to another [1]. Echinococcus are most commonly found in the liver (55-70%) and in the lungs (18-35%) [3]. The symptoms can vary and depend on the location of the cyst, hence it can mimic many conditions but usually pain and fever are present [2]. HE is a major zoonotic disease and is globally a major burden both financially and in terms of public health. The disease is emerging in Europe but it is unclear if the parasite range is spreading or the surveillance has led to greater detection rates [4]. X-rays are the most used examination in echinococcosis of the lung. CT and MRI are nevertheless better at diagnosing HE due to a better recognition of certain details, lesions and surrounding structures [5]. Diagnosis of HE has the highest sensitivity and specificity when using ultrasound-guided core-needle biopsies; cystology (ELISA) with a sensitivity of 96, 5% and histology with a sensitivity of 100% [6,7].However, needle aspiration and biopsy from the cyst is a controversial issue due to the risks of allergic reactions and anaphylaxis [8].Treatment is primarily chemotherapy or/and surgery depending on different criteria. Prognosis is satisfactory if treated surgically. Most complications include pleural infections and prolonged air leakage. Operative mortality is between 1-2 % [9].In our case it was surprising that neither cytology nor histology from different areas of the cyst showed echinococcus whereas CT was classic for the disease.Written informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Echinococcosis., Metastases, Other, parasite, infections, such, as, amoebiasis, Schistosomiasis, Trematode, infection, and, fungal, infection, Candidiasis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014071/000003.jpg?itok=AcedHbuu",
            "caption": "Waterlily-sign membranes floating in the fluid."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014071/000004.jpg?itok=clZv7N86",
            "caption": "The left hemithorax in coronal plane. There is an impression of the waterlily-sign in the fluid of the cyst."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014071/000005.jpg?itok=KHcZGUMB",
            "caption": "CT showed a cyst in the upper lobe of the left hemithorax with fluid and air bubbles. It also showed atelectasis and pleural fluid in the inferior lobe."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/14071",
    "time": "01.08.2018"
  },
  "14074": {
    "case_id": 14074,
    "title": "Bronchocele caused by congenital bronchial atresi",
    "section": "Chest imaging",
    "age": "42",
    "gender": "female",
    "diagnosis": "Bronchocele caused by a congenital bronchial atresia",
    "history": "A 42-year-old woman with no history of respiratory problems or other relevant diseases came to the emergency department of our hospital with complaints of coughing and auto-limited haemoptysis.",
    "image_finding": "The patient underwent a chest X-ray where a well-defined lobulated opacity was seen. It was located in the apicoposterior segment of the left upper lobe and extended from the hilum to the pulmonary apex. Subsequently, a chest CT with multiplanar reformations was performed, which revealed a branching lobulated mass with homogeneously low density that reminded of a mucoid impaction in the apicoposterior segment of the left upper lobe. The CT showed a lack of communication between the mass and the hilum as well as hypoattenuating lung, air trapping and focal parenchyma oligaemia surrounding the mass. A bronchocele caused by congenital bronchial atresia was diagnosed, but the patient underwent a bronchoscopy and a PET-CT to rule out a tumoral origin. Both were normal.One month later, the patient underwent a follow-up chest X-ray that revealed the decreased size of the mass, an additional finding that is consistent with the CT diagnosis of bronchocele.",
    "discussion": "A bronchocele is a dilated bronchus with mucus impactation at the proximate of an atretic or obstructed bronchus. The cause of bronchocele formation can be either obstructive (bronchial atresia, neoplasia, intrapulmonary bronchogenic cyst, intralobar sequestration, broncholithiasis, tuberculous stricture\u2026) or non-obstructive (asthma, ABPA or cystic fibrosis) [1]. From all of them, congenital bronchial atresia is the most common cause of bronchocele and the apicoposterior segment of the left upper lobe is the most common location of this entity, as it happened in our case [2]. Bronchial atresia is a rare variety of chest anomaly. It generally results from a localized defect in normal broncho-pulmonary embryogenesis.Even though the patients are usually asymptomatic, they may also suffer from symptoms such as dyspnoea, cough, recurrent pneumonia and haemoptysis [3, 4].Bronchocele can be diagnosed radiologically or by bronchoscopy. Bronchoscopically, stenosis may be demonstrated at the atretic bronchus yet it may be normal as well [3], as in our case, which is why radiological images are imperative. Bronchoscopy and PET/CT are also recommended for patients with bronchial atresia in order to exclude other possible pathologies, such as tumoral masses (there is no endobronchial lesion or FDG activity, as in our case). The classic findings in the chest X-ray of bronchocele caused by bronchial atresia is a lobed, branching tubular or nodular opacity that extends from the hilum with surrounding hyperlucent lung parenchyma. In the CT, bronchocele is seen as a lobed hypodense mass with lack of communication with the hilum. CT is the most sensitive imaging modality, and when findings are typical, as in our case, it provides the diagnosis [2, 3]. In an estimated 20% of cases, segmental bronchial atresia causes recurrent infection, which is manifested radiologically as consolidation and, occasionally, as an enlarging nodule or mass that varies in size over the course of time [5].The treatment of this entity depends on the symptoms. Asymptomatic patients don't need any treatment but surgical excision may be required for patients with complications secondary to the atretic bronchus [2].",
    "differential_diagnosis": "Bronchocele, caused, by, a, congenital, bronchial, atresia, Tumoral, masses, Congenital, abnormalities, (congenital, cystic, adenomatoid, malformation, pulmonary, sequestration, bronchogenic, cyst), Bronchiectasis, in, asthma, ABPA, and, cystic, fibrosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014074/000001.jpg?itok=GXmQyJAy",
            "caption": "Chest X-ray showing a branching nodular opacity with well-defined borders in the apicoposterior segment of the left upper lobe. There is no pleural effusion."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014074/000002.jpg?itok=BEr2PAzI",
            "caption": "Axial (a and b), coronal (c), sagittal (d) mediastinal window sections and sagittal parenchymal (e) window section show branching lobulated mass with a homogeneously low density in the apicoposterior segment of the left upper lobe."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014074/000003.jpg?itok=0rr-q8zr",
            "caption": "Axial (a and b), coronal (c), sagittal (d) mediastinal window sections and sagittal parenchymal (e) window section show branching lobulated mass with a homogeneously low density in the apicoposterior segment of the left upper lobe."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014074/000004.jpg?itok=dM0Wy2hR",
            "caption": "Axial (a and b), coronal (c), sagittal (d) mediastinal window sections and sagittal parenchymal (e) window section show branching lobulated mass with a homogeneously low density in the apicoposterior segment of the left upper lobe."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014074/000005.jpg?itok=8lXaD5Qe",
            "caption": "Axial (a and b), coronal (c), sagittal (d) mediastinal window sections and sagital parenchymal (e) window section show branching lobulated mass with a homogeneously low density in the apicoposterior segment of the left upper lobe."
          },
          {
            "number": "Figure 2e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014074/000008.jpg?itok=BYP5FkkI",
            "caption": "Axial (a and b), coronal (c), sagittal (d) mediastinal window sections and sagittal parenchymal (e) window section show branching lobulated mass with a homogeneously low density in the apicoposterior segment of the left upper lobe."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014074/000007.jpg?itok=cvncAPRh",
            "caption": "Chest X-ray reveals that the opacity has decreased in size."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/14074",
    "time": "15.10.2016"
  },
  "14078": {
    "case_id": 14078,
    "title": "Flow artefact mimicking atrial thrombus/mass",
    "section": "Chest imaging",
    "age": "79",
    "gender": "male",
    "diagnosis": "Flow artefact simulating pseudothrombus/mass",
    "history": "79-year-old male patient with chest pain radiating to the back. Hypertensive with concern for aortic dissection.",
    "image_finding": "Figure 1a-c: Axial arterial phase CECT demonstrates a round, hypoattenuating pseudothrombus (white arrow) with ill-defined margins that appears to be extending into the left atrium (LA) from the right atrium (RA). This \u201clesion\u201d measures 89 HU.Coronal reconstruction demonstrates the pseudothrombus (white arrow) within the IVC which appears to create a filling defect in the left atrium (LA). Anterior slices (not demonstrated here) show the defect continuing into the right atrium. Sagittal reconstruction shows the pseudothrombus (white arrow) within the IVC and entering the right atrium (RA).Figure 2 a-b:15 minute delayed axial CECT images demonstrate resolution of the pseudothrombus which was previously seen within the right atrium (RA) and IVC (asterisk). Note the mitral annular calcification (white arrow).",
    "discussion": "Flow-related artefact is a commonly encountered and sometimes overlooked phenomenon with early-phase contrast enhanced CT. Mixing and volume averaging of unenhanced blood with enhanced blood can imitate thrombus, referred to as pseudothrombus, or even masses. Flow artefacts can be problematic depending on their location. Mixing in the lower lungs can mimic pulmonary embolism while mixing within the heart, IVC or portal system may be mistaken for thrombus or neoplasm. [1, 2]  In this particular patient, mixing within the right atrium mimicked a mass or thrombus that appeared to cause a filling defect within the left atrium. Initially, it was called a left atrial mass originating from the interatrial septum. However, closer inspection of the images showed that this was only a flow artefact which appeared to extend into the left atrium. This was later confirmed by transthoracic echocardiography which demonstrated no mass or thrombus. Delayed images were overlooked which showed resolution of the \u201clesion\u201d and would have confirmed that this was just an artefact.     Flow artefacts can be difficult to distinguish from real pathology. Mixing within the right atrium is thought to be accentuated by inspiration, during which negative intrathoracic pressures bring unopacified blood from the IVC. Avoiding exaggerated inspiration prior to scanning can help limit this phenomenon [3]. However, mixing may be unavoidable especially in situations where lung consolidation or atelectasis increases vascular resistance and causes focal slow pulmonary artery flow. [3] Atrial fibrillation also poses a problem due to stasis within the left atrium. Zimmerman looked at 402 patients with atrial fibrillation. 40 of which were found to have filling defects in the left atrial appendage mimicking thrombus. Only 9 of these 40 were confirmed to have true thrombus by transoesophageal echocardiography. [4]   Mistaking flow artefact for real pathology can result in unnecessary treatment, imaging or preclude procedures such as cardiac ablation for atrial fibrillation. Thus, it is critical for the radiologist to distinguish between the two. Imaging characteristics of ill-defined margins with Hounsfield units measuring greater than 78 confirms mixing artefacts. [1] Correlation with precontrast or delayed imaging can also identify flow artefacts in most situations. However, further imaging may sometimes need to be performed. [3, 5]",
    "differential_diagnosis": "Flow, artefact, simulating, pseudothrombus/mass, Thrombus, Neoplasm, Flow, Artefact",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014078/000001.jpg?itok=UZ9ubOQx",
            "caption": "Axial arterial phase CECT demonstrates a round, hypoattenuating pseudothrombus (white arrow) with ill-defined margins that appears to be extending into the left atrium (LA) from the right atrium (RA). This \u201clesion\u201d measures 89 HU."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014078/000002.jpg?itok=fQOi18tc",
            "caption": "Coronal reconstruction demonstrates the pseudothrombus (white arrow) within the IVC which appears to create a filling defect in the left atrium (LA). Anterior slices (not demonstrated here) show the defect continuing into the right atrium."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014078/000003.jpg?itok=uqaYf3VS",
            "caption": "Sagittal reconstruction shows the pseudothrombus (white arrow) within the IVC and entering the right atrium (RA)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014078/000006.jpg?itok=hplpY6t0",
            "caption": "15 minute delayed axial CECT images of the same slice demonstrate resolution of the pseudothrombus which was previously seen within the right atrium (RA). Left atrium (LA)."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014078/000005.jpg?itok=L4dCssaX",
            "caption": "15 minute delayed axial CECT images demonstrate resolution of the pseudothrombus which was previously seen within the right atrium (RA) and IVC (asterisk). Note the mitral annular calcification (white arrow)."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Cardiac"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/14078",
    "time": "21.09.2016"
  },
  "14089": {
    "case_id": 14089,
    "title": "Multiple pulmonary nodules: an unfrequent etiology",
    "section": "Chest imaging",
    "age": "65",
    "gender": "female",
    "diagnosis": "Nodular amyloidosis",
    "history": "An asymptomatic 50-year-old woman was found to have an incidental pulmonary abnormality in a preoperative chest X-ray. She underwent surgery in 2007 from a pheochromocytoma and a parotid tumour. She suffered from Sj\u00f6gren's syndrome and was waiting to be operated for a pancreatic cystic tumour.",
    "image_finding": "Chest X-ray revealed the presence of multiple pulmonary nodules, the biggest with 25 mm in diameter in the upper segment of the right lower lobe (RLL) (Fig. 1).Computed tomography showed multiple pulmonary nodules with a peripheral distribution and well-defined edges. They varied from 5 to 18 mm in diameter, with the largest one located on the apical segment of the RLL (Fig. 2). They were not calcified or cavitated. Neither pathologically-sized lymph nodes nor signs of pleural disease were found.As oncologists suggested metastasis of previous pheochromocytoma (neuroendocrine malignancy), SPECT was made. However, it demonstrated absence of pulmonary uptake after intravenous administration of Octreotide-In 111 (Fig. 3).",
    "discussion": "In the presence of multiple pulmonary nodules (MPN), we must bear in mind some details regarding the differential diagnoses [1]:- According to the patient's medical history, the semiology of the described nodules is compatible with metastatic lesions. Also the possibility of a primary pulmonary lesion could not be dismissed, although the X-ray presentation was not the typical one. In view of the pheochromocytoma antecedent, SPECT was made. It was negative, however, it did not discard malignancy (Fig. 3).- Rheumatoid nodules, nodular sarcoidosis or other inflammatory diseases may cause MPN. Other less frequent entities include vasculitis, pneumoconiosis and amyloidosis. However, laboratory and clinical parameters were not suggestive of such entities.- Granulomatous diseases (e.g. tuberculosis), septic embolism, lung abscess, fungal or viral infections and other parasites may cause MPN. However, radiological signs are not typical of any of them and the clinical and laboratory data were not suggestive of such possibilities.- Vascular malformations should have been observed in previous studies. Pulmonary infarction may cause MPN but the patient did not show pulmonary embolisms.Due to lack of specificity of the findings, the multidisciplinary committee agreed to perform a CT-guided pulmonary biopsy of the largest lesion (Fig. 2c). The first biopsy cylinder was successfully obtained. However, immediately the patient developed an intense cough associated with haemoptysis that required postural measures, oxygen therapy and aspiration of material accumulated in the bronchial tree. Procedure was then stopped.Tissue obtained by fine needle aspiration biopsy shows typical findings in pulmonary amyloidosis (Fig. 4): the normal lung is replaced by a mass of amorphous, eosinophilic, extracellular Congo red-positive material.First control of pulmonary nodules 5 months after detection has shown no changes. The most frequent form of pulmonary amyloidosis is nodular amyloidosis [2, 3] and it is usually a local process. Its X-ray appearance may be indistinguishable from neoplastic lesions. It may appear as solitary or multiple pulmonary nodules, which are rounded and well-defined. Cases of irregular edges are usually due to vascular involvement or to involvement of adjacent septa. Lesions generally grow slowly and have therefore a good prognosis.Diffuse septal involvement (amyloid deposits in alveolar septa) is less frequent, although it is associated with higher clinical involvement due to a higher risk of pulmonary hypertension and respiratory insufficiency [4]. In such cases, a much more varied semiology may be found: micronodules (2-4 mm), septal thickening, reticular opacity, basal peripheral consolidations that tend to converge, pleural effusion, pleural thickening, etc.",
    "differential_diagnosis": "Nodular, amyloidosis, Metastasic, or, primary, malignant, nodules, Nodular, sarcoidosis, Pneumoconiosis, (e.g., silicosis), Granulomatorus, diseases, (e.g., tuberculosis), Reumathoid, nodules, Fungal, or, viral, infections, Vascular, malformations, Pulmonary, infarctions",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014089/000001.png?itok=PidIMdik",
            "caption": "Pulmonary parenchyma showed multiple nodules in both fields."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014089/000002.png?itok=KQaKQMIf",
            "caption": "Pulmonary parenchyma showed multiple nodules in both fields."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014089/000004.png?itok=lz8xh-xY",
            "caption": "Pulmonary parenchyma showed multiple nodules in both fields. The largest one was located in the apical segment of the right lower lobe and was 18 mm in diameter."
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014089/000005.png?itok=8KXOeN5J",
            "caption": "Pulmonary parenchyma showed multiple nodules in both fields."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014089/000006.jpg?itok=C0jzhtNF",
            "caption": "Hematoxylin and eosin stain: This view shows a solid mass of amorphous, eosinophilic, extracellular material. A multinucleated giant cell reaction is present."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014089/000007.jpg?itok=vzEu4Agz",
            "caption": "This view shows amorphous Congo red-positive deposits."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014089/000008.jpg?itok=0xFa3tPh",
            "caption": "A Congo red-stained section view under polarizing microscopy demonstrates classic apple-green birefringence."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014089/000009.jpg?itok=7-0k3NaK",
            "caption": "Multiple pulmonary nodules, the biggest with 25 mm in diameter in the upper segment of the right lower lobe (RLL)."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014089/000010.jpg?itok=i3SfVZDt",
            "caption": "Multiple pulmonary nodules, the biggest with 25 mm in diameter in the upper segment of the right lower lobe (RLL)."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014089/000012.jpg?itok=cqTl1Z2S",
            "caption": "Negative image shows better view of smaller nodules at both mid-lung fields."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014089/000011.jpg?itok=mwK7RO1u",
            "caption": "Absence of pulmonary uptake after intravenous administration of Octreotide-In 111."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "SPECT",
      "Conventional radiography",
      "CT",
      "Percutaneous"
    ],
    "link": "https://www.eurorad.org/case/14089",
    "time": "16.04.2017"
  },
  "14106": {
    "case_id": 14106,
    "title": "Neurogenic pulmonary oedem",
    "section": "Chest imaging",
    "age": "27",
    "gender": "female",
    "diagnosis": "Neurogenic pulmonary oedema",
    "history": "Young female patient with no significant past medical history presented to the emergency department with asystole.According to her boyfriend the patient had suffered from severe headache for the last few hours which was not relieved by analgesics. She went to sleep in order to feel better.The boyfriend awoke to find the patient gasping.",
    "image_finding": "The patient was intubated during resuscitation and portable chest X-ray was performed, which showed endotracheal tube with the distal tip in the right main bronchus.Bilateral extensive patchy air space opacities with no pleural effusion or pneumothorax. Based on the patient's history, the findings suggest non-cardiogenic pulmonary oedema.CT brain correlation was needed.Findings were conveyed to the referring physician. Plain CT brain was done immediately and showed a large subarachnoid haemorrhage along with intraparenchymal haematoma in the right basifrontal lobe.There was also associated interventricular haemorrhage with predominant involvement of both lateral ventricles.Significant changes of diffuse cerebral oedema were present with effacement of basal cisterns.No hydrocephalus at present.No mid-line structures shift.Bony skull vault was unremarkable.CT brain angiography was suggested for further and proper evaluation but it was not done due to the patient's condition.",
    "discussion": "Pulmonary oedema is fluid accumulation in the lung tissue and air spaces which may lead to impaired gas exchange causing respiratory failure. It is differentiated into two types, non-cardiogenic and cardiogenic. Non-cardiogenic pulmonary oedema (NPE) is caused by changes in permeability of the pulmonary capillary membrane as a result of either a direct or an indirect pathologic insult. [1]Distinguishing between non-cardiogenic and cardiogenic causes is difficult, since the clinical symptoms are non-specific. The diagnosis is important, however, because treatment changes considerably depending upon the related cause. [2]Most patients with non-cardiogenic pulmonary oedema (NPE) are immobile and seriously ill. Chest X-ray is the examination of choice as it is readily, universally available and it has the added advantage of portability. [1]Neurogenic pulmonary oedema is a rare form of (NPE), which is caused by an increase in pulmonary alveolar and interstitial fluid. It can occur within a few hours of the neurologic insult. Intracranial hypertension is considered an important factor as most common neurological events are associated with high intracranial pressure. [3]Major causes of neurogenic pulmonary oedema are head injury, cerebral haemorrhage, subarachnoid haemorrhage or epileptic seizures. [3]Patients most commonly complain of diaphoresis, dyspnoea or orthopnoea. Symptoms are mainly of gradual onset.Chest X-ray findings of non-cardiogenic pulmonary oedema are:Bilateral peripheral air space disease with central bat-wing pattern. Normal cardiothoracic ratio. Pleural effusions and Karley B lines are not common. [5]CT findings:Ground glass opacifications with air bronchogram and gravity-dependent consolidation are common. [5]Neurogenic pulmonary oedema usually is generally well tolerated by the patient, although some patients require supportive management.Mechanical ventilation may be necessary, either non-invasive with a face mask or by an endotracheal tube. The goals of mechanical ventilation are to prevent iatrogenic lung injury and to assure adequate oxygenation. [3]Diuretics to reduce fluid overload with adequate cerebral perfusion and cardiac output is a reasonable approach. [3](NPE) usually resolves within 2-3 days. Prognosis is determined more by the course of the underlying neurological problem rather than by the neurogenic pulmonary oedema, unless significant respiratory complications develop. [3]",
    "differential_diagnosis": "Neurogenic, pulmonary, oedema, Drowning, Allergic, reaction., Inhalation, or, nephrogenic, oedema, Cardiogenic, pulmonary, oedema, Diffuse, pneumonia",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014106/000001.png?itok=J2GYbrfF",
            "caption": "Endotracheal tube with the distal tip to the right main bronchus, needs to be adjusted. \nBilateral extensive patchy air space opacities with air bronchogram. No obvious Kerley B lines or pleural effusions. \nNo pneumothorax."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014106/000002.jpg?itok=FhkfsJN_",
            "caption": "Large subarachnoid haemorrhage along with intraparenchymal haematoma in the right basifrontal lobe. \nDiffuse cerebral oedema with effacement of basal cisterns and cortical sulci bilaterally."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014106/000005.jpg?itok=2KX8YNkF",
            "caption": "Subarachnoid haemorrhage along with intraventricular extension inducing massive brain oedema noted by loss of grey-white matter differentiation and effacement of cortical sulci."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Head and neck"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/14106",
    "time": "16.11.2016"
  },
  "14124": {
    "case_id": 14124,
    "title": "A Rare Case of 18F-FDG-avid Granular Cell Tumor of the Esophagus",
    "section": "Chest imaging",
    "age": "31",
    "gender": "female",
    "diagnosis": "Benign esophageal granular cell tumor",
    "history": "A 31-year-old African-American female presented with abdominal pain and dysphagia. CT and EGD performed at an outside facility demonstrated an oesophageal mass. Immunohistochemistry showed positive S-100 reactivity. Outside CT, EGD, and immunohistochemistry are not available. PET demonstrated hypermetabolic oesophageal mass and excluded metastatic disease. The patient underwent curative excision.",
    "image_finding": "18F-FDG PET/CT maximum intensity projection (Fig. 1) and multi-planar fused PET/CT and low-dose CT images (Fig. 2) showed an intensely avid mass in the mid-thoracic oesophagus producing mass effect on the left atrium and aorta. The mass had an estimated size of 2 x 2 x 4.5 cm and a maximum standardized uptake value (SUVmax) of 3.9, which was substantially higher than the reference activities of blood pool (SUVmax 1.6) and liver (SUVmax 2.2). There is no evidence of multifocal or metastatic disease. Histology of H&E stained sections (Fig. 3) revealed monotonous infiltrate of large cells with abundant eosinophilic granular cytoplasm and bland nuclei without significant pleomorphism or mitotic activity. A previously obtained biopsy of the mass at an outside institution revealed diffuse positivity of S-100 via immunohistochemical analysis, confirming neuroendocrine cell origin (no longer available). Gross anatomic image (Fig. 4) demonstrates surgical excision of esophageal mass via right thoracotomy.",
    "discussion": "Background: Granular cell tumours (GCTs) are rare, usually benign, primarily neuroectodermal neoplasms which can affect all parts of the body, but are most commonly found in the mucus membranes of the aerodigestive tract, soft tissue, and skin [1-3]. Both benign and malignant GCTs are reported to be avid on 18F-FDG PET/CT, which may be useful in the evaluation of GCTs. Clinical Perspective: Differentiating benign and malignant GCTs on pathology can be challenging, with lesions being classified as benign, atypical, and malignant [4]. However, given the FDG-avidity of GCTs, it is reasonable to consider utilizing PET/CT for staging and treatment monitoring of GCTs.Imaging perspective: Due to their rarity, the optimal imaging approach for GCTs has not been established, and no characteristic features have been readily described on MRI [5]. Irrespective of location, GCTs appear as soft tissue masses on CT and do enhance with contrast administration both on CT and MRI. Previously reported GCT SUV max values range from blood pool level (SUV 1.8) to intense activity (SUV 15.8) [6]. Benign GCTs have reported SUV max values of 1.8 to 9.1 and malignant GCTs have reported SUV max values of 5.8 to 15.8 [7-8]. Outcome: The mass was producing left atrial mass effect and was ultimately excised by cardiothoracic surgery. The surgery consisted of right thoracotomy, excision of esophageal mass, esophageal repair with closure, and placement of nasoduodenal feeding tube. Take home message, teaching points: Cases of both benign and malignant GCTs demonstrating 18F-FDG avidity have been reported in the soft tissue, breast, colon, and lung [9]. To the best of our knowledge, this is the first case of FDG-avid benign esophageal GCT in the literature (SUV 3.9). At this time, there is not enough data to suggest if 18F-FDG avidity is useful in differentiating benign and malignant GCT. In another histologically-related entity, neurofibromatosis-1 (NF-1), 18F-FDG avidity proved to be useful in differentiating benign neurofibromas from transformed malignant peripheral nerve sheath tumors [10]. Because GCTs are FDG avid, it is reasonable to consider utilizing PET/CT for staging to detect multifocal or metastatic disease and for treatment monitoring of GCTs, particularly those with atypical or malignant histology.",
    "differential_diagnosis": "Benign, esophageal, granular, cell, tumor, Neoplasm, Malignant, granular, cell, tumour",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014124/000002.jpg?itok=z2IYFA99",
            "caption": "An intensely avid mass (arrow) measuring 2x2x4.5 cm in the mid-thoracic oesophagus producing mass effect on the left atrium and aorta."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014124/000004.jpg?itok=cv2LnZWA",
            "caption": "Monotonous infiltrate of large cells with abundant eosinophilic granular cytoplasm and bland nuclei without significant pleomorphism or mitotic activity."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014124/000005.jpg?itok=0bBMq8un",
            "caption": "2x2x4.5cm mass excised from oesophagus by right thoracotomy."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014124/000006.jpg?itok=biI_FqR5",
            "caption": "Figure 2A: Coronal fused PET/CT image\nFigure 2B: Sagittal fused PET/CT image\nFigure 2C: Sagittal LDCT image\nFigure 2D: Transverse fused PET/CT image\nFigure 2E: Transverse LDCT image"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Oesophagus",
      "Thorax",
      "Gastrointestinal tract"
    ],
    "imaging_technique": [
      "Percutaneous",
      "PET",
      "PET-CT"
    ],
    "link": "https://www.eurorad.org/case/14124",
    "time": "30.12.2016"
  },
  "14126": {
    "case_id": 14126,
    "title": "Right sided lobar agenesis with multiple uncommon  vascular anomalies \u2013 a rare case",
    "section": "Chest imaging",
    "age": "20",
    "gender": "male",
    "diagnosis": "Right sided lobar agenesis with duplication of SVC and Bovine arch",
    "history": "A 20-year-old man presented with chronic vague chest pain and mild cough. X-RAY chest PA view showed tracheal and mediastinal shift towards the right side, rib crowding in the right hemithorax with elevation of the right hemidiaphragm.",
    "image_finding": "Contrast enhanced CT shows an absence of the right upper lobe with a significant tracheal and mediastinal shift towards the right side. Excessive proliferation of extrapleural fat is seen in the right upper zone. The origin of the right upper lobe bronchus from the right main bronchus is not seen, suggesting lobar hypoplasia. The right pulmonary artery is seen hypoplastic, measuring 8mm, although the main pulmonary artery and left pulmonary artery are normal. Duplication of the superior vena cava is seen on contrast study. The feft sided SVC is draining into the coronary sinus. Both right pulmonary veins are seen hypoplastic, suggesting Congenital unilateral pulmonary vein stenosis or atresia. Bifurcation of the ascending aorta is seen at its origin from the left ventricle, the larger lumen continues as arch of aorta and gives rise to all branches, the smaller lumen is hypoplastic. The left-sided common carotid artery arises from the right brachiocephalic artery suggesting bovine variant. The right superior intercostal vein is dilated and draining into the right-sided superior vena cava.",
    "discussion": "Lobar agenesis of the lung is a very rare anomaly that may be observed in isolation or may be accompanied by other congenital defects of the cardiovascular, musculoskeletal, or gastrointestinal systems [1].Lobar agenesis\u2013aplasia complex is a group of pulmonary malformations affecting, almost exclusively, the right hemithorax. All of these malformations present pulmonary anomalies in the form of one or more absent or underdeveloped pulmonary lobe. The right upper lobe is most often affected. This gives a bronchial pattern of the right lung similar to that observed in the left lung in normal conditions (hypoarterial bronchus). It is called bilobed or bilateral left lung. Lung agenesis\u2013hypoplasia complex can be associated with malformations in other systems, including the skeletal, digestive, cardiac and urinary systems, and even in the contralateral lung [2, 3].If underdevelopment is very pronounced, one can observe extrapleural fat deposits along the thoracic wall simulating pleural thickening similar to, though not as striking as, those seen in the lung agenesis-hypoplasia complex. Ipsilateral pulmonary artery hypoplasia is associated with lobar agenesis [4]. Absence (atresia or interruption) of the main right or left pulmonary artery (APA) is an isolated vascular malformation that goes together with small homolateral lung, but should not be considered a part of lung agenesis\u2013hypoplasia complex.Lobar agenesis is associated with varying degree of pulmonary venous anomalies as Congenital unilateral pulmonary vein stenosis or atresia, anomalous pulmonary venous return, levo-atriocardinal vein and congenital venolobar syndrome (scimitar syndrome) etc.A persistent left SVC is an incidental finding in less than 0.5% of the general population but occurs in approximately 4% of patients with congenital heart disease. In most cases, the left SVC is a component of a duplicated SVC. The left brachiocephalic vein is absent, and the right SVC is smaller than the left in 65% of SVC duplications [5-7]. It mostly drains into the coronary sinus. The left SVC descends lateral to the aortic arch and anterior to the hilum, enters the pericardium in the posterior atrioventricular groove, and drains into the coronary sinus. The common brachiocephalic trunk, in which both common carotid arteries and the right subclavian artery arise from a single trunk off the arch, is the most frequent normal variant of aortic arch branching. This so-called bovine trunk occurs in ~10 to 22% of individuals according to the literature and accounts for more than two thirds of all arch vessel anomalies [8, 9].",
    "differential_diagnosis": "Right, sided, lobar, agenesis, with, duplication, of, SVC, and, Bovine, arch, Scimitar, syndrome, Lobar, collapse",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014126/000001.jpg?itok=H4O2dGlu",
            "caption": "(a)3D volume rendered image  CT chest shows small, bilobed and dysmorphic right lung. Left lung is seen normal."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014126/000002.jpg?itok=m85U8dfX",
            "caption": "Coronal image shows Abundant extrapleural fat seen in right upper hemithorax (yellow triangle), prominent right superior intercostal vein (green arrow)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014126/000003.jpg?itok=CeQnVG23",
            "caption": "3D volume rendered image posterior aspect shows hypoplastic right PA (white arrow), hypoplastic right pulmonary veins (red arrows) and normal left pulmonary veins (green arrows). Left-sided superior vena cava seen (star)."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014126/000004.jpg?itok=W_S8PyVl",
            "caption": "Coronal reformatted image CECT chest in arterial phase shows duplication of superior vena cava. Non opacified Right sided SVC (yellow arrow) and left-sided SVC opacified with contrast (red arrow)."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014126/000005.png?itok=7NS76kt6",
            "caption": "3D volume rendered image CT chest shows both right carotid artery (green arrow) and left carotid artery (red arrow) arising from common innominate trunk (star) bovine variant ."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014126/000006.jpg?itok=1gFegoni",
            "caption": "Coronal reformatted image CECT chest shows two lumens arising from left ventricular cavity (red star). Small hypoplastic right lumen (blue arrow), large left lumen (brown arrow)."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Cardiovascular system",
      "Cardiac"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/14126",
    "time": "28.10.2016"
  },
  "14137": {
    "case_id": 14137,
    "title": "Pulmonary AVM with 3D reconstruction images",
    "section": "Chest imaging",
    "age": "40",
    "gender": "female",
    "diagnosis": "Pulmonary arteriovenous malformation.",
    "history": "A 40-year-old female patient presented for evaluation of dyspnoea. The patient had previous work up at an outside institution, and prior history is unavailable.",
    "image_finding": "Contrast-enhanced CT of the thorax was obtained following intravenous contrast administration. Multiplanar reformatted and 3D-reconstructed images were also available for review. The examination demonstrated a solitary serpiginous enhancing lesion in the left costophrenic angle arising from the left interlobar pulmonary artery.",
    "discussion": "BackgroundPulmonary Arteriovenous Malformation (pAVM) refers to the abnormal communication between a pulmonary artery branch and pulmonary vein branch, bypassing the pulmonary capillary bed. These communications are usually congenital in nature. Risk factors include family history of Hereditary Heamorrhagic Telangiectasia (HHT), female sex, hepatopulmonary shunt, schistosomiasis, actinomycosis, and Fanconi syndrome [1]. Of these, HHT (also known as Osler-Weber-Rendu syndrome) has the strongest association with pAVM. 30 to 50% of HHT patients have pulmonary AVMs and roughly 90% of pAVM patients have HHT [1, 2, 3]. These lesions have predilection for the lower lobes, with the left side more commonly affected than the right [1]. The malformation can be classified as simple or complex, depending on the feeding artery\u2019s structure. A simple pAVM has a single feeding segmental artery, while a complex pAVM is fed by more than one segmental artery. A subset of complex AVM includes diffuse pAVM, in which innumerable feeding arteries are present and is in particular difficult to treat [2]. Clinical PerspectiveAlthough many patients may remain asymptomatic, symptoms often are the result of right to left shunting, which may be associated with dyspnoea, migraine headache and cyanosis. Major complications of pAVM include TIA, stroke, and brain abscess due to paradoxical embolism. [4, 5] The prevalence of neurologic manifestations becomes greater for patients with multiple pAVM [6].Imaging PerspectiveThe modality of choice is contrast enhanced helical CT, and the most common finding is a simple AVM located in the lower lobes. Catheter-based pulmonary angiography, which is usually reserved for treatment after primary diagnosis was made, also can show the relationship between the pAVM and its feeding artery. Limitations of CT include the possibility of \u201csteal phenomenon\u201d, resulting in non-enhancement of some accessory feeding vessels. Additionally, measurement of feeding vessel calibre for the purposes of choosing the embolic device should be confirmed on catheter-based pulmonary angiography, as the feeding artery may be under-distended during the time of CT examination [2]. OutcomeThe treatment of choice for pAVM is percutaneous transcatheter embolization, with a size cut-off of less than 3 mm for the feeding artery [2]. Surgery is indicated to control bleed or for lesions not amenable to catheter embolization [1, 2]. Lifelong follow up contrast-enhanced chest CT is necessary due to the potential for growth of new pAVM or recanalization of treated pAVMs [1, 2]. Take Home MessagePulmonary AVM may be incidentally discovered. Treatment is required because of the risk of paradoxical embolism.",
    "differential_diagnosis": "Pulmonary, arteriovenous, malformation., Abnormal, systemic, vessels, Highly, vascular, parenchymal, mass",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014137/000001.jpg?itok=HqJY-mJj",
            "caption": "Axial contrast enhanced CT of the thorax shows an enhancing serpiginous lesion in the left costophrenic angle (red arrow)."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014137/000002.jpg?itok=9-5xRboG",
            "caption": "Left image: Sagittal view of the same lesion (red arrow). Right image: Magnified view of lesion."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014137/000003.jpg?itok=v6_9Ecb3",
            "caption": "Left image: Coronal view of the same lesion (red arrow). Right image: Magnified view of lesion."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014137/000004.jpg?itok=UQ24QL3v",
            "caption": "3D reconstructed images from source CECT images (red arrow)."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014137/000005.jpg?itok=9jBnQEcB",
            "caption": "Magnified and oblique view of the same lesion (red arrow)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014137/000006.jpg?itok=5FA1Kk6b",
            "caption": "Left image: Pulmonary angiography demonstrating vascular lesion and its relation to the supplying vessels. Right image: Occlusion of feeding vessel after embolization."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT",
      "Catheter arteriography"
    ],
    "link": "https://www.eurorad.org/case/14137",
    "time": "15.10.2016"
  },
  "14195": {
    "case_id": 14195,
    "title": "A rare complication of esophagectomy",
    "section": "Chest imaging",
    "age": "45",
    "gender": "female",
    "diagnosis": "Acquired diaphragmatic hernia secondary to previous minimally invasive esophagectomy.",
    "history": "Our 45-year-old patient had a history of minimally invasive esophagectomy for localized cancer after neoadjuvant chemoradiation. Three years later, she presented with a one-week history of shortness of breath and cough. A retrospective review of case notes revealed multiple recent visits with abdominal pain and dyspeptic symptoms.",
    "image_finding": "Chest x-ray revealed an apparent left pleural effusion (Panel A) and a thoracocentesis was planned. However, pre-procedural lung ultrasound showed absence of an effusion. A CT Thorax then confirmed herniation of small bowel and colon into the hemithorax suggesting a diaphragmatic hernia (Panel C & D).",
    "discussion": "Early esophageal carcinoma is increasingly detected with active and robust endoscopic surveillance for Barrett's esophagus. Curative management for localized esophageal carcinoma is surgical resection via open or minimally invasive procedures[1]. Minimally invasive surgery remains the preferred technique due to fewer post operative complications. However, the incidence of post procedural diaphragmatic hernia, a rare complication, is observed to be higher in the minimally invasive group compared to open surgery [2]. Diaphragmatic hernias are characterized by herniation of abdominal contents namely small bowel and colon into the thoracic cavity through a diaphragmatic defect. Clinical symptoms range from being asymptomatic to dyspeptic symptoms or florid respiratory failure [3].Chest radiography could effectively clinch the diagnosis, however, diagnostic dilemmas do occur as with our case. Her previous history of esophageal cancer coupled with a chest X-ray suggesting a pleural effusion led to a presumed diagnosis of malignant effusion secondary to recurrence of primary neoplastic disease. Though a sensible oncological differential,  a diagnosis of diaphragmatic hernia should always be suspected in any patients with previous esophagectomy. The commonest time frame for occurrence of this post operative complication is 2 years, relatively similar to our case [3]. A pre-procedural (thoracocentesis) lung ultrasound provided valuable diagnostic information in showing only trace pleural effusion. This necessitated a CT Thorax to further investigate the initial findings on the presenting chest X-ray which confirmed the diagnosis demonstrating multiple bowel loops in the hemithorax displacing the left lung. Our patient underwent a laparoscopic diaphragmatic hernia repair and made an unremarkable recovery. The utilization of radiography and ultrasound in making an accurate diagnosis and computed tomography in both confirming and planning for surgery yielded an optimal outcome for our patient. Our case highlights the importance of combined multimodal imaging and clinical suspicion in addressing diagnostically challenging scenarios.",
    "differential_diagnosis": "Acquired, diaphragmatic, hernia, secondary, to, previous, minimally, invasive, esophagectomy., Recurrence, of, primary, disease, with, malignant, effusion, (initial), Diaphragmatic, rupture",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014195/000001.jpg?itok=QsYPON_3",
            "caption": "Chest X-ray showing an apparent pleural effusion."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014195/000002.jpg?itok=YMTgbywa",
            "caption": "Pre-procedural lung ultrasound showing only trace pleural effusion."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014195/000003.jpg?itok=V1yigGEz",
            "caption": "CT Thorax with coronal view confirming herniation of small bowel and colon suggesting a diaphragmatic hernia."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014195/000004.jpg?itok=HBbfYgtl",
            "caption": "CT Thorax with axial view demonstrating herniation of small bowel and colon suggesting a diaphragmatic hernia."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Thorax"
    ],
    "imaging_technique": [
      "CT",
      "Ultrasound"
    ],
    "link": "https://www.eurorad.org/case/14195",
    "time": "27.11.2016"
  },
  "14223": {
    "case_id": 14223,
    "title": "Posttraumatic abdominal and thoracic splenosis.",
    "section": "Chest imaging",
    "age": "60",
    "gender": "male",
    "diagnosis": "Posttraumatic abdominal and thoracic splenosis.",
    "history": "Thoracoabdominal CT after administration of contrast material (CECT) control study in a patient with Non-Hodgkin Lymphoma in remission. The patient had been in a motor vehicle accident which resulted in diaphragmatic rupture and rib fractures.",
    "image_finding": "Thoracoabdominal CT after administration of contrast material (CECT) revealed the presence of a round homogenously enhancing mass in the left upper thorax, measuring approximately 30 mm, adjacent to another similarly enhancing nodule of 7 mm in size (Figure 1a and 1b).Healed fractures in the 5th, 6th and 7th ribs of the left hemithorax and sequelae of diaphragmatic rupture with a small round well circumscribed intraabdominal nodule of 12mm in size (Firuge 2a and 2b).Absence of the spleen is consistent with a history of splenectomy, observing a round homogeneously enhancing mass in splenic angle measuring 31 mm and similarly enhancing 14 mm nodule anterior to the left hepatic lobe (Figure 3a and 3b).",
    "discussion": "Splenosis is defined by the presence of normal splenic tissue in abnormal locations. The most common sites include the mesentery, peritoneum, and omentum presenting significant variability in shape and size [1].Unlike accessory spleens, splenosis occurs as a result of dissemination of splenic tissue and thus, derives its irrigation from the tissues nearby. Thorax is an infrequent site for splenosis, commonly requiring a history of splenic injury in association with diaphragmatic disruption [2]. Although most patients are asymptomatic, recurrent hemoptysis and pleurisy have been reported. The importance of acknowledging this entity is reassured by its ability to mimic malignant disease [3].This case presents some classic CT findings such as [4]. - Multiple variably sized homogeneously enhancing nodules and masses within the left hemithorax and abdomen.- Absence of spleen in splenic angle. - Diaphragmatic rupture in association with healed fractures, consistent with the history of traumatic injury as a result of motor vehicle accident reported by the patient. As for differential diagnosis, the history of Hodgkin's lymphoma should prompt the possibility of recurrence. However several considerations should be made [5]:- The enhancement pattern is unusual for a thoracic lymphoma.- An association with pleural effusion would be expected.- And, most importantly, control CECT have been reporting stability for a period of 5 years. A forethought for extramedullary intrathoracic hematopoiesis should also be made, keeping in mind that it has a predisposition for posterior mediastinum in a bilateral paravertebral distribution.Other diagnostic options such as fibrous tumors of the pleura, malignant mesothelioma and invasive thymoma, although inconsistent with the multiple nature of the nodules, should be kept in mind [5].Technecium 99m sulfur colloid scintigraphy of the liver and spleen has been reported as being useful in cases of diagnostic uncertainty [6].The asymptomatic thoracic splenosis should not be surgically removed, while the procedure might actually make the patient pron to infections with encapsulated microorganisms [7].Homogeneously enhancing round shaped multiple nodules with the history of traumatic diaphragmatic disruption in association with splenectomy, should indicate the diagnosis of thoracic splenosis.",
    "differential_diagnosis": "Posttraumatic, abdominal, and, thoracic, splenosis., Lymphoma, Extramedullary, hematopoiesis, Malignant, pleural, disease, Invasive, Thymoma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014223/000001.png?itok=CUr9tjHh",
            "caption": "Thoracoabdominal CECT revealed the presence of a round homogenously enhancing mass in the anterior left mediastinum, measuring approximately 30 mm and another similarly enhancing nodule of 7 mm. Healed fractures of 5th, 6th and 7th left ribs."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014223/000002.jpg?itok=tFCrCyjq",
            "caption": "Thoracoabdominal CECT revealed the presence of a round homogenously enhancing mass in the anterior left mediastinum, measuring approximately 30 mm and another similarly enhancing nodule of 7 mm. Healed fractures of 5th, 6th and 7th left ribs."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014223/000003.png?itok=6VamPGAJ",
            "caption": "Sequelae of diaphragmatic rupture with small round well circumbsribed intraabdominal nodule of 12mm."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014223/000004.jpg?itok=v-79laQT",
            "caption": "Sequelae of diaphragmatic rupture with small round well circumbsribed intraabdominal nodule of 12mm."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014223/000005.png?itok=zYAABx8q",
            "caption": "Absence of spleen, observing a round homogenously enhancing mass in splenic angle measuring 31 mm in size. Similarly enhancing 14 mm nodule anterior to left hepatic lobe."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014223/000006.jpg?itok=TJVncKzc",
            "caption": "Absence of spleen, observing a round homogenously enhancing mass in splenic angle measuring 31 mm in size. Similarly enhancing 14 mm nodule anterior to left hepatic lobe."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Abdomen",
      "Abdominal wall",
      "Spleen",
      "Trauma",
      "Thoracic wall",
      "Thorax"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/14223",
    "time": "29.11.2016"
  },
  "14238": {
    "case_id": 14238,
    "title": "A rare case report of Extraskeletal Ewing&#039;s sarcoma of the trache",
    "section": "Chest imaging",
    "age": "14",
    "gender": "female",
    "diagnosis": "Primary Extraskeletal Ewing's sarcoma of the trachea",
    "history": "A 14-year-old female presented with complaints of breathlessness upon exertion for 6 months, and aggravated since 1 week. Chest x-ray taken appeared unremarkable. Contrast enhanced CT was performed for further Evaluation.",
    "image_finding": "Chest X ray PA view-trachea appeared central. No significant abnormality was noted.\nCECT thorax showed a well defined enhancing polypoidal soft tissue density lesion in the left anterolateral wall of the trachea at the T2 vertebral Level, with significant luminal narrowing and mediastinal extension.\nBronchoscopy showed a polypoidal lesion in the lateral wall of the trachea projecting into the tracheal lumen with luminal narrowing.\nMicroscopy showed diffuse proliferation of round cells within a hyalinized stroma, which had high-grade nuclei, occasional nucleoli, and minimal cytoplasm.",
    "discussion": "Primary endotracheal tumours are uncommon in childhood. The most common malignant endotracheal lesions are carcinoid tumour and mucoepidermoid carcinoma. Inflammatory pseudotumour and endotracheal hamartoma are common benign pathologies. Most of the malignant lesions are found in adolescents while benign lesions like hemangiomas are commonly seen in infants and children [1].\n\nThese tumours most frequently present as wheezing, stridor and recurrent pneumonia in childhood. Imaging should be considered to rule out an obstructive process when there is no response to standard treatment with antibiotics and bronchodilators. Chest radiograph is usually normal. Contrast enhanced CT is the imaging modality of choice [1].\n\nExtraskeletal Ewing's sarcoma (EES) of the trachea is extremely rare with only 2 published cases. EES belongs to the Ewing's sarcoma family of tumours which also include osseous Ewing's sarcoma, Askin's tumour and PNET. They are neuroectodermal in origin and share the cytogenetic marker, translocation of chromosomes t (11;22)(q24;q12). The most common locations of EES are paravertebral region, lower extremities, chest wall, retroperitoneum, pelvis and hip [2].\nThe criteria proposed for the diagnosis of EES are absence of osseous involvement at MRI, no increased uptake in bone or periosteum on scintigraphy, and small blue round cells on histology [2]. Immunohistochemical and histochemical staining positive for glycogen(PAS), NSE, S-100 and MIC-2 marker [3].\nThe imaging features of EES on CT as an enhancing soft tissue mass of muscle attenuation are nonspecific. Necrosis and haemorrhage may correspond to low attenuation areas. On MRI EES is heterogenous, isointense to muscle on T1 and iso- to hyperintense on T2. Features suggestive of haemorrhage, fluid levels, serpentine flow voids and a pseudocapsule may be seen [2]. Tracheal EES manifests as an enhancing endoluminal mass with significant stenosis and mediastinal infiltration. Proper airway intervention at the time of diagnosis is important prior to definitive treatment [4].\nThe role of imaging is for staging, which includes a CT of the chest, Tc99 bone scan and FDG PET scan for evidence of metastatic disease. At FDG PET, this tumour can demonstrate avid uptake depending on metabolic activity [4]. Often the diagnosis of primary tracheal EES is made after bronchoscopy and biopsy.\nThe treatment of EES involves combined systemic chemotherapy and local therapy by surgical resection, radiation, or both.\nIn conclusion, endotracheal tumours in the adolescent population is more likely to be malignant. Although the imaging appearance of primary EES of the trachea is nonspecific it must be considered as a possibility in case of a rapidly growing endotracheal soft tissue mass.",
    "differential_diagnosis": "Primary, Extraskeletal, Ewing's, sarcoma, of, the, trachea, Mucoepidermoid, carcinoma, carcinoid, inflammatory, pseudotumour",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014238/000002.png?itok=Tq6mDMh_",
            "caption": "Plain CT Thorax shows a well defined  polypoidal soft tissue density lesion  in the left anterolateral wall of the trachea at T2 vertebral level with significant luminal narrowing and mediastinal extension"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014238/000003.png?itok=VLM6wybm",
            "caption": "The lesion shows significant post contrast enhancement."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014238/000004.png?itok=k8RPH6cY",
            "caption": "CT Thorax lung window shows no abnormalities in lung parenchyma."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014238/000005.jpg?itok=Mrm1R_M5",
            "caption": "Diffuse proliferation of round cells within a hyalinized stroma, which has high-grade nuclei, occasional nucleoli, and minimal cytoplasm"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014238/000007.jpg?itok=96PNXL8h",
            "caption": "Chest xray showed no significant abnormality"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/14238",
    "time": "22.02.2017"
  },
  "14255": {
    "case_id": 14255,
    "title": "Complicated left subclavian artery pseudoaneurysm after pacemaker implantation",
    "section": "Chest imaging",
    "age": "64",
    "gender": "male",
    "diagnosis": "Complicated left subclavian artery pseudoaneurysm after pacemaker implantation.",
    "history": "A 64-year-old man with a third-degree atrioventricular block was admitted to the intensive care unit to implant a transitory pacemaker. Later, an attempt to implant a permanent pacemaker using subclavian veins was unsuccessful. The next day, the cannulation of the left subclavian vein was achieved and the permanent pacemaker was implanted.",
    "image_finding": "Although the patient was asymptomatic, a chest-X-ray was performed after the unsuccessful cannulation attempt. It showed a loculated pleural effusion in the apical and lateral costal pleura and a mediastinal widening (Fig.1).The next day, after implanting the permanent pacemaker, a chest CT with multiplanar reformations and intravenous contrast-enhancement was performed. Thus, the presence of a left multiloculated pleural effusion was confirmed. This collection, with a density around 50UH, was compatible with hemothorax (Fig.2). In addition, the CT revealed a saccular mass,  located in the prevascular mediastinal region between the left subclavian artery and subclavian vein. This well-defined mass had a diameter of 2.3x1.7 cm. After the introduction of contrast iv, the mass showed a homogeneous enhancement, as well as a communication with the left subclavian artery. These findings were consistent with a pseudoaneurysm of the left subclavian artery (Fig. 3-4).Finally, a stranding of the paratracheal mediastinal fat was suggestive of mediastinal bleeding.",
    "discussion": "Serious complications of central venous access occur in 0.4% to 9.9% of patients undergoing attempted central venipuncture. These complications include local hematoma, pneumothorax, hemothorax, hydrothorax, central venous thrombosis, air embolism, diaphragmatic paralysis, arrhythmia and cardiac tamponade due to superior vena cava or right heart perforation. Nevertheless, pseudoaneurysm formation of the great vessels and the right subclavian artery is a rare complication in patients undergoing central veni puncture [1].A pseudoaneurysm development results from an arterial wall disruption, then blood dissects the adjacent tissues of the damaged artery causing an aneurysm sac that communicates with the arterial lumen. The sac can be contained by the media, adventitia or the tissue surrounding the vessel [2].Once it occurs, it can let to secondary complications, such as rupture and subsequent bleeding, arterial thrombosis, compression of adjacent structures and even fistulization through the skin.In our case, the rapid diagnosis prevented the pseudoaneurysm progression resulting in the mentioned complications above.Years ago, when this entity was suspected, a diagnostic angiography was used [1]. However, currently, CT with intravenous contrast allows us to locate and properly identify the neck of the pseudoaneurysm thanks to the great anatomical resolution it offers.The treatment of this condition is generally surgical [3], in fact, a subclavian false aneurysm, even if it is small and asymptomatic, should be treated surgically without delay to prevent permanent neural damage or other associated sequelae related with this anatomical region [2].Its classical approach requires the combination of a supraclavicular incision and resection of the clavicle, or sternotomy with a supraclavicular extension. This approach represents up to 24% of postsurgical complications and a mortality of 5-30%. Checking the patency of the contralateral vertebral artery is important to ensure an adequate flow to the basilar artery, given that the ostium of the ipsilateral vertebral artery is usually compromised by pseudoaneurysm surgical treatment. Endovascular treatment is a good alternative in which the main benefit lies in avoiding injury distally. The difficulties of dissecting this area can thus be avoided, although it is not exempt from other complications that are common with other endovascular procedures [3]. Another treatment option could be ecoguide thrombin injection, but the presence of collaterals communicating with the brain contraindicates its use in subclavian artery pseudoaneurysms due to its risk of embolization [3].Finally, the procedure performed in this case was the placement of an endoprosthesis, resulting in a post implant technical success.",
    "differential_diagnosis": "Complicated, left, subclavian, artery, pseudoaneurysm, after, pacemaker, implantation., Local, hematoma, Neurogenic, tumr, Lymph, mass",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014255/000005.jpg?itok=u2kE5f7J",
            "caption": "A. Chest-X-ray previous to the unsuccessful pacemaker implantation."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014255/000006.jpg?itok=n838TqR7",
            "caption": "B.  Apical and lateral pleural effusion (black arrows), as well as mediastinal thickening (black line) appeared in the control after the failed attempt."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014255/000007.jpg?itok=9rCBW3iA",
            "caption": "A. In a coronal CT reconstruction the black arrow marks the pleural effusion located in the left apex (black arrow)"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014255/000013.jpg?itok=waxKvwcl",
            "caption": "In B and C we can see other pleural collection in differents axial planes (white arrows)."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014255/000014.jpg?itok=ru6oMAkn",
            "caption": "In B and C we can see other pleural collection in differents axial planes (white arrows)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014255/000010.jpg?itok=M8s3Y8su",
            "caption": "A. Coronal CT plane showing a well-defined saccular mass (black arrow) with an homogeneous enhancement."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014255/000011.jpg?itok=1d_qcHX5",
            "caption": "B. Sagittal CT reconstruction in which the neck of the pseudoaneurysm can be distinguished (white arrow)."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014255/000012.jpg?itok=fkxhcFGf",
            "caption": "Another axial plane in which we can see the homogenous enhanced mass (black arrow), located in the prevascular mediastinum. The neck is also identified in this image."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Mediastinum",
      "Interventional non-vascular",
      "Education",
      "Lung"
    ],
    "imaging_technique": [
      "CT-High Resolution",
      "Conventional radiography"
    ],
    "link": "https://www.eurorad.org/case/14255",
    "time": "30.01.2017"
  },
  "14259": {
    "case_id": 14259,
    "title": "Thymic hyperplasia in a patient with Grave\u2019s disease: MRI findings.",
    "section": "Chest imaging",
    "age": "27",
    "gender": "female",
    "diagnosis": "Thymic hyperplasia associated with Grave's disease.",
    "history": "A 27-year old woman presented with diabetes mellitus type I and Grave\u2019s disease. An ultrasound examination of the thyroid gland revealed enlargement of the thyroid gland with suspicion of extension of the gland to the upper mediastinum. MRI examination was performed for further investigation.",
    "image_finding": "MRI revealed a diffuse symmetrical thyroid gland enlargement extending into the upper mediastinum until the level of the aortic arch. Additionally, in the retrosternal anterior upper mediastinum, the thymus gland was homogenous hyperplastic with normal shape, a hyperintense signal on STIR images and almost the same signal with the muscles on plain T1 TSE images (Fig.1-4). MR-Angiography revealed the enlarged thyroid gland and the hyperplastic thymus gland with the mediastinum vessels (MRA-source images Fig. 5, 6).",
    "discussion": "Grave's disease is an autoimmune condition commonly associated with other autoimmune conditions such as myasthenia gravis, Addison disease, type 1 diabetes mellitus, and vitiligo [1]. There is also a rare but well-documented association between Grave's disease and thymic hyperplasia [2]. The association between Grave's disease and thymic hyperplasia was first recognized in 1968 by Franken [3]. Thymic involvement may range from microscopic abnormalities in the thymus consisting of medullary lymphoid follicles [4] to massive enlargement of the thymus [5]. The exact pathophysiology of thymic hyperplasia in Grave's is not well understood. The thymic hyperplasia is more likely due to Grave's disease. Earlier literature suggested that the hyperplastic thymus played an etiologic role in Grave's disease as it does in myasthenia gravis by playing a central role in determining self versus non-self recognition by T cells [6]. However, most patients with Grave's disease do not have obvious immune dysfunction except predisposition to autoimmunity.  Treatment with antithyroid drugs (ATDs) can induce rapid, although often incomplete, thymic involution. Murakami et al. [7] studied thymic size and density in 23 untreated patients with Grave's disease with use of computerized tomography. In comparison with 38 age-matched controls, both thymic size and density were higher in patients with Grave's disease. After treatment with ATDs, both thymic size and density were significantly reduced [8]. The decrease in thymic size and density by ATD could be produced, partly due to decreased circulating thyroid hormone levels by ATD and also by immunosuppressive effects of the drugs [9]. About 91 cases of thymus hyperplasia and Grave's disease association have been reported in the literature, of which about 20 were histologically confirmed. Among these 91 cases, 35 cases showed a thymic mass regression under medical treatment alone [9, 10]. It is important that radiologists are able to distinguish thymic hyperplasia from neoplasm. Diffuse symmetric enlargement of the gland is the key morphologic feature of hyperplasia, whereas neoplasm tends to manifest as a focal mass, as in thymoma. However, differentiation may be difficult on the basis of morphologic features alone. Chemical shift  MR imaging was recently used  to distinguish normal thymus from thymic hyperplasia, with the latter demonstrating homogeneously decreased signal intensity on opposed-phase images. This finding suggests that chemical shift imaging may be used to differentiate normal and hyperplastic thymus from neoplastic involvement of the thymus (11). However, further investigation with  large study population will be needed.",
    "differential_diagnosis": "Thymic, hyperplasia, associated, with, Grave's, disease., Thymoma, Thymolipoma, Lymphomas, Intrathoracic, thyroid, tissue",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014259/000001.jpg?itok=HTm99p8Z",
            "caption": "STIR coronal image shows a diffusely and symmetrically enlarged thyroid gland extending in the upper mediastinum (arrows) and  a homogenous normal shaped hyperplastic thymus gland (curved arrows)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014259/000002.jpg?itok=5sHD-Dfy",
            "caption": "T1 TSE coronal  image shows a diffusely and symmetrically enlarged thyroid gland extending in the upper mediastinum (arrows) and a homogenous normal shaped hyperplastic thymus gland (curved arrows)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014259/000003.jpg?itok=5t15m_kg",
            "caption": "STIR axial image shows the enlarged thyroid gland (arrows)."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014259/000004.jpg?itok=S1dVtCvK",
            "caption": "STIR axial images shows the retrosternal thymus hyperplasia in the upper mediastinum (curved arrows)."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014259/000005.jpg?itok=L8eUh4fr",
            "caption": "Coronal images (A,B) from the angiographic program  reveal the enlarged thyroid gland (arrows) and the hyperplastic thymus gland (curved arrows)."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014259/000006.jpg?itok=A4cOzs2q",
            "caption": "Coronal images (C,D) from the angiographic program  reveal the enlarged thyroid gland (arrows) and the hyperplastic thymus gland (curved arrows)."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Mediastinum"
    ],
    "imaging_technique": [
      "MR",
      "MR-Angiography"
    ],
    "link": "https://www.eurorad.org/case/14259",
    "time": "06.12.2016"
  },
  "14279": {
    "case_id": 14279,
    "title": "Hepatopulmonary syndrome and portopulmonary hypertension: a case report",
    "section": "Chest imaging",
    "age": "47",
    "gender": "female",
    "diagnosis": "Hepatopulmonary syndrome and portopulmonary hypertension",
    "history": "A 47-year-old female presented with worsening dyspnoea and weakness. The patient was noted for HCV/HIV co-infection.",
    "image_finding": "A pulmonary angiography CT was performed to exclude embolism. CT ruled out embolism and showed main pulmonary artery enlargement (figure 1a, b), and diffuse dilatation of the pulmonary vessels in the upper, middle and lower zones of both lungs (figure 2a, b, c). Small and hazy ground-glass areas were detected in lower zones (figure 2c). A following contrast CT of the abdomen documented irregularity of the external contour of the liver, hypertrophy of the caudate and volume reduction of right lobe, findings consistent with cirrhotic changes, moreover splenomegaly, esophageal varices and ascites were found (figure 3).A transthoracic doppler echocardiography revealed a value of 45mm Hg of the pulmonary artery pressure, result judged as sign of mild pulmonary hypertension.Finally, laboratory tests documented elevated values of hepatic enzymes (aspartate aminotransferase and alanine aminotransferase) and decreased albumin.On the basis of the described data, a hepatopulmonary syndrome and portopulmonary hypertension were suspected.",
    "discussion": "Hepatopulmonary syndrome is defined as the triad of  liver disease, increased alveolar-arterial oxygen gradient while breathing room air, and pulmonary vascular dilatation. It manifests clinically as progressive dyspnea, cyanosis, and clubbing in patients with cirrhosis, and is secondary to excessive vascular production of vasodilators, particularly nitric oxide [1, 2].   In our case, dyspnea, laboratory results consistent with liver failure and hypoxemia were identified. The radiologic manifestations of hepatopulmonary syndrome may include distal vascular dilatation associated with an abnormally large number of visible terminal vessel branches, more concentrated in the lower lung zones [1, 2]. Portopulmonary hypertension is defined as pulmonary artery hypertension that develops in a setting of portal hypertension. Dyspnea on exertion is the most common presentation [1, 2]. Suggested criteria for the diagnosis of portopulmonary hypertension are mean pulmonary artery pressure greater than 25 mm Hg at rest, increased pulmonary vascular resistance, pulmonary capillary wedge pressure less than 15 mm Hg, and evidence of portal hypertension [1]. We found CT and ecocardiographic signs of pulmonary hypertension, furthermore in absence of tromboembolism findings, and in an liver dysfunction setting, we correlated these data to a portopulmonary hypertension. There are several mechanisms by which portal hypertension might causes pulmonaryhypertension; the presence of vasoactive substances, not metabolized by the diseased liver, such as serotonin, interleukin 1, endothelin 1, and thromboxane, might cause vasoconstriction in pulmonary arteries, or venous blood clots might pass through porto-systemic shunts and reach the pulmonary circulation, causing pulmonary hypertension, and finally, high cardiac output associated with cirrhosis might increased shear stress of the pulmonary artery causing vasoconstriction and proliferation of endothelial cells [1].The differential diagnosis includes pulmonary edema and pulmonary veno-occlusive disease. Pulmonary edema is generally characterized by ground-glass opacity, interlobular septal thickening, peribronchovascular thickening, increased vascular caliber, and pleural effusion. Pulmonary veno-occlusive disease includes signs as smoothly thickened interlobular septa and ground-glass opacity, prominence of pulmonary artery and of right chambers of the heart. Finally, to date, liver transplant remains the only effective treatment of hepatopulmonary syndrome and portopulmonary hypertension, although post-transplant survival is often reduced compared with patients without hepatopulmonary syndrome and there are also reports on post-transplant progression of portopulmonary hypertension [2].",
    "differential_diagnosis": "Hepatopulmonary, syndrome, and, portopulmonary, hypertension, Veno-occlusive, pulmonary, disease, Pulmonary, edema",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014279/000001.jpg?itok=77dzhr6H",
            "caption": "Axial CT image, mediastinal window: the main pulmonary artery is enlarged, at this level it presents a caliber of 38mm. \nNo further mediastinal anomalies are evident."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014279/000002.jpg?itok=YYebF9jo",
            "caption": "Axial CT image, mediastinal window: the main pulmonary artery is enlarged, at this level it presents a caliber of 32mm. \nNo further mediastinal anomalies are evident."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014279/000003.jpg?itok=xjW4fEOE",
            "caption": "Axial CT image at upper zone, lung window:  the lungs show a marked and diffuse dilatation of  pulmonary veins and arteries at upper, middle and lower zones."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014279/000004.jpg?itok=8jJKKo_2",
            "caption": "Axial CT image at middle zone, lung window."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014279/000005.jpg?itok=7HTBQDOB",
            "caption": "Axial CT image at lower zone, lung window: the vessel dilatation is more evident in the lower zones, small and hazy ground glass areas are also evident."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014279/000006.jpg?itok=f8NDnOoh",
            "caption": "Abdominal contrast-enhanced CT shows liver signs of cirrhosis: tortuous hepatic arteries, enlarged lobe caudate, volume reduction of right lobe, irregular liver edges. A perihepatic and perisplenic amount of ascites is also evident."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Abdomen"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/14279",
    "time": "14.12.2016"
  },
  "14286": {
    "case_id": 14286,
    "title": "A rare surgical outcome - post pneumonectomy syndrome",
    "section": "Chest imaging",
    "age": "47",
    "gender": "female",
    "diagnosis": "Post pneumonectomy syndrome",
    "history": "A 47-year-old female presented with intermittent cough, dyspnoea and asthenia over 5 months. The previous history revealed right-sided pneumonectomy 8 years ago due to lung carcinoid. A chest radiograph was performed.",
    "image_finding": "The chest radiograph revealed a hypotransparency of the lower half of the right hemithorax and rightward deviation of the trachea. The cardiac silhouette did not occupy its usual place and its contour was not seen. There was evidence of aired lung in the right hemithorax.A CT study was performed in order to investigate the anatomical alterations and to assess the possible cause of the symptoms. The left lung was well ventilated, hyperinflated and completely herniated to the right. Also, the heart and mediastinum shifted excessively towards the side of the pneumonectomy and underwent counterclockwise rotation. The major vessels also rotated significantly. There was no evidence of pneumothorax or pleural effusion. The distal trachea and the left main bronchus were stretched and pushed against the vertebral body by the pulmonary artery. Partial endobronchial filling was more evident in the lower left lobe but also in the lower lingular bronchus.",
    "discussion": "It is expected that anatomical changes occur in a procedure as radical as a pneumonectomy. Typically, the postoperative pneumonectomy space is filled by air which is gradually replaced by liquid over the following weeks or months. Complete opacification on chest radiograph occurs in most patients [1].Our case refers to a post pneumonectomy syndrome, a very rare condition affecting approximately 1 in 640 cases [2]. After either right or left pneumonectomy, the remaining distal trachea and/or main bronchus can become compressed against the vertebral column or aorta by the pulmonary artery [3]. This results in symptomatic central airway compression and dynamic airway obstruction [4, 5].The degree of mediastinal shift depends on the compliance and hyperexpansion of the remaining lung. According to literature, young women and children have a greater tendency to develop this syndrome due to their increased capacity of expanding the lung [6]. Postpneumonectomy syndrome seems to be more common after right pneumonectomy [2].Since this patient presented with obstructive symptoms, she should be closely followed up and examined through bronchofibroscopy to better assess the degree of airway obstruction. In this particular case, the presence of mucus within the bronchi is already a reflection of a partially obstructed bronchial tree. There is a risk of developing even more serious symptoms such as inspiratory stridor and recurrent infections in the remaining lung [7]. If obstruction or symptoms are demonstrably severe, surgery to reposition the mediastinum should be considered. Silicone breast implants are an option that has been used in the postpneumonectomy space to prevent rotational shifting after pneumonectomy in children, a method that has brought good results [2].To study the postpneumonectomy space, the positioning of the major vessels and the trachea, CT scan should be the first choice exam to assess the anatomical changes that occur after such procedure [3].",
    "differential_diagnosis": "Post, pneumonectomy, syndrome, Recurrence, of, lung, carcinoid, Chronic, pulmonary, thromboembolism",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014286/000001.jpg?itok=UlW8V_Ks",
            "caption": "Right deviation of the trachea.\nHypotransparency of the lower half of the right hemithorax. Displacement of the cardiac silhouette. There is evidence of aired lung in the right hemithorax since vascular markings are clearly seen."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014286/000002.png?itok=hmoWDKqY",
            "caption": "Left pulmonar artery (red arrow) compressing the distal trachea (blue arrow) against the vertebral body."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014286/000003.png?itok=fCrq7BAa",
            "caption": "Counterclockwise rotation of the mediastinum and hyperinflation and herniation of the left lung. Note the stretching of the left bronchus (red arrow)."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014286/000005.jpg?itok=Y-_K6WGr",
            "caption": "Narrowing of distal trachea due to compression of the left pulmonary artery. Shift in major vessel positioning."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014286/000004.jpg?itok=HTZsEQxV",
            "caption": "Cardiac silhouette shifted to right hemithorax. Left main bronchus is stretched but not completely obstructed."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014286/000006.png?itok=q3CrV-gz",
            "caption": "Presence of mucus within the bronchus (red arrow).\nCrowding of ribs: The interspace between ribs on the right is narrower compared to the opposite side."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014286/000007.jpg?itok=xkevRpoM",
            "caption": "Chest radiograph.\nAfter a pneumonectomy, the resulting resection cavity fills with fluid. No aerated lung is depicted in the right hemithorax.\nThe cardiac silhouette shifted rightwards to fill the space vacated by the removed lung."
          },
          {
            "number": "Figure 6b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014286/000008.jpg?itok=ieVsM-t7",
            "caption": "CT scan - axial view.\n\nRight hemithorax cavity filled with fluid after right pneumonectomy.\nThere is mild rightward deviation of the mediastinum and hyperinflation of the remaining lung."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT",
      "CT-Angiography"
    ],
    "link": "https://www.eurorad.org/case/14286",
    "time": "15.12.2016"
  },
  "14340": {
    "case_id": 14340,
    "title": "A case of mediastinal haematoma mimicking a mediastinal mass",
    "section": "Chest imaging",
    "age": "73",
    "gender": "male",
    "diagnosis": "Spontaneous right paratracheal haematoma",
    "history": "A 73-year-old male, non-smoker, presented with an isolated complaint of non-productive cough for 1 month. The patient was on regular haemodialysis and appropriate medication due to chronic kidney disease.",
    "image_finding": "The frontal chest radiograph showed a widening of the superior mediastinum on the right side with a wide right paratracheal stripe. The right dome of the diaphragm was elevated with a blunt right costophrenic angle. There was no obvious displacement of the anterior junction line. The tracheo-bronchial air column was well visualized with no deviation or narrowing of the trachea. Corresponding plain and contrast CT images show a well-defined right para-tracheal and paravertebral oval-shaped hyperdense mediastinal mass with homogeneous attenuation (mean HU 63 units). The mass extended from the lung apex to the venacaval entry. There was no calcification, necrosis or cystic component. Contrast enhanced CT showed no enhancement, no active bleeding and no compression of vascular structures.",
    "discussion": "Mediastinal haematoma can mimic a mediastinal neoplasm. They can be caused by blunt or penetrating trauma, vessel rupture and coagulopathies. There are a few reported cases of mediastinal haemorrhage after iatrogenic injury [1]. Recognition of a mediastinal haematoma may avoid unnecessary interventions. The mediastinal haematoma should be suspected in patients with a sudden widening of the mediastinum and concomitant chest pain [2]. Spontaneous mediastinal haematomas are rare but very important and can lead to rapid deterioration and death. Shimokawa et al reported four clinical settings in which mediastinal haematomas occur: as a complication of enlarging mediastinal masses, in sustained hypertension, in haematological conditions, and due to a transient increase in intrathoracic pressure [3]. The differential diagnosis of anterior mediastinal lesions includes thymic neoplasms, lymphomas, germ cell tumours, thyroid lesions, also pericardial cysts, epicardial fat pad and Morgagni hernia [4]. In the presented case, a brachial arteriovenous fistula developed 5 months before, after which the patient stayed in intensive care, where a central line was inserted on the right side. Follow-up portable radiographs did not reveal any obvious superior mediastinal widening. The patient was on regular follow-up and presented with non-productive cough two months later when a routine chest radiograph demonstrated right paratracheal stripe widening, leading to subsequent imaging. The lesion was fairly hyperdense (mean HU 62 units), showed no evidence of clot retraction and liquefaction suggesting a recent onset and thus made a late complication of the central line placement performed 2 months earlier unlikely. No surgical interventions were advised. Procedures aimed to lower the BP were preferred to prevent the haematoma from increasing in size and/or rupturing [5]. Treatment options in cases like this are mostly conservative. In patients with signs of active bleeding, chest tube placement and coiling of the active bleeding or vascular repair via thoracotomy or median sternotomy are frequently required [6]. In cases in which the haematoma extends to the retropharyngeal region, a protective intubation is a must to prevent airway compromise [7]. Our patient got better by conservative management for his occasional cough. Follow-up serial radiograph performed 3 months later showed a decrease in size of the opacity. The right hemidiaphragm was elevated in all radiographs, likely secondary to phrenic nerve impingement or neuropathy. This was persistent even after the patient became clinically asymptomatic. The clinical and imaging findings corresponded with a case of spontaneous mediastinal haematoma presenting as a mass.Take home message:Spontaenous mediastinal haematomas - though rare - are an important differential diagnosis in patients with a mediastinal widening. Mediastinal haematomas have to be considered a diagnostic possibility, in particular after central line placement.",
    "differential_diagnosis": "Spontaneous, right, paratracheal, haematoma, Thrombosed, aneurysm, Old, infection, with, thrombosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014340/000001.jpg?itok=mqJcUnhg",
            "caption": "Frontal radiograph showing a widening of the superior mediastinum on the right side with a wide right paratracheal stripe, negative cervicothoracic sign and elevated right hemidiaphragm."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014340/000002.jpg?itok=J3yNnlPV",
            "caption": "Coronal CT reconstruction at mid-tracheal level shows a well-defined, oval-shaped, slightly hyperdense, homogenously attenuating mediastinal lesion. Cleavage with lung parenchyma and midline structures is well maintained."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014340/000003.jpg?itok=B3LINYsF",
            "caption": "Arterial phase coronal reconstruction shows no increase in HU values. No cystic density, fat attenuation, calcifications, tracheal deviation, vascular compression."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014340/000005.jpg?itok=PTwg7yjp",
            "caption": "Follow-up radiograph in October shows interval reduction in the paratracheal lesion."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Mediastinum"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT",
      "Digital radiography"
    ],
    "link": "https://www.eurorad.org/case/14340",
    "time": "25.01.2017"
  },
  "14388": {
    "case_id": 14388,
    "title": "Giant Solitary Fibrous Tumor of the Pleura(SFTP)",
    "section": "Chest imaging",
    "age": "51",
    "gender": "female",
    "diagnosis": "A solitary fibrous tumour of the pleura was confirmed on histology.",
    "history": "A 51-year-old non-smoking female hairdresser, presented to her primary care physician with a 3-4 month history of increased shortness of breath especially on exertion. Upon examination she was found to have dullness to percussion and reduced air entry to the left lung base, and oxygen saturation of 99% on air.",
    "image_finding": "Changes in the left hemi-thorax are due to a large soft tissue mass measuring a maximum of 15cm AP, 10 cm transverse and approximately 20 cm cranial causal. This appears to be based in the pleura and has a slightly heterogeneous attenuation. No obvious feeding vessels are seen within, with a dilated left upper lobe vein draining from it into the left atrium. In retrospect, the mass was present on the chest radiograph in 2010 and has increased in size since. No significant intrathoracic lymphadenopathy is identified, no pulmonary deposits seen. Solid upper abdominal organs look unremarkable. No metastases were identified, no significant upper abdominal lymph nodes seen. The appearances would suggest a slow growing soft tissue mass which may be a sarcoma of some sort.",
    "discussion": "Solitary Fibrous Tumours of the Pleura (SFTP) account for <5% of all pleural tumours. They are usually asymptomatic (despite being very large (up to 40mm)) and consequently are usually an incidental finding on chest radiograph. Alternatively they can present with either cough, shortness of breath or chest pain. They most commonly present between 60-70 years of age [3].They are usually slow growing benign lesions and commonly affect the mid/lower zones of the chest. In 80% of cases they arise from the visceral pleura, the rest arise form parietal pleura [2]. They are associated with hypertrophic pulmonary osteoarthropathy and hypoglycemia (Doege-Potter syndrome) but are not associated with asbestos exposure [3].Chest radiograph usually uncovers a relatively transcribed mass that often forms an obtuse angle with the chest wall. Calcification, pleural effusions and rib destruction are not associated features. On non-enhanced CT they tend to show soft tissue attenuation and on enhanced scans they tend to show relatively homogeneous intense background enhancement (due to rich vascularization) [3].Treatment of both benign and malignant SFTP is by way of complete surgical excision.Prognosis for the benign type is excellent (about 8% will recur but recurrence is cured following additional surgery). About 63% of patients with the malignant type experience a recurrence of their tumour, half of which will die due to disease progression within 2 years [1].",
    "differential_diagnosis": "A, solitary, fibrous, tumour, of, the, pleura, was, confirmed, on, histology., pleural, lipoma, intercostal, neurilemoma, (schwannoma)",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014388/000001.jpg?itok=UFif4IEO",
            "caption": "Axial slice - CT Thorax - large soft tissue mass in the left hemi-thorax."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014388/000002.png?itok=sbke12GM",
            "caption": "Coronal slice - CT Thorax - giant soft tissue mass in the left heme-thorax"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014388/000003.jpg?itok=EuGSMDI7",
            "caption": "Chest X-ray showing opacification of left heme-thorax"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax",
      "Lung"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/14388",
    "time": "05.02.2017"
  },
  "14391": {
    "case_id": 14391,
    "title": "An Unusual Cause of Dyspnoea in a Young Patient: Myeloid Sarcom",
    "section": "Chest imaging",
    "age": "17",
    "gender": "female",
    "diagnosis": "Myeloid Sarcoma",
    "history": "A 17-year-old female without any prior history presented with a three week history of exertional dyspnoea and palpitations. She was asymptomatic at rest. Other than a persistent sinus tachycardia, examination was unremarkable. Baseline laboratory investigations did not reveal any abnormality.",
    "image_finding": "The initial chest radiograph (Figure 1) shows cardiomegaly with a rounded contour suggestive of a pericardial effusion, and blunting of the costophrenic angles in keeping with pleural effusions. Subsequent CTPA (Figure 2) revealed a large soft tissue mass in the anterior and superior mediastinum encasing the aorta, its branching vessels and also the left main bronchus. The mass was causing severe luminal narrowing of the right pulmonary artery. There was also a large pericardial effusion with evidence of cardiac congestion - consistent with a cardiac tamponade.The patient went on to have CT-guided biopsy (Figure 3) and was ultimately diagnosed with myeloid sarcoma. The initial treatment was with high dose intravenous dexamethasone and systemic chemotherapy and subsequent to this a repeat CT thorax was obtained (Figure 4), with measurable reduction in the size of the soft tissue mass and improvement in the calibre of the right pulmonary artery.",
    "discussion": "Myeloid sarcoma is a rare manifestation in which a tumour composed of myeloid blast cells occurs at a site other than the bone marrow [1]. It occurs most commonly in patients with acute myeloid leukaemia, however, can also be seen in patients with chronic myeloid leukaemia and myelodysplastic syndromes. Rarely de novo myeloid sarcoma without underlying malignancy can occur [2] (as in this case). The most common extramedullary locations include the skin, bone and lymph nodes. Mediastinal involvement is rare and described only in case reports [3].The patient presented to the emergency department and unusually, initial laboratory investigations were normal. The first clue to the diagnosis was provided by an abnormal chest radiograph. Subsequent cross-sectional imaging of the thorax diagnosed a large mediastinal mass, revealing its precise anatomical location and the extent of invasion into adjacent structures. CT guided core biopsy was essential to determine a histopathological diagnosis.Following tissue diagnosis, the patient was treated with high dose intravenous steroids and systemic chemotherapy (daunorubicin and cytosine arabinoside). A short interval CT Thorax demonstrated a significant treatment response with a measurable decrease in the size of the tumour. The patient is now four months post initial presentation and has just undergone allogeneic bone marrow transplant having completed the initial course of chemotherapy. The overall prognosis of this condition is poor.",
    "differential_diagnosis": "Myeloid, Sarcoma, Lymphoma, Germ, cell, tumour, Thymic, neoplasm",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014391/000001.jpg?itok=iaCBXKEk",
            "caption": "PA erect chest radiograph; an enlarged heart with a rounded contour consistent with a large pericardial effusion. Bilateral costophrenic angle blunting is in keeping with pleural effusions. The lungs are clear."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014391/000002.jpg?itok=-CgiNMLR",
            "caption": "Axial Computed tomography pulmonary angiogram (CTPA) at the level of the\npulmonary trunk. There is  narrowing of both main pulmonary arteries\nsecondary to large mediastinal soft tissue mass."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014391/000003.jpg?itok=tt8F8LJ1",
            "caption": "Axial CTPA at the level of the superior mediastinum, the soft tissue mass is demonstrated encasing the main branch aortic vessels and trachea. The trachea is slightly deviated to the right."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014391/000004.jpg?itok=ytYtxiAo",
            "caption": "Coronal CTPA showing a massive pericardial effusion and soft tissue mass extending\ninto the superior mediastinum encasing the visualized mediastinal vasculature. Left\npleural effusion noted."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014391/000005.jpg?itok=FjyHRXqM",
            "caption": "Sagittal CTPA at the level of the aortic arch, a large soft tissue mass in the anterior\nand superior mediastinum encases the aorta, its branching vessels and the left main bronchus."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014391/000006.jpg?itok=WV2INQHm",
            "caption": "CT guided biopsy of the mediastinal mass"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014391/000007.jpg?itok=pc4FUhu_",
            "caption": "CT Thorax with intravenous contrast post treatment with\u00a0high dose intravenous\nsteroids and systemic chemotherapy (daunorubicin and cytosine arabinoside) with significant reduction in size of the superior mediastinal soft tissue mass."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Mediastinum",
      "Lung"
    ],
    "imaging_technique": [
      "CT",
      "Digital radiography",
      "CT-Angiography"
    ],
    "link": "https://www.eurorad.org/case/14391",
    "time": "06.02.2017"
  },
  "14430": {
    "case_id": 14430,
    "title": "Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia (DIPNECH); a case of multiple pulmonary nodules",
    "section": "Chest imaging",
    "age": "76",
    "gender": "female",
    "diagnosis": "Diffuse Idiopathic Pulmonary Neuroendocrine Cell Hyperplasia (DIPNECH)",
    "history": "This case involves a non-smoking 76-year-old female patient with a 7-year history of persistent cough (occasionally productive) and breathlessness on exertion, with no haemoptysis or weight loss. She underwent a VATs-wedge resection for tissue diagnosis as part of a work-up for suspected pulmonary metastases from an undetermined primary.",
    "image_finding": "The patient\u2019s CT chest demonstrated multiple nodules of varying sizes (< 5mm) and mosaicism affecting all lobes of both lungs. No other imaging abnormalities were evident. Her imaging findings are consistent with DIPNECH with tumourlets. This was confirmed with histopathology analysis of CT-guided lung nodule biopsy samples.",
    "discussion": "A. BackgroundThe normal respiratory tract has neuroendocrine cells scattered throughout the tracheo-bronchial epithelium. These cells may proliferate in response to high altitude, cigarette smoking, chronic inflammation and chronic lung diseases [2, 3]. If cell proliferation does not extend beyond the epithelial basement membrane, it is known as DIPNECH (Diffuse Idiopathic Pulmonary Neuroendocrine Cell Hyperplasia). The described proliferation can form larger clusters of cells known as cell nests. These do extend beyond the basement membrane. If cells nests are <5mm these are known as tumourlets, if >5 mm they are known as carcinoids. These entities commonly co-exist [3].The most common presentation of DIPNECH is usually of women in their thirties or forties who are non-smokers. [1, 2, 3]. Most are asymptomatic, others have an insidious onset of symptoms including cough, breathlessness, wheezing and chest tightness. Symptom onset may be present between 2 - 25 years prior to diagnosis. Lung function tests often demonstrate an obstructive pattern and/or obliterative bronchiolitis. [1, 3].On histopathology, findings include neuroendocrine cell hyperplasia, tumourlets, fibrosis, constrictive bronchiolitis, bronchiolectasis, airway wall thickening and mucus plugging [1]. B. Clinical PerspectiveIn this case study, the patient demonstrates the typical demographics associated with DIPNECH - a female, non-smoker with insidious onset of symptoms of 7 years. She underwent a VATs wedge resection for tissue diagnosis as part of a work-up for suspected pulmonary metastases from an undetermined primary.  C. Imaging PerspectiveThe patient\u2019s imaging findings of multiple nodules <5mm and mosaicism are typical of DIPNECH with tumourlets. The definitive diagnosis was made by histopathology.D. OutcomeMore studies are required to adequately determine the natural history of the condition, treatment and prognosis. Some patients remain asymptomatic with stable radiological features; in other cases patients become increasingly symptomatic with progressive radiological features. [1]Patients with DIPNECH require follow up. If symptomatic, a trial course of inhaled and/or oral steroids has been advocated [1]. For asymptomatic patients, observation with no active treatment is considered. Treatment with steroids may become warranted if the patient becomes symptomatic and/or the radiological features demonstrate progression. E. Take Home Message, Teaching Points DIPNECH is a rare and somewhat under-recognised disease. As CT scans are performed with increasing frequency and improving resolution, there is a subsequent increasing number of lung biopsies. As such the number of DIPNECH diagnoses is reportedly increasing, and some knowledge of this condition is useful for the radiologist.",
    "differential_diagnosis": "Diffuse, Idiopathic, Pulmonary, Neuroendocrine, Cell, Hyperplasia, (DIPNECH), Pulmonary, metastases, Exposure, to, inhaled, toxins/mineral, dust, Drug, reactions, Connective, tissue, diseases, Asthma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014430/000001.jpg?itok=-rB8KxAi",
            "caption": "Image 1:\nHaematoxylin and Eosin (H&E) stained section of lung tissue showing a fibrotic focus with associated neuroendocrine cell hyperplasia (black arrows). (x4 objective)"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014430/000002.jpg?itok=MiIyXoYp",
            "caption": "Image 2: \nH&E stained section of a neuroendocrine cell nest. The cells have granular nuclear chromatin (black arrows) and eosinophilic cytoplasm (red arrows). (x40 objective)"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014430/000003.jpg?itok=YjBHJwIJ",
            "caption": "Neuroendocrine cells showing strong diffuse positive (brown) membranous staining of neuroendocrine marker CD56 (x20 objective)."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014430/000006.jpg?itok=JquJqVIq",
            "caption": "Axial CT chest demonstrating multiple nodules affecting all lobes of the lung, particularly the lower lobes."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014430/000007.jpg?itok=G804xSni",
            "caption": "Axial CT chest demonstrating multiple nodules affecting all lobes of the lung, particularly the lower lobes."
          },
          {
            "number": "Figure 4c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014430/000005.jpg?itok=cJ32m0zm",
            "caption": "Axial CT chest demonstrating multiple nodules affecting all lobes of the lung, particularly the lower lobes."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014430/000008.jpg?itok=hWN0HK3O",
            "caption": "Coronal CT chest demonstrating mosaicism."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "CT-High Resolution"
    ],
    "link": "https://www.eurorad.org/case/14430",
    "time": "25.07.2017"
  },
  "14432": {
    "case_id": 14432,
    "title": "Catamenial pneumothorax: A rare diagnosis",
    "section": "Chest imaging",
    "age": "34",
    "gender": "female",
    "diagnosis": "Catamenial pneumothorax",
    "history": "A 34-year-old female patient presented with sudden onset of shortness of breath and left-sided chest pain for 2 days. She had a history of multiple episodes of similar symptoms every 30-40 days for the past 4 years and it was always followed by menstruation. A chest radiograph was performed.",
    "image_finding": "The frontal chest radiograph revealed a left-sided pneumothorax for which Tube-thoracostomy was done. A previous radiograph showed a dense homogeneous opacity in the right middle and lower zone obliterating the right heart border and right dome of the diaphragm suggesting right-sided pleural effusion with chest tube drain in situ.",
    "discussion": "Catamenial pneumothorax (CP) is defined as recurrent pneumothorax (at least two episodes) occurring between the day before and within 72 hours after the onset of menstruation. It may affect up to one-third of women with spontaneous pneumothoraces [1]. It is encountered in 3-6% of spontaneous pneumothorax cases among menstruating women [2]. There is right side preponderance [3, 4, 5]. It usually involves the right side (85-95%) and can be left-sided or bilateral [2]. It is associated with diaphragmatic perforations and/or thoracic endometriosis [2].Thoracic endometriosis syndrome (TES) is the presence of endometrial tissue in or around the lung. Although endometriosis in general can affect up to 15% of women in their reproductive years, TES remains an exceedingly rare condition [6, 7].TES occurs almost exclusively in the right hemithorax (approximately 95% of cases) [8, 9]. Although congenital diaphragmatic hernias are far more common on the left side, congenital diaphragmatic defects, particularly fenestrations, are known to occur more commonly on the right, leading to the right-sided predominance of TES [10].CP is responsible for only 2.5% to 5% of cases of women with spontaneous pneumothorax [11, 12] even though it accounts for 73% of the cases of TES [6]. The first case of CP was described by Maurer et al. [13] in 1958, but the term catamenial pneumothorax was not introduced until 1972. [14] CP is typically defined as spontaneous and recurrent pneumothorax occurring within 72 hours from the onset of menstruation. [8, 11] According to Karpel et al, [15] the number of recurrent pneumothoraces can range from 2 to 42 per patient.Three theories have developed to explain this entity. The first is transdiaphragmatic passage, or movement, of air from the vagina to the peritoneum via the fallopian tubes, and subsequently to the thorax via diaphragmatic fenestrations. This is thought to occur during the menstrual cycle when the cervical mucus plug is absent. [5, 7, 13]. Thesecond is air leakage triggered by sloughing of the endometrial implants located on the pleura. [5, 7] The third proposes a hormonally mediated mechanism in which high levels of prostaglandin from thoracic endometrial implants cause vascular and bronchiolar vasoconstriction, leading to ischaemic injury and ultimately causing alveolar rupture andsubsequent air leakage. [5] Another theory that has been proposed as a cause of catamenial pneumothorax is the spontaneous ruptures of blebs. Teaching pointsWhenever a female patient in the reproductive age group present with chest pain or recurrent pneumothorax; it's worthwhile to record an elaborated mensuration history and evaluate for catamenial pneumothorax.",
    "differential_diagnosis": "Catamenial, pneumothorax, Primary, spontaneous, pneumothorax, Iatrogenic, pneumothorax",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014432/000004.jpg?itok=9kKobc-e",
            "caption": "Catamenial pneumothorax"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "Conventional radiography"
    ],
    "link": "https://www.eurorad.org/case/14432",
    "time": "06.04.2017"
  },
  "14480": {
    "case_id": 14480,
    "title": "Isolated absence of the right pulmonary artery with advanced emphysema in the right lung.",
    "section": "Chest imaging",
    "age": "54",
    "gender": "female",
    "diagnosis": "Right UAPA with advanced emphysema in the right lung.",
    "history": "A 54-year-old women who had to undergo cardiac ablation because of atrial tachycardia presented at our radiology department for a preoperative cardiac CT-scan. Previous history showed recurrent respiratory tract infections. She recently quit smoking (31 pack years).",
    "image_finding": "The cardiac CT-scan revealed an absent right main pulmonary artery. Despite this abnormality the ablation procedure was performed but failed and subsequently she received a pacemaker implantation. Afterwards, she underwent a computed tomography pulmonary angiogram (CTPA) to evaluate the abnormal hilar configuration. The CTPA showed the absence of the right main pulmonary artery, right-sided displacement of the heart and the mediastinum, volume loss of the right lung and little collateral circulation. Remarkably, there were advanced emphysematous changes with multiple bullae and bronchiectasis in the right lung. No pulmonary embolism, obstructing malignancy or surgical alterations around the right hilum were noticed.",
    "discussion": "Unilateral absence of the pulmonary artery (UAPA) is a rare congenital cardiovascular malformation with an estimated prevalence of 1 in 200000. There is no gender or race predilection. UAPA is thought to be the result of failure of the fusion between the pulmonary trunk and the sixth aortic arch during embryologic development. The right pulmonary artery is most frequently affected, accounting for two thirds of the cases. Left-sided agenesis seems to be more frequently associated with cardiac abnormalities such as tetralogy of Fallot or cardiac septal defects [1]. Clinical presentation of isolated UAPA is diverse. It can be asymptomatic until late adulthood, but more often symptoms such as dyspnoea, chest pain, decreased exercise tolerance, haemoptysis and recurrent respiratory tract infections are reported. Haemoptysis is caused by large collateral circulations, which exposes the venous systems to abnormally elevated pressures. Other complications are pulmonary hypertension, right heart failure and bronchiectasis. Typical chest radiographic findings are absent hilar shadow, displacement of cardiac and mediastinal shadow, elevation of the diaphragm and contralateral lung hyperinflation. The definitive diagnosis of UAPA can be made by CT or MRI. Cross-sectional imaging shows the absence of the pulmonary artery with collateral circulation, cardiac and mediastinal displacement, lung volume loss, mosaic parenchymal alterations and bronchiectasis due to recurrent infections. Transthoracic echocardiogram can also be used to establish the diagnosis. Angiography is considered the golden standard but is invasive and is rarely performed unless a surgical intervention is considered. A remarkable aspect of our case is the presence of advanced asymmetric emphysematous changes in the right lung. Currently, it is assumed that emphysema is the result of an imbalance in protease-antiprotease activity. Cigarette smoking is associated with the induction of proteases, but in our case the emphysema presented mainly in the hypoperfused right lung. A possible explanation could be that hypoperfusion of the right lung prohibits the antiproteases in the blood to reach the proteinases produced locally in the lung, hereby inducing an imbalance [2]. Currently, there is no consensus regarding treatment of patients with isolated UAPA. Treatment options include revascularisation surgery, pneumonectomy or lobectomy and embolization of collateral haemorrhage.In conclusion, UAPA is an extremely rare congenital disorder and is sometimes asymptomatic until late adulthood, postponing the diagnosis. Multiple imaging modalities are available to establish the definite diagnosis. Our case describes the rare finding of advanced asymmetric emphysematous changes in the affected lung.",
    "differential_diagnosis": "Right, UAPA, with, advanced, emphysema, in, the, right, lung., Primary, pulmonary, hypertension, Pulmonary, embolism",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014480/000001.jpg?itok=s-UKZ5G4",
            "caption": "Plain radiograph after pacemaker implantation revealed the absence of the right hilar shadow with diminished right pulmonary vascular markings, cardiac and mediastinal displacement to the right and loss of volume of the right lung."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014480/000004.jpg?itok=SjP58Axs",
            "caption": "CTPA with soft window settings shows the absence of the right main pulmonary artery. The right internal thoracic artery is enlarged."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014480/000005.jpg?itok=ahJxxNwN",
            "caption": "CTPA with lung window settings showing the advanced emphysematous changes and bronchiectasis in the right lung. The mediastinum is displaced to the right."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014480/000006.jpg?itok=Zr1XwcLX",
            "caption": "This coronal MIP shows the absent arterial pulmonary vasculature in the right lung with prominent venous structures. Very little collaterals are seen. The vasculature in the left lung is normal."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Cardiovascular system",
      "Thorax"
    ],
    "imaging_technique": [
      "CT-Angiography"
    ],
    "link": "https://www.eurorad.org/case/14480",
    "time": "18.03.2017"
  },
  "14497": {
    "case_id": 14497,
    "title": "Birt-Hogg-Dub\u00e9 syndrome",
    "section": "Chest imaging",
    "age": "47",
    "gender": "male",
    "diagnosis": "Birt-Hogg-Dub\u00e9 syndrome",
    "history": "A 47-year-old male patient presented with recurrent pneumothorax and a solid lesion in the upper part of the right kidney, suggestive for a renal cell carcinoma. A partial nephrectomy of the right kidney was performed. Histopathology confirmed a chromophobe renal cell carcinoma. He has fibrofolliculomas on the face and neck.",
    "image_finding": "A Computed Tomography (CT) of the chest revealed several cysts along the right major fissure, bibasal subpleural in the lower lobes of both lungs and paramediastinal in the left lung.  Bilateral pleural thickening was seen. A contrast-enhanced CT of the abdomen showed several cysts in the left kidney and two small cysts in the upper pole of the spleen. There was no presence of thoracic or abdominal lymphadenopathies.",
    "discussion": "Birt-Hogg-Dub\u00e9 syndrome, initially described in 1977, is a rare autosomal-dominant disorder characterized clinically by skin fibrofolliculomas, renal tumours, pulmonary cysts and spontaneous pneumothorax. Fibrofolliculomas are benign hamartomatous tumours of hair follicles and present clinically as multiple small, dome-shaped, whitish papules mainly on the nose, cheeks and the neck [1]. The renal tumours can range from benign oncocytomas to renal cell carcinomas. Benign renal cysts have been documented in patients with BHD. More than 80% of the adult patients with BHD have multiple lung cysts, often lentiform and subpleural in distribution and typically found in the basal regions of both lungs [1]. Spontaneous pneumothorax may be seen in 24% of the patients [2]. BHD syndrome is caused by mutations in the folliculin gene (FLCN), which is localized on the short arm of chromosome 17 (17p11.2) [3]. The FLCN gene encodes folliculin, a tumour suppressor protein, whose function is largely unknown. FLCN mutation analysis should be considered if patients have unexplained cystic lung disease, pneumothorax or familial renal cancer. The mutation detection rate is around 88% in a study of 58 families [4]. Counselling at-risk family members is indicated. With regard to this case, DNA analysis confirms the diagnosis of BHD. The diagnosis is complicated by the clinical heterogeneity. Affected individuals can have inconspicuous fibrofolliculomas or even no skin manifestations at all. This patient had fibrofolliculomas on the face and neck, confirmed by dermatology. In addition, patients have an increased risk of developing a wide range of renal neoplasms from benign oncocytomas to renal cell carcinomas. The pulmonary cysts and the renal tumours can be detected by computed tomography. The localization, the shape and the distribution of the cysts on CT are important in the differentiation between Birt-Hogg-Dub\u00e9 syndrome and other cystic lung diseases [5].  The treatment of skin fibrofolliculomas consist of excision or shave and cautery. Recurrent pneumothorax can be treated with talcage. Quitting smoking is strongly recommended as it increases the risk of spontaneous pneumothorax and kidney cancer [1]. The current approach for renal lesions in the context of BHD is to perform nephron sparing surgery when possible. Annual screening of affected patients or those at risk is strongly recommended starting in the fourth decade of life [6]. MRI is the best surveillance method due to high sensitivity without radiation exposure. Ultrasonography can also be used, but it has a low sensitivity for small lesions [1].",
    "differential_diagnosis": "Birt-Hogg-Dub\u00e9, syndrome, Langerhans, cell, histiocytosis, Lymphangioleiomyomatosis, Lymphocytic, interstitial, pneumonia",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014497/000001.jpg?itok=LIye3Nzn",
            "caption": "Multiple lung cysts, often lentiform and subpleural in distribution, typically found in the basal regions of both lungs (1a, 1b) and against the right major fissure (1c)."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014497/000002.jpg?itok=uNWSwsrR",
            "caption": "Multiple lung cysts, often lentiform and subpleural in distribution, typically found in the basal regions of both lungs (1a, 1b) and against the right major fissure (1c)."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014497/000003.jpg?itok=beG3YTCY",
            "caption": "Multiple lung cysts, often lentiform and subpleural in distribution, typically found in the basal regions of both lungs (1a, 1b) and against the right major fissure (1c)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014497/000004.jpg?itok=6Urbwf4A",
            "caption": "A chromophobe renal cell carcinoma\u00a0in the upper pole of the right kidney."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014497/000005.jpg?itok=tsAgoJ-P",
            "caption": "Several cysts in the left kidney."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014497/000006.jpg?itok=xiUsumP4",
            "caption": "Several cysts in the left kidney."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014497/000007.jpg?itok=7LoRyLwN",
            "caption": "Several cysts in the left kidney."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014497/000008.jpg?itok=na-iuhCN",
            "caption": "Partial nephrectomy in the upper pole of the right kidney and small cyst in the upper pole of the spleen."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax",
      "Kidney",
      "Spleen"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/14497",
    "time": "16.02.2017"
  },
  "14502": {
    "case_id": 14502,
    "title": "The Reversed Halo Sign in Pulmonary Mucormycosis with cerebral dissemination in immunocompromised host.",
    "section": "Chest imaging",
    "age": "57",
    "gender": "male",
    "diagnosis": "Pulmonary mucormycosis with cerebral dissemination.",
    "history": "A 57-year-old man underwent allogeneic haematopoietic stem cell transplant (HCT) for primary myelofibrosis. The patient presented severe neutropenia and received prophylaxis to prevent graft-versus-host-disease. On the same day of the infusion, spiking of fevers began that did not remit despite broad-spectrum antibiotics.",
    "image_finding": "The chest radiography in the third day after HCT (Fig. 1) revealed a pseudonodular consolidation on the right upper lobe (RUL), which progressed after empirical antibiotic therapy (Fig. 2). An enhancement thoracic CT was performed and a rounded area of airspace consolidation accompanied by central (\u201creversed halo\" sign) and peripheral (\u201chalo sign\u201d) ground-glass opacity was found in the RUL. The broncoloalveolar lavage (BAL) isolated the typical hyphae of mucormycosis [1]. After 6 days of HCT, the patient presented nasal stuffiness and brain CT demonstrated a hypodense lesion in right frontal lobe with loss of the cortical\u2013subcortical differentiation suggestive of septic embolism (Fig. 4). There were no lesions of the nasal cavity and paranasal sinuses. Although the patient was asymptomatic neurologically, control enhanced brain CT demonstrated a cerebral abscess formation in the same place as the previous lesion (Fig. 5).",
    "discussion": "Mucormycosis infection is caused by fungi of the class Zygomycetes, most commonly the order Mucorales [2]. This is an opportunistic infection, often fatal clinically, typically in immunocompromised patients such as those with diabetes mellitus, haematologic malignancies, or those that have undergone transplantation [3].The symptoms of pulmonary mucormycosis include fever, dyspnoea, cough and chest pain.The right lung is more commonly involved than left, and there is a predilection for the involvement of the upper lobes [2, 1]. The radiological manifestations including a variety of findings: lobar consolidation, isolated mass, nodular disease and cavitation [4-5]. Recently the \"reversed halo\" sign has been demonstrated as a fairly specific sign of mucormycosis in the correct clinical setting. The reversed halo sign is a focal rounded area of ground-glass opacity surrounded by a crescent or complete ring of consolidation. In contrast to cryptogenic organizing pneumonia (COP), the peripheral capsule in the reverse halo sign tends to be thicker [6\u20138].In immunocompromised patients, the halo sign (ground-glass opacity surrounding a pulmonary nodule or mass) and \"reversed halo\" sign are highly suggestive of early infection by an angioinvasive fungus. The halo sign is most commonly associated with invasive pulmonary aspergillosis and reversed halo sign with pulmonary mucormycosis [6] (Fig. 6). Pulmonary mucormycosis in neutropenic patients has the highest incidence of dissemination, although haematogenous dissemination may originate from any primary site of infection. The most common site of dissemination is the brain, as in our case.In the present case report, haematogenous spread from pulmonary mucormycosis was followed by cerebral fungal embolism and cerebral abscess. The mortality associated with dissemination to the brain approaches 100%. Cerebral mucormycosis usually manifests as rhino-cerebral mucormycosis where lesions of the nasal cavity and paranasal sinuses extend to the adjacent central nervous system [9].The management of pulmonary mucormycosis is a combination of surgical and medical treatment. Amphotericin B remains the gold standard antifungal agent used against mucormycosis. Combined surgical/medical treatment may provide a better survival outcome than medical therapy alone [2]. Our patient was treated with liposomal amphotericin B and caspofungin, however, he did not improve and he died. Mucormycosis prognosis is poor, the overall mortality is approximately 50-70% but increases to 95% with extrathoracic dissemination [2].Take home points: In a situation of neutropenia, the \"reversed halo\" sign should make us suspect a mucormycosis, especially if the standard antifungal therapy is not effective.",
    "differential_diagnosis": "Pulmonary, mucormycosis, with, cerebral, dissemination., Differential, diagnosis, of, halo, sign, and, reversed, halo, sign, (Fig., 6), -",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014502/000001.jpg?itok=KtUP3rLR",
            "caption": "+1 day HCT. PA (a) and lateral (b) chest X-ray. Pseudonodular consolidation (white arrow) on the right upper lobe (RUL)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014502/000002.jpg?itok=1pblhcUw",
            "caption": "+3 days HCT. PA (a) and lateral (b) chest X-ray. Evolution of the nodular opacity (white arrow) with an increase of density and size."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014502/000003.jpg?itok=TvGNhyH3",
            "caption": "Axial (a), sagittal (b) and coronal (c) chest CT demonstrate a pulmonary mass with three components: central ground glass opacity (\u201creversed halo sign\u201d) (*) and peripheral (arrow) ground glass opacity (halo sign) and intermedial consolidation."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014502/000004.jpg?itok=GB6w_4zu",
            "caption": "+6 days HCT. Axial non-enhanced brain CT scan shows corticosubcortical hypoattenuation in the right frontal lobe which suggests a septic embolism, with a lineal hyperdensity that could indicate a minimal petechial haemorrhage (arrow)."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014502/000005.jpg?itok=r3bWy0bL",
            "caption": "+22 days HCT. Axial enhanced brain CT scan shows a brain abscess with enhanced peripheral rim and vasogenic oedema associated, which is causing mass effect and shift of midline structures."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014502/000006.jpg?itok=-FXvI126",
            "caption": "Differential diagnosis of halo sign and reversed halo sign."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/14502",
    "time": "22.04.2017"
  },
  "14510": {
    "case_id": 14510,
    "title": "Pleural synovial sarcom",
    "section": "Chest imaging",
    "age": "33",
    "gender": "female",
    "diagnosis": "Pleural synovial sarcoma",
    "history": "A 33-year-old Caucasian female presented with acute shortness of breath and cough. Patient had a renal transplant 9 years prior and was on immunosuppressants for many years. Following biopsy and pathological confirmation of synovial sarcoma, she underwent a left lung wedge resection and radiation therapy. She is doing well one year post-radiation.",
    "image_finding": "Radiographs and CT examinations of the thorax without contrast were obtained. Radiographs showed an ipsilateral left pleural effusion with round homogenous opacity in left suprahilar region (see Fig. 1). The mass had sharply marginated borders with a lobulated, ovoid contour. CT also showed a left upper lobe posterior, suprahilar, lobulated soft tissue density measuring approximately 4.3 X 2.7 x 3.8 cm (see Fig. 2). Due to underlying renal insufficiency, no contrast was given.",
    "discussion": "Synovial sarcomas are rare soft tissue malignancies mostly affecting the large joints of the extremities; other locations include the chest wall, mediastinum, pleura, or heart [1]. Pleural synovial sarcoma (PSS) is a subtype comprising only 0.1%-0.5% of primary lung malignancies [2].\n\nPSSs typically occur in adolescents and adults between the ages of 15 and 40 years without sex predilection. Symptoms can include dyspnoea, chest pain, and cough. The histogenesis of PSS is uncertain, though they are hypothesised to arise from primitive pluripotent mesenchyme and can differentiate into spindle and/or epithelial cells [2, 3]. Many subtypes exist, including liposarcoma, chondrosarcoma, osteosarcoma, and malignant schwannoma [2]. PSS was only first described in literature in 2009. Detailed history, imaging, histology, immunochemistry, and cytogenetics are useful for accurate diagnosis. It is important to distinguish PSS from histologically similar spindle cell tumours since they are often mistaken for malignant mesothelioma [3], but PSS is aggressive with a high rate of recurrence [1].\n\nPSS has sharp borders with round or lobulated contours [2]. On chest radiographs, PSS is homogenous, pleural-based soft-tissue mass, usually without calcifications, cavitation, or associated lymphadenopathy [4]. It is most often peripheral with ipsilateral pleural effusion [4]. On CT and MR, PSS heterogeneously enhances with nodular soft-tissue elements and occasional septa; the enhancement pattern is secondary to haemorrhage and necrosis [5]. It occasionally has thin rim enhancement. PSS is isointense to surrounding musculature on T1-weighted sequences [5] with intermediate to high signal intensity on T2-weighted sequences [5, 2]. Fluid-fluid levels can be seen on T1 and T2-weighted sequences due to haemorrhage [2]. Good history and clinical evaluation are necessary to rule out other malignancies like fibrosarcoma, mesothelioma, and leimoyosarcoma as PSS is difficult to diagnose on imaging [2]. Intravenous contrast helps to characterise more cystic PSS from other malignancies [5].\n\nTreatment includes chemotherapy and radiation therapy, although resection is most curative [2, 1]. Synovial sarcomas are extremely sensitive to ifosfamide-based chemotherapy with a 5-year survival rate up to 60% [2]. Although the prognosis is poor in PSS [4], more targeted chemotherapy to a t(X;18)(p11.2;q11.2) translocation in 80-90% of these tumours and specific fusion proteins may improve prognosis [2, 3].\n\nOur case emphasises the importance of synovial sarcomas as a possible primary pleural malignancy, especially in a young patient. It is important to assess for underlying malignancy in settings of unilateral pleural effusion, especially in immunocompromised patients.",
    "differential_diagnosis": "Pleural, synovial, sarcoma, Mesothelioma, Malignant, fibrous, histiocytomas, Carcinosarcoma, Adenocarcinoma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014510/000001.png?itok=1-cXVMek",
            "caption": "Expiratory chest radiograph demonstrates a moderate to large left pleural effusion with superimposed consolidation, initially interpreted as pneumonia with parapneumonic effusion. There is also a rounded opacity in the left suprahilar region, concerning for mass."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014510/000002.png?itok=hJEtMoGO",
            "caption": "Coronal (A) and axial (b) non-contrasted chest CT images demonstrate a rounded posterior mediastinal mass with associated left pleural effusion and left lower lobe atelectasis."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014510/000003.png?itok=8mOfVdfL",
            "caption": "Coronal (A) and axial (b) non-contrasted chest CT images demonstrate a rounded posterior mediastinal mass with associated left pleural effusion and left lower lobe atelectasis."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014510/000004.jpg?itok=D2rBAwqj",
            "caption": "4X H&E images of pleural synovial sarcoma. Histologically, on the scanning power the lesion shows alveolar ling tissue with the sarcoma."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014510/000006.jpg?itok=DB1QDb1a",
            "caption": "20X H&E images of pleural synovial sarcoma.  Histologically, on higher power the lesion show highly cellular spindle cells areas that are densely packed into an interwoven herringbone pattern."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Mediastinum",
      "Respiratory system",
      "Salivary glands"
    ],
    "imaging_technique": [
      "CT",
      "Percutaneous"
    ],
    "link": "https://www.eurorad.org/case/14510",
    "time": "17.12.2017"
  },
  "14538": {
    "case_id": 14538,
    "title": "Hypermetabolic PET positive pleural nodular thickening five years after pleurodesis.",
    "section": "Chest imaging",
    "age": "48",
    "gender": "male",
    "diagnosis": "Hyper-metabolic pleural nodules attributed to talc pleurodesis",
    "history": "A 48-year-old gentleman presented with a persistent pneumothorax despite a chest drain. The patient underwent pleurodesis with 12 grams of talc. Five years later, hypermetabolic FDG avid pleural thickening was noted on the PET scan.",
    "image_finding": "CT scans from 2012 and 2016 were reviewed and these demonstrated increasing pleural nodular thickening around the left upper lobe and in the interlobar fissure. FDG-PET scan with CT images was performed in 2017, which was 5 years after pleurodesis, and showed a multifocal hypermetabolism of the left pleural thickening, predominating at the apex of the lung (SUV max 30 g/ml). Percutaneous CT-guided biopsy of the pleural thickening was performed. Foreign body reaction was seen in the specimen. There was no evidence of malignancy or granulomas.",
    "discussion": "Background The efficacy of talc pleurodesis in cases of recurring pneumothorax or pleural effusion is well known [1, 2]. Talc incites granulomatous inflammation and causes pleural adhesions within 24h of the procedure. These changes evolve into a more collagenous response after a few weeks and leads to talc granuloma formation. However, after a few months, the reaction usually leads to pleural fibrosis [3, 4]. Clinical Perspective Pleural fibrosis post talc pleurodesis can be seen on CT and should not be confused with other conditions, such as pleural plaques from asbestos exposure or malignant pleural mesothelioma or metastasis. Murray et al. [5] described variable degrees of pleural thickening and nodularity with residual pleural effusion, most often loculated and located in the posterior portion of the pleural space. Imaging PerspectiveTalc deposits present as focal areas of high attenuation (320 H). The first report of high FDG uptake after talc pleurodesis was by Murray et al. [6]. Other studies have since described such findings for up to 5 years after talc pleurodesis [7-10]. If FDG-PET is performed soon after the procedure, pleural uptake can be normal and then increase with subsequent exams [8-10]. Clinicians should be aware of this possibility. Follow-up of hypermetabolic pleural lesions attributed to talc pleurodesis is important for the detection of new pleural lesions.Outcome Correlation between FDG-PET and CT scan images is necessary in order to compare the areas of talc deposits to regions of increased FDG uptake [10]. In patients with increased pleural uptake, monitoring the stability of lesions with increased activity is also important in order to detect new pleural lesions such as metastases or neoplastic evolution. In patients with significant asbestos exposure who are at risk for malignant mesothelioma, diagnostic tools such as transthoracic or thoracoscopic biopsy should be undertaken, especially if they present significant chest-wall pain. However, in patients with no clear asbestos exposure, radiological follow-up could be the initial first step, with a more aggressive approach for progressive lesions.Teaching Points Talc pleurodesis induces a granulomatous reaction that can last more than 5 years. This can result in high FDG uptake and hypermetabolism. Clinicians should be aware of this possibility and question patients about past pleural procedures. Follow-up of hypermetabolic pleural lesions attributed to talc pleurodesis is important for the detection of new pleural lesions.",
    "differential_diagnosis": "Hyper-metabolic, pleural, nodules, attributed, to, talc, pleurodesis, Pleural, metastases, Mesothelioma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014538/000001.jpg?itok=urfef-P6",
            "caption": "Dense nodular pleural thickening is seen along the left upper lobe after 12 months of pleurodesis."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014538/000002.jpg?itok=sv-aUOHJ",
            "caption": "Increased nodular pleural thickening was seen four years after the baseline scan."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014538/000003.jpg?itok=gRcxsz8W",
            "caption": "The nodular pleural thickening showed high uptake on PET (SUV 30)."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT-Quantitative",
      "PET-CT"
    ],
    "link": "https://www.eurorad.org/case/14538",
    "time": "26.03.2017"
  },
  "14547": {
    "case_id": 14547,
    "title": "Benign diffuse pleural thickening",
    "section": "Chest imaging",
    "age": "76",
    "gender": "male",
    "diagnosis": "Benign diffuse pleural thickening",
    "history": "An asymptomatic 76-year-old man with left lung nodular opacities and pleural space shadowing demonstrated on a chest X-ray underwent thoracic CT for further characterization. Past history of extensive left pneumonia was noted.",
    "image_finding": "Chest X-ray showed two nodular opacities in the periphery of the left lower zone and pleural shadowing over the middle and lower zones on the same side (figure 1). Unenhanced thoracic CT was performed, and demonstrated a smooth and diffuse pleural thickening >3mm extending more than 8 cm craniocaudally and 5 cm laterally (Fig. 2 and 3). Nodular opacities seen in the chest X-ray corresponded to areas of round atelectasis (Fig. 4). After careful scrutiny of the medical records, a previous chest CT was retrieved, confirming the stable appearances of the pleural thickening and round atelectasis (not shown).",
    "discussion": "Benign diffuse pleural thickening (BDPT) results from a fibrosing process of the visceral pleura with fusion to the parietal pleura over a wide area [1]. The pathophysiological mechanism is thought to be an intense and continuous inflammatory insult that drives an excessive deposition and abnormal turnover of fibrinous matrix in the pleural space, which in turn becomes obliterated and fibrosed [1].CT criteria fulfilment implies visualization of a continuous and smooth sheet of pleural thickening of >3mm extending for more than 8 cm craniocaudally and 5 cm laterally [2, 3]. BDPT usually extends along the posterior and lateral surfaces of the lower hemithorax, and sometimes is accompanied by parenchymal bands or foci of round atelectasis [4]. Almost always there is blunting of the costophrenic angles and volume loss on the affected lung [5]. Thickening >10mm, nodular thickening, and mediastinal pleural involvement are findings not usually associated with BDPT and should raise concern for malignancy (such as mesothelioma) [4].Multiple aetiologies of BDPT are recognized, such as infection (including tuberculosis), haemothorax, asbestos exposure, collagen vascular diseases (notably systemic lupus erythematosus and rheumatoid arthritis) and thoracic irradiation [5]. Since it can be a cause of significant restrictive lung disease, some authors recommend follow-up for BDPT patients with physical examination, chest imaging and pulmonary function tests to monitor and manage deteriorations of the lung function [6].",
    "differential_diagnosis": "Benign, diffuse, pleural, thickening, Mesothelioma, Asbestos, pleural, plaques",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014547/000001.jpg?itok=WBXUEjnc",
            "caption": "Chest X-ray showing two nodular opacities in the left lower zone (red arrows). Ill-defined pleural thickening is also demonstrated. Angular blunting of the left costophrenic angle may suggest pleural thickening over pleural fluid (red square)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014547/000002.jpg?itok=2P9dyaaA",
            "caption": "Axial CT showing smooth pleural thickening >3mm extending >5cm laterally. Retropleural fat is seen (white ovals), likely due to pleural retraction. Parenchymal bands (red ovals) and foci of folded lung (red square) are also noted."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014547/000003.jpg?itok=W9Ahl8Wo",
            "caption": "Coronal (left image) and sagittal (right image) CT reconstructions demonstrating diffuse pleural thickening extending >8cm craniocaudally (red oval). Costophrenic angle blunting is shown (red square). No mediastinal pleural thickening is demonstrated."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014547/000004.jpg?itok=G4JWBz8Y",
            "caption": "Axial CT reconstruction showing foci of round atelectasis (red arrows), accounting for the nodular opacities visible on figure 1. Note the subtle converging/bending of bronchovascular structures towards the areas of round atelectasis (red ovals)."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Education"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/14547",
    "time": "19.03.2017"
  },
  "14560": {
    "case_id": 14560,
    "title": "Air-fluid levels within an emphysematous giant bullae",
    "section": "Chest imaging",
    "age": "58",
    "gender": "male",
    "diagnosis": "Infected emphysematous bulla",
    "history": "A 58-year-old man was admitted to first aid for onset of left thoracic pain, dyspnoea and low-grade fever. His clinical history included a previous diagnosis of bullous emphysema with several giant bullae in the left lung.Laboratory tests showed a moderate increase of inflammatory parameters.",
    "image_finding": "The chest X-ray showed two well-defined air-fluid levels inside of large emphysematous bubbles in the left lung. An unenhanced CT showed a severe bilateral bullous emphysema with medium-sized bullae in the right lung and several large cavities in the left lung, containing some liquid with air-fluid levels. The walls of the bullae were regular and very thin. The comparison with a previous chest radiograph (Fig. 1c-d) and a CT examination (Fig. 2c-d) performed several months before showed an increase in size of the large bubbles in the left lung and the appearance of fluid inside them. Based on the radiological findings, the minimal symptomatology and evidence of pre-existing emphysematous bubbles without air-fluid levels, a diagnosis of infected emphysematous bulla was suggested. The patient underwent prolonged systemic antibiotic therapy and follow-up. An unenhanced CT performed after four weeks showed considerable reduction of the amount of fluid inside the bulla (Fig. 2e)",
    "discussion": "The presence of air-fluid levels inside an emphysematous bulla is not a frequent radiological evidence and for this reason it is rarely reported in the literature [1].Its pathophysiology is not clear yet, however, several theories have been proposed: an insufficient bronchial communication can cause an inadequate drainage of the bulla resulting in a fluid accumulation inside it. The fluid can initially be sterile and can afterwards become infected due to the spread of an infection in the surrounding lung or via haematogenous spread. A bleeding within the bulla or a malignancy are other more rare but possible aetiologic mechanisms [1, 2, 3].First described in 1947 by Drouet [4], this pathology occurs predominantly in male smokers and shows no predilection of side or age.The clinical presentation varies from incidental symptomless findings to symptoms of acute lung infection but generally milder signs are identified such as low-grade fever, cough, chest pain and dyspnoea.The chest radiography shows one or more air-fluid levels inside a radiolucent bulla. CT is the most appropriate imaging modality to determine the exact size and site of the bulla, the amount of fluid and the features of the cavity's walls. These are generally regular and very thin; unlike lung abscess which remains the main differential diagnosis.The diagnosis relies on the discrepancy between the radiological findings and the presence of a minimal symptomology; especially if there is evidence of pre-existing emphysematous bullae without air-fluid levels [1, 2, 5].The most common therapeutic approach for this condition is the prolonged administration of systemic antibiotics and follow-up until recovery, which might take up to several weeks.If the conservative treatment fails, a percutaneous or endoscopical drainage can be considered, while surgical resection is considered a contraindication because of the persistent air leakage due to lung damage [2, 6, 7, 8].",
    "differential_diagnosis": "Infected, emphysematous, bulla, Lung, abscess, Tuberculosis, Swyer-James, syndrome",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014560/000001.png?itok=CCxDw6-h",
            "caption": "Chest X-ray at admission (posterior-anterior view) shows a large emphysematous bulla in the left upper lobe with 2 well-defined air-fluid levels."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014560/000002.png?itok=DQPhSVb8",
            "caption": "Chest X-ray at admission (lateral view) shows a\nlarge emphysematous bulla in the left upper lobe with 2 well-defined air-fluid levels."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014560/000003.png?itok=e4duAHES",
            "caption": "Posterior-anterior view of a previous chest X-ray obtained 8 months before demonstrates a giant emphysematous bulla in the left upper lobe but no air-fluid levels."
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014560/000004.png?itok=ZJlF0w4c",
            "caption": "Lateral view of a previous chest X-ray obtained 8 months before showed a giant emphysematous bulla in the left upper lobe but no air-fluid levels."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014560/000005.png?itok=ptXfGHuy",
            "caption": "Unenhanced CT (axial view) shows large emphysematous bubbles in the left lung with some fluid inside them."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014560/000007.png?itok=TglhoQSK",
            "caption": "Unenhanced CT (sagittal view) shows large emphysematous bubbles in the left lung with some fluid inside them."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014560/000011.png?itok=C8Wm-6B_",
            "caption": "Previous unenhanced CT (axial view) shows large emphysematous bubbles in the left lung without  fluid inside them."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014560/000006.png?itok=f_nI6F6y",
            "caption": "Previous unenhanced CT (sagittal view) shows large emphysematous bubbles in the left lung without  fluid inside them."
          },
          {
            "number": "Figure 2e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014560/000014.png?itok=rGyRPlvT",
            "caption": "Follow-up unenhanced CT performed after four weeks (axial view) shows considerable reduction of amount of fluid inside the bulla."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/14560",
    "time": "26.04.2017"
  },
  "14586": {
    "case_id": 14586,
    "title": "Pulmonary hyalinizing granulom",
    "section": "Chest imaging",
    "age": "63",
    "gender": "male",
    "diagnosis": "Pulmonary hyalinizing granuloma",
    "history": "A 63-year-old man came to the emergency department of our hospital with complaints of cough and dysphonia for 1 month. Our patient had no fever, weight loss, or history of cancer.",
    "image_finding": "Chest radiograph revealed multiple well-defined lung nodules (Fig. 1). Subsequently, computed tomography (CT) of thorax-abdomen-pelvis was performed to rule out malignancy. CT showed several lung nodules in both lungs with variable size (from 4 millimetres to 2, 4 cm) (Fig. 2a, b, c). No lymphadenopathies or osseous erosion were observed. CT also revealed a perihepatic solid, heterogeneous mass with peripheral and central gross calcifications and two hypodense intrahepatic lesions (Fig. 2d). These findings suggested metastatic disease, so we performed: brain MRI, testicular and neck ultrasound, mammography, colonoscopy, all normal. Tumour markers and rheumatologic antibodies were also normal.The biopsy of perihepatic mass revealed a benign fibrous tumour. Due to the absence of malignancy, a lung biopsy was performed and showed a pulmonary hyalinizing granuloma (PHG), without signs of malignant degeneration.After 4 months, a follow-up CT was performance showing stability of all the findings.",
    "discussion": "PHG is a very rare fibrotic nodular disease whose aetiology remains unknown. It is related to an abnormal immune response and can be associated with extrapulmonary fibrotic conditions like sclerosing mediastinitis, retroperitoneal fibrosis or Riedel\u2019s thyroiditis [1, 2, 3]. Our case was associated with a perihepatic mass (the other 2 intrahepatic hypodense lesions have not yet been characterized).  Most patients are asymptomatic and the disease is usually diagnosed as an incidental finding trough an image test. However, some individuals may suffer non-specific symptoms like cough, fever, fatigue or dyspnoea [1, 2, 3].Chest radiographs show multiple (70%) or solitary (30%) nodules with well-defined borders, diameter ranging from 0.2 to 15cm (mean 2cm), bilateral and randomly distributed. Calcification and cavitation are not common. Nodules often remain stable for long periods, but they can grow slowly. Lymphadenopathies are not observed in this entity [1, 2, 3].When these findings are present you should rule out a malignant metastatic disease or a primary (lung or lymphoma) tumour. Other possibilities are infection (tuberculosis, septic emboli or fungal infections), sarcoidosis, amyloidosis, silicosis, rheumatoid nodules, Wegener's granulomatosis, lymphomatoid granulomatosis, and plasma cell granuloma [1, 2, 3].Final diagnosis is made by histopathological examination. Microscopically, a hypocellular network of concentric hyalinised collagen surrounded by a lymphocytic infiltrate is presented [1, 2, 3]. Macroscopically, whitish and well-defined nodules similar to a cotton-ball are characteristics [3].This entity has a good prognosis. Nowadays, malignant degeneration has not been described. Treatment consists in resection and watchful waiting for solitary lesions or corticosteroid drugs in cases of multiple lesions [1, 2, 3].In conclusion, PHG is a rare benign disease that can mimic a metastatic lung cancer. Biopsy is necessary for the diagnosis.",
    "differential_diagnosis": "Pulmonary, hyalinizing, granuloma, Malignant, metastatic, Primary, tumour, Infection, (tuberculosis, septic, emboli, or, fungal, infections), Sarcoidosis, Amyloidosis, Silicosis, Rheumatoid, nodules, Wegener's, granulomatosis, Lymphomatoid, granulomatosis, Plasma, cell, granuloma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014586/000001.png?itok=uoYp4ZG1",
            "caption": "Multiple well-defined nodules distributed throughout both lungs."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014586/000002.png?itok=XPBbLuW-",
            "caption": "Multiple well-defined nodules distributed throughout both lungs."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014586/000003.png?itok=qCZewr4F",
            "caption": "Multiple and bilateral nodules"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014586/000004.png?itok=nlVheOk9",
            "caption": "The nodule in the lower left lobe (bigger) show microlobulated contornous, while the one in the lingula (smaller) has smooth borders."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014586/000005.png?itok=t2I-Mqoz",
            "caption": "This upper right nodule was one of the biggest and its density was heterogeneous.\nNo lymphadenopathy."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014586/000006.png?itok=r0JMb4Kw",
            "caption": "Heterogeneous mass with peripheral and central  gross calcifications and one hypodense intrahepatic lesion located at III segment."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax",
      "Lung",
      "Abdomen"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/14586",
    "time": "22.04.2017"
  },
  "14592": {
    "case_id": 14592,
    "title": "Solitary fibrous tumour of the chest wall",
    "section": "Chest imaging",
    "age": "75",
    "gender": "female",
    "diagnosis": "Solitary fibrous tumour of the chest wall",
    "history": "75-year-old female patient with history of diffuse lipomatosis. In the follow up, the patient presented with a painless mass located in the right upper quadrant which had grown slowly in recent years. The patient underwent multiple imaging tests (ultrasound, MRI, CT with contrast and angiography) and surgical excision was recommended.",
    "image_finding": "Ultrasound demonstrated a 10 cm well-defined heterogeneous hypoechoic solid mass located in the right anterolateral thoracoabdominal wall. Important Doppler vascularization was noted (Fig. 1).Contrast-enhanced CT images showed a well-defined soft-tissue heterogeneously enhancing lobular mass (Fig. 2 and 3).MRI was performed and showed a well-defined soft-tissue mass of heterogeneous intermediate signal intensity on both T1 and T2 images. Areas of high intensity within the lesion consistent with myxoid change, necrosis, or cystic degeneration are shown on T2 images. Flow voids corresponding to prominent perilesional feeding vessels are shown on STIR image. Contrast-enhanced MRI revealed intense heterogeneous enhancement with central areas of low intensity (Fig. 4 and 5).Preoperative embolization to reduce intraoperative blood loss was required and the angiogram showed important feeding vessels from a large and tortuous internal mammary artery (Fig. 6).",
    "discussion": "Solitary fibrous tumors (SFT) are rare mesenchymal tumors that can be benign or malignant. SFT are most commonly located in the thorax, but can occur throughout the body. SFT commonly present during the fifth and sixth decades and there is no sex predilection [1, 2].SFT in the thoracic cavity, particularly those with small size, are asymptomatic and are diagnosed as incidental findings on imaging tests. Large intrathoracic and extrathoracic SFT, however, are usually symptomatic; the manifestations are a painless mass or local pressure effects. Systemic complaints may occur. Paraneoplastic syndromes such as hypoglycemia, digital clubbing, and hypertrophic osteoarthropathy are uncommon [1 - 4].On CT, small SFT are well-defined, homogeneously hyperdense masses, while large tumors, may appear heterogeneous. Tumors were usually highly vascular and enhancement is typically heterogeneous with central areas of low attenuation. Serpiginous branching linear areas of enhancement consistent with intralesional vessels can be seen [1, 2, 4].On MRI, SFT demonstrate intermediate heterogeneous signal intensity on both T1 and T2 images. Areas of cystic degeneration, hemorrhage, necrosis and prominent vascular structures may appear as high signal intensity on T2 images. Flow voids corresponding to prominent perilesional feeding vessels may be seen. SFT show intense heterogeneous enhancement after administration of gadolinium [2 \u2013 4].On ultrasound, the majority of small SFT appear as homogeneous hypoechoic masses. Occasionally, large SFT are heterogeneous, and this feature corresponds to the heterogeneity seen on images obtained with other modalities [1, 2].Angiography is useful in determining the vascular supply to the lesion and may be performed to lesions requiring preoperative embolization in order to reduce intraoperative blood loss [2, 4].In general, the finding of a well-defined large, solid, highly vascular tumor, particularly with prominent feeding vessels, should alert the radiologist to the possible diagnosis of SFT [3].Biopsy is required for definitive diagnosis and the final diagnosis of our case was made with the histologic findings of the surgical specimen (Fig. 7). SFT are composed of whorls of reticulin and collagen with interspersed spindle-shaped cells. These tumors have a variety of architectural patterns. Because of the variable microscopic appearances of SFT, immunohistochemical analysis plays an important role in the diagnosis. Typically, diffuse positivity for CD34, bcl-2, CD99 and vimentin is the basis of a certain diagnosis (Fig. 8) [1-5].Surgical resection is the treatment of choice, because approximately 20% of these tumors are malignant, and even benign SFT have indeterminate malignant potential [1 - 3, 5].",
    "differential_diagnosis": "Solitary, fibrous, tumour, of, the, chest, wall, Malignant, fibrous, histiocytoma, Leiomyosarcoma, Alveolar, soft-part, sarcoma, Angiosarcoma, Solitary, vascular, metastatic, lesion",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014592/000001.jpg?itok=-TopeSKd",
            "caption": "A) US demonstrates a well-defined slightly heterogeneous hypoechoic solid mass in the right anterolateral thoracoabdominal wall. \nB) Doppler US shows important vascularization (arrow)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014592/000002.jpg?itok=_CFtRIcw",
            "caption": "Contrast-enhanced CT shows a well-defined heterogeneously enhancing lobular mass. Serpiginous linear areas of enhancement consistent with intralesional vessels are shown in the arterial phase (arrow)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014592/000003.jpg?itok=5Hp-Jtdm",
            "caption": "Contrast-enhanced CT shows a well-defined heterogeneously enhancing lobular mass. Areas of low attenuation within the lesion consistent with myxoid change, necrosis, or cystic degeneration are noted in the portal phase (arrows)."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014592/000004.jpg?itok=s5HR4dbr",
            "caption": "Axial T1 and T2 MR images show well-defined soft-tissue mass of heterogeneous intermediate signal intensity. Areas of high intensity within the lesion consistent with myxoid change, necrosis, or cystic degeneration are shown on T2 (arrows)."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014592/000005.jpg?itok=elICJL5-",
            "caption": "A) Axial STIR MR image. Flow voids corresponding to prominent perilesional feeding vessels are seen within the lesion (arrow). \nB) Axial contrast-enhanced MR image. Intense heterogeneous enhancement with central areas of low intensity (arrows)."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014592/000007.jpg?itok=klZvXDNm",
            "caption": "A) Intraoperative gross photograph shows a well-circumscribed, encapsulated and highly vascular mass with lobular external surface. \nB) Intraoperative gross photograph of the vascular pedicle of the mass which contains feeding vessels (arrow)."
          }
        ]
      },
      {
        "number": "Figure 7",
        "subfigures": [
          {
            "number": "Figure 7",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014592/000008.jpg?itok=Ax1jdp8P",
            "caption": "A) Digital subtraction angiogram shows important feeding vessels from the internal mammary artery (arrow). \nB) 3D volume rendering CT reconstruction image shows the tumour blood supply from the large and tortuous internal mammary artery (arrow)."
          }
        ]
      },
      {
        "number": "Figure 8",
        "subfigures": [
          {
            "number": "Figure 8",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014592/000009.jpg?itok=Io6pToar",
            "caption": "Hematoxylin-eosin (H-E) photomicrograph. Highly cellular proliferation of spindled cells arranged in a storiform pattern. Staghorn-like vessels are shown (arrow).  \nImmunohistochemical analysis. The tumor has diffuse positive immunohistochemical result for CD34, CD99 and Bcl-2."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thoracic wall"
    ],
    "imaging_technique": [
      "Ultrasound",
      "Ultrasound-Colour Doppler",
      "CT",
      "CT-Angiography",
      "MR",
      "MR-Angiography",
      "Catheter arteriography",
      "Image manipulation / Reconstruction",
      "Experimental"
    ],
    "link": "https://www.eurorad.org/case/14592",
    "time": "26.03.2017"
  },
  "14597": {
    "case_id": 14597,
    "title": "Stage I sarcoidosis",
    "section": "Chest imaging",
    "age": "25",
    "gender": "male",
    "diagnosis": "Stage I sarcoidosis",
    "history": "A 25-year-old man was referred from another hospital with a 2-month history of fever, erythema nodosum and lower extremities joints pain. Chest radiograph (Fig. 1) was performed, followed by thoracic CT scan (Fig. 2) and EBUS (endobronchial ultrasound) biopsy. Histopathology was positive for non-necrotic epithelial granulomas.",
    "image_finding": "Chest radiographs (Fig. 1) revealed bilateral hilar lymphadenopathy and paratracheal lymph node enlargement. There were no pulmonary opacities. CT scans (Fig. 2) showed bilateral hilar, paratracheal, subcarinal and prevascular lymph node enlargement. There were no pulmonary abnormalities.",
    "discussion": "Sarcoidosis is a systemic disease of unknown aetiology that is characterized by formation of noncaseating granulomas. Even though they may be found in any organ, most commonly affected structures are hilar and mediastinal lymph nodes, lungs, skin and eyes. Sarcoidosis incidence varies greatly around the world, from about 1.01 to 35.5 in 100 000. The highest prevalence is reported in African\u2013American, Danish and Swedish individuals, and the lowest in the Japanese population. [1]Sarcoidosis is often (in 30-60%) asymptomatic, the only finding being abnormal chest imaging studies. Clinical symptoms if present include persistent cough, fatigue, fever, erythema nodosum, joints pain, uveitis and peripheral lymph node enlargement. [2] Pathologic chest radiograph findings are reported in 60% to 70% of patients with sarcoidosis. [3] The pattern of these chest radiographic abnormalities is a basis of classic sarcoidosis staging system (Fig. 3) [4] Stage 1 is described as isolated intrathoracic lymphadenopathy. The most typical chest radiograph lympadenopathy pattern, occurring in 85-95% of diagnosed patients, is bilateral, symmetric, well-defined hilar lymph node enlargement. Right paratracheal lymph nodes are enlarged in 75% of cases. Together they form a sign named Garland's triad or a 1-2-3 sign. Lymphadenopathy in other localizations is less frequent, it is found in 50-75% in the aortopulmonary window, 20% in the subcarinal region, 10-15% in the anterior mediastinum, <5% in the posterior mediastinum, <5% intramammary. (Fig. 4) [3] Lymph node enlargement usually resolves in 2 years\u2019 time, however it may persist for many years. Recurrence following resolution is uncommon. Lymph node calcifications are reported in chest X-rays of up to 20% of patients with sarcoidosis lasting for 10 year or more. [5]CT (computed tomography) due to its superior sensitivity displays a different pattern of lymphandenopathy in patients who have sarcoidosis. Right lower paratracheal lymph nodes are enlarged in 100%; subaortic and paraaortic lymph nodes (lymph nodes of aortopulmonary window) in 95%; hilar in 90%, prevascular in 65%; in posterior mediastinum in 15%. Calcifications are observed in CT in 25-50% of patients, and its prevalence increases with disease duration. In contrast to densely calcified lymph nodes characteristic for tuberculosis, sarcoid lymph nodes often display a hazy or eggshell calcification pattern. [3]Even though lymphandenopathy in sarcoidosis is often prominent, it rarely causes any symptoms. [6] Take home message Sarcoidosis is the most common cause of bilateral asymptomatic hilar lymphadenopathy and should always be included in the differential diagnosis of such a finding.",
    "differential_diagnosis": "Stage, I, sarcoidosis, Infectious:, Tuberculosis, Mononucleosis, Histoplasmosis, Blastomycosis, Coccidiomycosis, Cryptococcosis, Cat, scratch, disease, Malignancy:, Lymphoma, Cancer, Inorganic, dust, diseases:, Berylosis, Silicosis, Others:, Amyloidosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014597/000001.jpg?itok=mX9G3ssF",
            "caption": "Chest radiographs shows bilateral hilar and paratracheal lymph node enlargement."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014597/000002.jpg?itok=dwkoeBLa",
            "caption": "Chest radiographs shows bilateral hilar and paratracheal lymph node enlargement."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014597/000003.jpg?itok=A7AD29zV",
            "caption": "Mediastinal window axial scan. There is bilateral hilar and subcarinal lymph node enlargement."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014597/000004.jpg?itok=FX_I6R7j",
            "caption": "Mediastinal window coronal reconstruction. There is bilateral hilar and paratracheal lymph node enlargement"
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014597/000005.jpg?itok=3PycgFnL",
            "caption": "Lung window coronal reconstruction. There are no pulmonary lesions."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014597/000006.jpg?itok=MuKVQNCQ",
            "caption": "1) Hilar lymph nodes 95% 2) Right superior mediastinal (paratracheal) lymph nodes 75% 3) Left superior mediastinal (aortopulmonary window) lymph nodes 50% 4) Subcarinal lymph nodes 20%"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014597/000007.jpg?itok=dzSOAqS-",
            "caption": "Sarcoidosis staging on the basis of the chest radiograph"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lymph nodes",
      "Mediastinum",
      "Thorax",
      "Lung"
    ],
    "imaging_technique": [
      "Digital radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/14597",
    "time": "31.03.2017"
  },
  "14619": {
    "case_id": 14619,
    "title": "Sitophobia secondary to aberrant right subclavian artery",
    "section": "Chest imaging",
    "age": "17",
    "gender": "female",
    "diagnosis": "Dysphagia lusoria secondary to aberrant right SCA, incomplete vascular ring",
    "history": "A 17-year-old female patient who was concurrently being evaluated for syncope presented with worsening dysphagia towards solids that caused her sitophobia, fear of eating. Echocardiogram showed unusual anatomical anomalies. Barium oesophagram and Computed Tomography Angiography (CTA) confirmed the anatomical anomalies. She eventually underwent surgical revision by paediatric cardiothoracic surgeons",
    "image_finding": "Barium oesophagogram (Panel A) demonstrated posterior narrowing of the oesophagus indicative of possible obstruction. CTA (Panel B) confirmed left aortic arch with aberrant right subclavian artery resulting in mild compression of the posterior wall of the oesophagus.",
    "discussion": "Compression of the oesophagus by anomalies of aortic root and arch vasculature defines the term, dysphagia lusoria. The most common anomaly of the aortic arch is aberrant origin and retroesophageal course of the right subclavian artery, which has an incidence ranging from 0.5 to 1.8%. Regression of the fourth vascular arch, between right CCA and right SCA, and right dorsal aorta with persistence of seventh intersegmental artery results in aberrant right SCA also known as arteria lusoria. [1] In 80% of the cases, the aberrant artery crosses between the oesophagus and vertebral column, such as in our patient. In rare cases, the aberrant artery may originate from a broad base known as Kommerell\u2019s diverticulum. Anatomic and physiologic changes to this diverticulum may explain delayed clinical presentations in some patients. Also, up to 37% of cases show coexisting vascular abnormalities. [2] Our patient was found to have bicuspid valve contributing to her syncope. However, most of vascular arch anomalies are clinically asymptomatic with up to 60 \u2013 80% of patient remaining asymptomatic in their lifespan. [1] Most cases are found incidentally or secondary to dysphagia and respiratory symptoms. Initial evaluation is barium oesophagram, but diagnosis is made with CT angiography which also helps in planning for surgery. [2] Since 1965, numerous surgical approaches have been instituted to correct the aberrant flow in symptomatic patients. Our patient underwent left posteriolateral thoracotomy and division of aberrant right SCA with reimplantation to the left SCA by the paediatric cardiothoracic surgery service and is doing well [3] This case highlights the importance of recognizing symptomatic presentation in an often clinically silent anatomical anomaly.",
    "differential_diagnosis": "Dysphagia, lusoria, secondary, to, aberrant, right, SCA,, incomplete, vascular, ring, Oesophageal, stricture, Achalasia, Oesophageal, web",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014619/000001.jpg?itok=Iq1Vcvyp",
            "caption": "Barium oesophagogram demonstrating kinking of the oesophagus on frontal and lateral views (red arrow), secondary to crossing vessel."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014619/000002.jpg?itok=5h7WfhJ8",
            "caption": "Barium oesophagogram demonstrating kinking of the oesophagus on frontal and lateral views (red arrow), secondary to crossing vessel."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014619/000003.jpg?itok=9sRl-xde",
            "caption": "Aberrant right subclavian artery is visualized coursing posterior to the trachea (red arrow)."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014619/000004.jpg?itok=xmr153zp",
            "caption": "There is mild compression of oesophagus between aortic arch, right subclavian artery, and trachea (Red-dotted arrow). This corresponds to the site of kinking on oesophagus as noted on barium study."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014619/000005.jpg?itok=mkL7_c44",
            "caption": "Abberrant subclavian artery has large origin known as Kommerell\u2019s diverticulum (asterisk)."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Gastrointestinal tract",
      "Anatomy",
      "Arteries / Aorta",
      "Vascular"
    ],
    "imaging_technique": [
      "Fluoroscopy",
      "CT-Angiography"
    ],
    "link": "https://www.eurorad.org/case/14619",
    "time": "31.05.2017"
  },
  "14626": {
    "case_id": 14626,
    "title": "An industrial worker with shortness of breath",
    "section": "Chest imaging",
    "age": "58",
    "gender": "female",
    "diagnosis": "Silicosis with progressive massive fibrosis.",
    "history": "The patient was a worker in a glass manufacturing factory with known past history of cough and shortness of breath due to exposure to silica. She presented with shortness of breath which had increased during the past 15 days. No personal history of any alcohol consumption or cigarette smoking.",
    "image_finding": "CE-CT scan study of chest reveals presence of large symmetric bilateral opacities with irregular margins in right upper and middle lobe and left upper and middle lobe. These show presence of linear streaks originating from hila with presence of areas of calcification. Features are suggestive of progressive massive fibrosis.\n\nThe remaining lung shows ground glass opacities, interstitial thickening and cystic areas. There is volume loss in bilateral lungs.\n\nMediastinum shows presence of multiple enlarged lymph nodes with egg shell calcification in the pre and paratracheal, prevascular, aortopulmonary window, subcarinal regions and bilateral hila.",
    "discussion": "Pneumoconiosis may be classified on the clinicopathological basis as fibrotic (focal or diffuse) or nonfibrotic (minimal or no fibrosis). [1] The regional differences in lymphatic flow (gravity dependent, left side inclination of main pulmonary trunk, chest wall motion milking) result in poor clearance of particles from the posterior part of the right upper lung zone. This superoposterior predilection of dust retention has been described in CT studies. [2]\n\nThe radiographic and HRCT findings of silicosis and coal worker pneumoconiosis are similar to a large extent. The findings are well circumscribed nodules, often bilateral, small (usually 2-5 mm in diameter but with a range of about 1- 10 mm), involving mainly upper and posterior lung zones migrating towards the hilum. Small nodules indicate uncomplicated disease and large (i.e. > 1 cm) nodules indicate complicated disease such as progressive massive fibrosis (PMF).\n\nTwo clinical forms of the disease are seen - Acute and classic, with acute presenting as alveolar silicoproteinosis and classic as interstitial reticulonodular. Acute typically presents as pulmonary alveolar proteinosis as far as imaging is considered, as diffuse ground glass opacities (GGO) in the perihilar region with air bronchogram on plain chest radiograph. [3]\n\nBilateral centrilobular nodule with GGO, multifocal and patchy in appearance with consolidation indicates that intraalveolar collection of proteinaceous content has already taken place. [4] Sometimes interlobular septal thickening caused by fibrous tissue is seen. Tuberculosis and infection with atypical mycobacteria are frequent complications. [5] The simple form of classical silicosis on chest radiographs appears as well-defined multiple nodular opacities, varying from 1-10 mm in diameter. On CT, the most characteristic feature of simple silicosis is the presence of several small nodules of 2-5 mm in diameter, accompanied by calcification. [6]\n\nNodules in the complicated form of classic silicosis, also known as progressive massive fibrosis (PMF) are conglomerated large nodules with multiple foci of central hyalinised collagen. Opacities are large due to accumulation of nodules commonly in the middle zone and the most favourite location being the upper lobe. At thin-section CT, nodules are usually observed in centrilobular, paraseptal, and subpleural regions and have a perilymphatic distribution. [6]\n\nTeaching Points: 1. The radiographic and HRCT appearances of these diseases may not be distinguishable from each other and may be similar to sarcoidosis. 2. Observing coinfection with tuberculosis is to be kept in mind while reporting.",
    "differential_diagnosis": "Silicosis, with, progressive, massive, fibrosis., Sarcoidosis, Langerhans, cell, histiocytosis, Infection, (tuberculosis), Haematogenous, metastases",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014626/000001.jpg?itok=u8kvGgM8",
            "caption": "Multiple calcified lymph nodes noted in right paratracheal and bilateral hilar region.\r\nHomogeneous opacities noted in bilateral mid and lower zones due to pneumoconiosis (silicosis)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014626/000002.jpg?itok=9OTGuzFQ",
            "caption": "Large bilateral opacities with irregular margins in bilateral upper and mid lobes.\nMediastinum - Multiple enlarged lymph nodes with egg shell calcification in the pre and paratracheal, prevascular, subcarinal regions and bilateral hila."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014626/000003.jpg?itok=xFcEreHy",
            "caption": "Remaining lung shows groung glass opacities, interstitial thickening and cystic areas. There is volume loss in bilateral lungs."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Lymph nodes"
    ],
    "imaging_technique": [
      "Digital radiography",
      "CT",
      "CT-High Resolution"
    ],
    "link": "https://www.eurorad.org/case/14626",
    "time": "17.04.2018"
  },
  "14679": {
    "case_id": 14679,
    "title": "Solitary fibrous tumour of the chest wall: case report",
    "section": "Chest imaging",
    "age": "37",
    "gender": "male",
    "diagnosis": "Solitary fibrous tumour",
    "history": "A 37-year-old male patient presented with an enormous chest mass. It debuted with a slightly painful swelling which grew progressively in two years. It was initially developed in the left breast area and extended afterwards to the lateral aspect of the chest wall.",
    "image_finding": "Enhanced chest CT showed a well-circumscribed solid mass of the anterior and lateral left aspect of the chest wall extending to the abdominal wall. It had lobulated edges and heterogeneous enhancement. Small dots of calcifications were also found in the tumour. There was no bone lysis or intra-thoracic extension. MRI imaging revealed the precise location of the mass which lay above the latissimus dorsi, the serratus anterior and the external abdominal oblique muscle. No infiltration of surrounding structures was found. The tumour had the same signal as the muscles in T1-weighted imaging and high signal in T2-weighted imaging. Low signal areas in both T1 and T2-weighted imaging were also present. The tumour measured 28 x 20 x 10 cm and was heterogeneously enhanced. The diagnosis of solitary fibrous tumour was performed after extensive resection and histopathological analysis. Adjuvant radiotherapy was administrated. 12 months after surgery; the patient is alive with no sign of tumour recurrence.",
    "discussion": "Solitary fibrous tumors (SFT) are uncommon neoplasms of mesenchymal origin that can be benign or malignant [1]. They were first described in the pleura by Klemperer and Rabin in 1931 [2]. These tumors occur mostly in pleura, but a wide spectrum of extra-thoracic sites has been reported, such as the head and neck regions, the abdomen, retroperitoneum, pelvis, and the soft tissues of the extremities. [3] Extra-pleural malignant SFT, especially those arising from chest wall, represent an exceedingly rare subset of soft tissue neoplasms. They principally affect adults between the fourth and seventh decades of life with no sex predilection [3]. Clinically, it is a slow-growing, painless, well-delineated exophytic mass; large tumors can cause compression symptoms, while rarely they are the source of para-neoplastic syndromes (i.e. hypoglycemia secondary to insulin-like growth factor). [1]At ultrasound, SFT are typically hypoechoic, but occasionally, they are heterogeneous. This heterogeneity is likely to be due to areas of myxoid degeneration.[4]On CT scan SFT can be hypodense or hyperdense compared to muscles. The attenuation is likely to depend upon the amount of collagen content, thus, lesions with abundant collagen appear hyperdense. The presence or absence of calcifications is not necessarily a helpful distinguishing feature. In addition, there is considerable overlap in the type of enhancement at CT, during which 100% of malignant and 60% of benign SFT exhibit heterogeneous enhancement. [4]At MRI, SFT are usually isointense on T1-weighted images in regards to muscles and variable on T2-weighted images, having what has been described as a \u201cblack-and-white-mixed pattern [5]. The presence of rounded or linear low-intensity foci on both T1 and T2-weighted images is attributable to the collagen content, low cellularity, and associated reduced proton mobility. SFT also are vascular tumors that are vigorously enhancing. This combination of these features produces a chocolate chip cookie\u201d appearance, which can help in their diagnosis. [4]Histologically, SFT are composed of spindle cells within a background of collagen stroma, often in a whorled pattern or patternless [6]. They are highly vascular and have a propensity to undergo myxoid degeneration. The diagnosis is confirmed by characteristic positive immunohistochemical staining for CD34 and negative staining for S-100 [6].Radical surgical resection represents the gold standard of SFT treatment. There is no evidence of effectiveness of chemotherapic and/or radiotherapic adjuvant treatments [7].In our case, the CT-scan and MRI features were in accordance with a SFT. Surgical resection associated with adjuvant radiotherapy was considered conclusive.",
    "differential_diagnosis": "Solitary, fibrous, tumour, Sarcoma, Desmoid, tumour, Schwannoma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014679/000006.jpg?itok=LF9rwJwK",
            "caption": "MR images show an anterolateral left chest mass with isosignal T1-weighted image (a) in regards to muscles, hypersignal T2-weighted image (b), with low-signal-intensity areas and heterogeneous enhancement (c)."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014679/000007.jpg?itok=3g814Prn",
            "caption": "MR images show an anterolateral left chest mass with isosignal T1-weighted image (a) in regards to muscles, hypersignal T2-weighted image (b), with low-signal-intensity areas and heterogeneous enhancement (c)."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014679/000008.jpg?itok=MS2Ai2N3",
            "caption": "MR images show an anterolateral left chest mass with isosignal T1-weighted image (a) in regards to muscles, hypersignal T2-weighted image (b), with low-signal-intensity areas and heterogeneous enhancement (c)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014679/000009.jpg?itok=HNN3cRTR",
            "caption": "CT scan showing an enormous mass of the left chest wall with heterogeneous enhancement."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014679/000010.jpg?itok=xhd0Vr8m",
            "caption": "The mass contains small calcifications."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thoracic wall"
    ],
    "imaging_technique": [
      "MR",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/14679",
    "time": "11.05.2017"
  },
  "14684": {
    "case_id": 14684,
    "title": "Atypical presentation of pulmonary tuberculosis in an infant",
    "section": "Chest imaging",
    "age": "7",
    "gender": "male",
    "diagnosis": "Mass-forming pulmonary tuberculosis",
    "history": "7-month-old male patient admitted with sudden onset of dyspnoea. On examination, failure to thrive, mild respiratory distress, reduced air entry on the left side. No history of vomiting, feeding difficulty or fever. Past history was suggestive of recurrent episodes of coughing relieved with conservative medical treatment. History of preterm delivery.",
    "image_finding": "Supine chest radiograph shows hyperinflated left lung field. Ill-defined haziness in the left upper zone. Shifting of mediastinum towards the right side.CT chest plain scans shows fairly large ill-defined heterogeneous mass-forming lesion with multiple scattered lobular areas of faint calcifications involving the left lung upper lobe, the left hilum and infiltrating the superior and middle mediastinum (Fig. 2).On post-contrast study, the lesion shows heterogeneous enhancement with multiple non-enhancing hypodense areas in it. The lesion shows loss of fat planes with arch of aorta and its branches and is seen encasing the trachea (Fig. 4).The subcarinal component of the lesion shows infiltration of the wall of the left main bronchus causing bronchial stenosis and hyperinflation of the lingula and left lung lower lobe with resultant displacement of superior mediastinal structure including thymus towards the right side (Fig. 2, 3, 4).Ill-defined haziness is seen in the right perihilar region possibly due to hypoventilation (Fig. 4).CT guided tru cut biposy of the lesion was done (Fig. 5).",
    "discussion": "Tuberculosis remains an important cause of morbidity and mortality worldwide. Mainly as a result of the worsening HIV epidemic, homelessness, drug abuse and migration from developing countries, the problem of pulmonary tuberculosis in Western countries has markedly increased [1, 2]. Children represent one of the high-risk groups in the resurgence of this disease. Among children, those younger than 5 years are at the highest risk for pulmonary tuberculosis [3].Pulmonary tuberculosis in infants has some differences from that seen in older children; it is more symptomatic, and the risk of severe and life-threatening complications such as tuberculous meningitis or miliary tuberculosis is higher [3]. Therefore, early diagnosis and prompt treatment are very important for infants with tuberculosis. Bacteriologic confirmation of the disease in children is difficult, and in younger infants (< 3 months), the tuberculin skin test is frequently negative [5]. Therefore, chest radiographs and a history of direct contact with patients who have contagious tuberculosis play essential roles in diagnosing tuberculosis in infants. The importance of the role of radiologists cannot be overemphasized.Frequent radiologic findings of pulmonary tuberculosis of infants are mediastinal or hilar lymphadenopathy with central necrosis and air-space consolidations, especially mass-like consolidations with low-attenuation areas or cavities within consolidations. Disseminated pulmonary nodules and airway complications are also frequently detected in this age group. CT can be a useful diagnostic technique for infant tuberculosis, as it can show parenchymal lesions and tuberculous lymphadenopathy better than chest radiography (as in our case). CT scans can also be helpful when chest radiographs are inconclusive or complications of tuberculosis are suspected [5].CT scans can reveal lymphadenopathy, calcifications, bronchogenic nodules, and complications such as airway narrowing, emphysema and pleural effusion [4]. Our case is interesting as the paediatrician initially suspected a foreign body based on clinical presentation and referred for CT chest which showed a mass-forming lesion in the lung with subtle lobular areas of calcification without airbronchogram or cavitations and was infiltrating mediastinal structures (like a neoplastic lesion) leading to symptoms. So our primary differential were mediastinal germ cell tumour and mesenchymal tumour. But the tumour marker level came normal so CT-guided biopsy was performed, which revealed granulomatous inflammation with caseous necrosis, occasional acid fast bacilli. The patient is responding well to anti-tubercular therapy.This case cautions the clinicians and radiologists about the possibility of tuberculosis in considering the differential diagnosis of mass forming lung and mediastinal lesions especially in infants in those areas where tuberculosis is endemic.",
    "differential_diagnosis": "Mass-forming, pulmonary, tuberculosis, Germ, cell, tumour, Mesenchymal, tumour, Infections",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014684/000001.jpg?itok=RejLf5GT",
            "caption": "X-ray chest supine view shows hyperinflated left lung. Ill-defined haziness in left upper zone. Deviation of trachea on right side."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014684/000002.jpg?itok=xbBZv8OO",
            "caption": "Ill-defined soft tissue density lesion with scattered lobular areas of soft calcification seen involving left lung upper lobe and superior mediastinum with shifting of trachea on the right side."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014684/000003.jpg?itok=HWeDhfkR",
            "caption": "CT scan chest at subcarinal level shows mediastinal mass infiltrating the wall of the left main bronchus causing bronchial stenosis."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014684/000004.jpg?itok=UmsmyNAv",
            "caption": "Hyperinflated left lung with shifting of mediastinum on the right side."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014684/000005.jpg?itok=quVl53ZB",
            "caption": "Hyperinflated lingula and left lung lower lobe with left main bronchus stenosis."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014684/000006.jpg?itok=DktCk3b0",
            "caption": "Lesion shows heterogeneous enhancement with nonenhancing hypodense area in it. Mediastinal component of lesion is seen encasing vessels of arch of aorta and trachea. Changes of pneumonitis in right upper lobe."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014684/000007.jpg?itok=B8r-GArx",
            "caption": "Lesion is extending up to the subcarinal region, encasing the left main bronchus and involving the left hilum."
          },
          {
            "number": "Figure 4c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014684/000008.jpg?itok=ECdiuVgY",
            "caption": "Coronal reconstructed image shows mass lesion encasing left common carotid artery."
          },
          {
            "number": "Figure 4d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014684/000009.jpg?itok=6lTdbYi6",
            "caption": "Coronal reconstructed image shows heterogenous mass with non-enhancing areas in it. Lesion causes stenosis of left main bronchus."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014684/000010.jpg?itok=WemxQ009",
            "caption": "CT guided tru cut biopsy from mass lesion."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Respiratory system"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/14684",
    "time": "27.05.2017"
  },
  "14733": {
    "case_id": 14733,
    "title": "Dyspnea in apparently healthy patient: from diagnosis to risk factors",
    "section": "Chest imaging",
    "age": "30",
    "gender": "male",
    "diagnosis": "Pneumocystis Jirovecci Infection in an HIV patient.",
    "history": "30-year-old male patient, hashish smoker. The patient presented at the emergency department with odynophagia, cough and fever that had been present for 20 days. The physical exam was normal. The blood test showed leukocytosis and the gasometry, hypoxemia. A chest x-ray and CT angiography of pulmonary arteries were performed.",
    "image_finding": "A chest x-ray and CT angiography of pulmonary arteries were performed to rule out pulmonary embolism. Chest x-ray showed bilateral, reticular interstitial pattern (Figure 1). CT angiography was negative for pulmonary embolism. However, it showed bilateral \u201cground glass\u201d opacities and cystic images (Figure 2). Due to the worsening of the patient's clinical situation and the radiological findings, the patient was admitted to modify the therapeutic management and complete the study of his process. Finally, microbiological findings and positive HIV serology suggested that the radiological findings could be compatible with Pneumocystis jirovecii infection. Antibodies and antiretroviral therapy were initiated and the patient showed a good evolution. The pre-discharge chest x-ray was normal (Figure 3).",
    "discussion": "The respiratory tract is the most frequent site of infection in HIV-positive patients. Despite the use of antiretroviral therapy, Pneumocystis jirovecci (PJP) remains the most frequent causative agent [1]. The risk of developing such infection is influenced by the degree of immunosuppression. Clinically, it presents with a non-productive cough, dyspnea, fever and marked hypoxemia [2].Although the final diagnosis is confirmed by microbiological tests, imaging tests are especially helpful when there are no data indicating that the patient is immunocompromised or has other related risk factors. From the radiological point of view, the \u201cground glass\u201d pattern presents a wide differential diagnosis, which includes respiratory infections caused by opportunistic germs, chronic interstitial diseases, acute alveolar disorders such as acute pulmonary oedema or alveolar haemorrhage and other causes such as drug toxicity. However, its association with cystic images (present in our patient) is highly suggestive of infection by opportunistic germs such as PJP vs Cytomegalovirus [3]. Other radiological findings typical of this entity are the predominance in upper lobes, focal areas of consolidation or nodules. Infections by opportunistic germs are usually associated to immunocompromised patients. At first, our patient did not show this condition, but microbiological findings and positive HIV serology suggested that the radiological features could be compatible with PJP infection. For these reasons, we confirmed that there was a good correlation between clinical and radiological findings. The correct interpretation of radiological findings and their clinical correlation is very important [4][5]. In our case, CT was very helpful to suggest the diagnosis of PJP and this diagnosis influenced the clinical approach towards a search for underlying causes, HIV infection was diagnosed in an apparently healthy patient.",
    "differential_diagnosis": "Pneumocystis, Jirovecci, Infection, in, an, HIV, patient., Cytomegalovirus, infection, Chronic, interstitial, disease, Acute, alveolar, disorder, (pulmonary, oedema, or, alveolar, haemorrhage), Drug, toxicity",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014733/000001.jpg?itok=DetRXLm1",
            "caption": "Chest x-ray (PA and side) which showed bilateral, reticular opacities. It was performed at the emergency department (pre-treatment)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014733/000003.jpg?itok=XJ1Z40GX",
            "caption": "Ches x-ray post-treatment showed normal findings in both PA (panel A) and side (panel B) scans."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014733/000004.jpg?itok=I-lK3LRK",
            "caption": "Axial scans Thorax CT which show bilateral, diffuse,  \"ground-glass\" opacities and cystic images (orange arrows). These radiologic features are common in infections caused by opportunistic germs."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014733/000005.jpg?itok=MiCf6Cxy",
            "caption": "Axial scans Thorax CT which show bilateral, diffuse,  \"ground-glass\" opacities and cystic images (orange arrows). These radiologic features are common in infections caused by opportunistic germs."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014733/000006.jpg?itok=JO88kwOP",
            "caption": "Axial scans Thorax CT which show bilateral, diffuse,  \"ground-glass\" opacities and cystic images (orange arrows). These radiologic features are common in infections caused by opportunistic germs."
          },
          {
            "number": "Figure 3d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014733/000007.jpg?itok=ROCzk2Vg",
            "caption": "Axial scans Thorax CT which show bilateral, diffuse,  \"ground-glass\" opacities and cystic images (orange arrows). These radiologic features are common in infections caused by opportunistic germs."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax",
      "Lung"
    ],
    "imaging_technique": [
      "Digital radiography",
      "CT-High Resolution",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/14733",
    "time": "10.08.2017"
  },
  "14779": {
    "case_id": 14779,
    "title": "Ruptured Anterior mediastinal lymphangiom",
    "section": "Chest imaging",
    "age": "36",
    "gender": "male",
    "diagnosis": "Ruptured Anterior Mediastinal Lymphangioma",
    "history": "A 36-year-old male patient was brought to the casualty complaining of acute onset chest pain and dyspnea following a minor fall.",
    "image_finding": "A chest radiograph (Fig. 1) was obtained which revealed a moderate sized left pleural effusion and left paramediastinal opacity.\nFurther, the patient was evaluated with CECT thorax (Figs. 2a, 2b, 2c, ), which showed a lobulated septate anterior mediastinal cystic lesion located in the left paramedian region with adjacent lung parenchymal changes and left pleural effusion.\nFollowing the CT examination, the patient was taken to surgery and partial excision of the cystic lesion was done. Pathological examination confirmed the diagnosis of cavernous lymphangioma.",
    "discussion": "Background: Cysts account for approximately 20% of all mediastinal masses and occur in anterior, middle as well as in the posterior mediastinum. Those commonly encountered in the anterior mediastinum include pericardial cysts, thymic cysts, cystic teratoma, and lymphangioma [1].\nClinical perspective: Lymphangiomas represent less than 5% of these and occur in two forms. In infants, they present as cystic masses extending often from the neck into the mediastinum; whereas in adults, they are often confined to mediastinum which accounts for about 1% of mediastinal cystic lesions [1, 2].\nComplications are unlikely in occurrences with lymphangiomas; infection, haemorrhage, rupture and compression of mediastinal structures owing to large dimensions, being those occasions which bring these otherwise asymptomatic lesions to light [1, 3].\nImaging Perspective: Radiography reveals lymphangiomas to be well defined rounded or lobular masses which on CT demonstrate homogenous fluid attenuation with imperceptible walls and thin septations. Owing to the pliable nature, the lymphangiomas often mold to or envelop or insinuate between adjacent structures rather than displacing them [1, 3, 4].",
    "differential_diagnosis": "Ruptured, Anterior, Mediastinal, Lymphangioma, Pericardial, cyst, Thymic, cyst",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014779/000001.jpg?itok=fuAbkR5j",
            "caption": "Chest radiograph showing left pleural effusion and a left paramediastinal opacity obliterating the left cardiac margin, likely representing an anterior mediastinal mass"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014779/000002.jpg?itok=DUwZxi4A",
            "caption": "Axial section at the level of aortic arch showing anterior mediastinal cystic lesion with clear fluid density (0 to 10HU) contents and thin imperceptible walls located in the midline and left paramedian location"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014779/000003.jpg?itok=iW8b3lpC",
            "caption": "Axial section at the level of right pulmonary artery showing the cystic lesion insinuating into the mediastinum with subsegmental compression atelectasis of the adjacent lung and mild left pleural effusion"
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014779/000004.jpg?itok=6Bs0i3fM",
            "caption": "Axial section at the level of aortic root showing the anterior mediastinal cystic lesion closely apposing the cardiac margin and mild left pleural effusion of attenuation value 0 to 10HU"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Mediastinum"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/14779",
    "time": "06.07.2017"
  },
  "14791": {
    "case_id": 14791,
    "title": "Isolated unilateral absent pulmonary artery - A case report",
    "section": "Chest imaging",
    "age": "23",
    "gender": "female",
    "diagnosis": "Isolated unilateral absent pulmonary artery (IUAPA)",
    "history": "A 23-year-old female patient with complaints of chest pain and dyspnoea during exercise for one year, which did not respond well to treatment, was suspected for cardiovascular congenital abnormality and referred to radiology department of French Medical Institute for Mothers and Children for contrast-enhanced chest CT scan.",
    "image_finding": "Chest CT scan with IV contrast was performed for the patient. Dilatation of the right atrium was noted (Fig. 1). Dilated pulmonary trunk was seen compared to the ascending aorta in the axial mediastinal window (Fig. 2). MIP and colour LUT images showed absent left pulmonary artery with evidence of abrupt cut-off in proximal part while right pulmonary artery and its branches existed (Fig. 3a-d). Prominent enhanced vessels were noted along the left side of thoracic vertebrae and descending aorta representing collateral vessels (Fig. 4a-c). Volume-rendered images clearly showed absent left pulmonary artery and normal right pulmonary artery and its branches (Fig. 5a-b).",
    "discussion": "Isolated unilateral absent pulmonary artery (IUAPA) is a rare congenital anomaly. The broader category is UAPA which is accompanied by other congenital heart anomalies like tetralogy of Fallot, cardiac septal defects, coarctation of the aorta and sub-valvular aortic stenosis. The prevalence of UAPA is 1/200000 in population with no sex predilection [1]. The anomaly was diagnosed for the first time in 1868 [2]. Failure of migration and rotation of the sixth aortic arch segment results in absence of the pulmonary artery [1]. UAPA is commonly seen in the site of the chest opposite the aortic arch with only 2% occurring in the same site of the aortic arch [3] as it was in our case. The distal branches of the pulmonary artery remain intact by getting blood from collateral vessels of bronchial, internal mammary, subclavian, sub-diaphragmatic, intercostal and even coronary arteries [2-4]. The clinical features of UAPA are chest pain, pulmonary oedema, dyspnoea during exercise, haemoptysis, pleural effusion, recurrent pulmonary infection, bronchiectasis and even death which is usually caused by severe pulmonary haemorrhage, right side heart failure and respiratory failure. Some of the cases are asymptomatic and detected incidentally [3-5]. One of the consequences of UAPA is pulmonary hypertension. Haemoptysis is another complication which can be serious sometimes, due to unusual high pressure in the collateral vessels [6]. The findings in a chest X-ray are asymmetric lung fields with absent or diminished hilar vasculature, shifting of mediastinum towards the affected hemithorax and elevation of the hemidiaphragm in the affected side [1-5]. The definitive diagnosis of UAPA can be made by angiography, chest CT, MRI, echocardiography and nuclear imaging. Ventilation perfusion scan can be done to differentiate the pulmonary hypertension of IUAPA from chronic thromboembolic pulmonary hypertension [1- 7]. Different treatment strategies exist, such as surgical, pharmacological and behavioural management. In recurrent haemoptysis, pulmonary infection and pulmonary hypertension pneumonectomy and surgical revascularisations are done. Selective embolisation of bronchial or non-bronchial systemic arteries is suitable for patients with massive haemoptysis who are not eligible for surgery. Pharmacological treatment is for patients not tolerating the revascularisation surgery or those who don\u2019t improve after surgery [8]. Our patient got medical treatment and advice. In conclusion, UAPA is a rare congenital problem that is usually diagnosed in adolescent and adult population and clinicians should keep in mind the possibility of undiagnosed cases.",
    "differential_diagnosis": "Isolated, unilateral, absent, pulmonary, artery, (IUAPA), Primary, pulmonary, hypertension, Swyer-James-McLeod, syndrome, Pulmonary, emboli, Chronic, thromboembolic, pulmonary, hypertension",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014791/000002.png?itok=oXehzdCs",
            "caption": "The axial section of chest CT in in mediastinal window demonstrates dilatation of the right chambers of the heart prominently in the right atrium."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014791/000004.png?itok=llIH9-qz",
            "caption": "Axial section of chest in mediastinal window demonstrates dilated pulmonary trunk compared to the ascending aorta."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014791/000007.png?itok=gwQwWd_O",
            "caption": "Coronal CT image shows collateral vessels along the left side of thoracic vertebrae and descending aorta."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014791/000008.png?itok=snmA0e5Z",
            "caption": "Sagittal CT image shows collateral vessels along the left side of thoracic vertebrae and descending aorta."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014791/000015.png?itok=qNHWj7dC",
            "caption": "Coronal MIP image shows collateral branches with no pulmonary arterial branches in the left side while normal enhancement of right pulmonary vessels are noted in the right hemithorax."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014791/000009.png?itok=6fHcq2Js",
            "caption": "The CT enhanced MIP section in coronal plane demonstrates dilated pulmonary trunk with normal enhancement of right pulmonary artery but evidence of abrupt cut-off in proximal part of left pulmonary artery."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014791/000010.png?itok=Ajepk1eW",
            "caption": "The CT colour LUT image in coronal plane shows dilated pulmonary trunk with normal right pulmonary artery but abrupt cut-off of left pulmonary artery."
          },
          {
            "number": "Figure 4c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014791/000011.png?itok=Ut0PFwCh",
            "caption": "The CT enhanced MIP section in axial plane demonstrates dilated pulmonary trunk with normal enhancement of right pulmonary artery but evidence of abrupt cut-off in proximal part of left pulmonary artery."
          },
          {
            "number": "Figure 4d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014791/000016.png?itok=tB_p9Z1W",
            "caption": "Sagittal MIP images  demonstrate normal right pulmonary vessels enhancement (right image) and no enhancement of the left pulmonary vessels with abrupt cut-off of left  main pulmonary artery (left image)."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014791/000012.png?itok=U6RzKsV_",
            "caption": "Volume-rendered image in anterior view clearly demonstrates absent left pulmonary artery with normal right pulmonary vasculature."
          },
          {
            "number": "Figure 5b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014791/000014.png?itok=Ay-LhXUa",
            "caption": "Left lateral volume-rendered image shows absent left pulmonary artery with abrupt cutoff, however, normal right pulmonary artery and its branches are normally seen."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Cardiovascular system",
      "Pulmonary vessels",
      "Salivary glands",
      "Vascular",
      "Lung"
    ],
    "imaging_technique": [
      "CT",
      "CT-Angiography"
    ],
    "link": "https://www.eurorad.org/case/14791",
    "time": "10.07.2017"
  },
  "14838": {
    "case_id": 14838,
    "title": "Sarcoidosis stage 2",
    "section": "Chest imaging",
    "age": "45",
    "gender": "male",
    "diagnosis": "Stage 2 sarcoidosis",
    "history": "A 45-year-old man was admitted to the hospital with one-year history of dry, non-resolving cough and fever. Chest radiograph (Fig. 1) was performed followed by thoracic CT scan (Fig. 2) and EBUS (Endobronchial Ultrasound) biopsy. Histopathology was positive for non-necrotic epithelial granulomas.",
    "image_finding": "Chest radiograph (Fig. 1) revealed diffused, multiple small nodular opacities predominantly located in the upper lung lobes. There was a moderate bilateral hilar lymphadenopathy. CT scan (Fig. 2) showed bilateral hilar, lymph node enlargement. There were numerous well-defined small nodules predominantly seen in a perilymphatic distribution in the upper and middle lung zones. Locally they tended to coalesce together forming consolidations, primarily in both upper and middle lung zones.",
    "discussion": "Sarcoidosis is a granulomatous multisystem disease of unknown aetiology. Even though non-necrotising granulomas characteristic for this disease may be present in any organ, thoracic involvement is most common and is responsible for most of morbidity and mortality. [1]Sarcoidosis can manifest in highly characteristic manner as a Lofgren\u2019s or Heerfordt\u2019s syndrome; however, in most cases initial symptoms are non-specific or even absent at all. Incidental abnormal chest radiograph is not an uncommon first finding. [2]Most common chest radiograph findings include hilar and mediastinal lymphadenopathy followed by interstitial lung disease. Pattern of chest radiological abnormalities is a basis for classic sarcoidosis classification. (Fig. 3) [3]Stage 2, observed in 25-30% of first time presenting patients, is described as a hilar and mediastinal lymph node enlargement associated with pulmonary abnormalities. Lymphadenopathy pattern is similar to that of stage 1 disease (Fig. 4), where 85-90% patients have symmetric, bilateral, well-defined, enlarged hilar lymph nodes. In 75% of cases mediastinal lyphadenopathy is also present. [4]Small nodules are the most common parenchymal changes, present in approximately 75-90% of patients. Although these lesions are predominantly found in the upper and middle lung zones, they can also occur in the lower lung zones. Nodules are primarily seen in peribronchovascular and supleural localisation, less frequently in the interlobular septa. In rare cases of patients with extensive disease, micronodules can appear to be randomly distributed. Even though they are initially individual lesions, they can coalesce over time forming larger entities. Such changes, observed in 15-25% of patients, take appearance of irregular consolidation measuring 1-4 cm. They can have airbronchogram and in solitary cases cavitate - which should raise question of fungal or mycobacterial infection. On periphery of consolidation individual small nodules can be spotted - an image named \u201cgalaxy sign\u201d. Even though these consolidations are commonly called \u201calveolar sarcoidosis\u201d, in fact they are the result of numerous interstitial micronodules coalescing together. [5]Airway abnormalities are relatively common in sarcoidosis, observed in 65% of patients. Most common manifestation is bronchial wall thickening and small endobronchial lesions. Hardly ever they lead to lobar or segmental atelectasis. [4]Pleural involvement is uncommon, it can present as a pleural thickening or pleural effusion. Effusions are typically minimal and usually resolve spontaneously in 2-3 months. However, there have been singular reports of massive pleural effusions. [5] Take home messageSmall nodules in perilymphatic distribution in association with symmetric bilateral hilar lymphadenopathy is a classic appearance of stage 2 sarcoidosis.Alveolar sarcoidosis is a term describing coalescing interstitial small nodules.",
    "differential_diagnosis": "Stage, 2, sarcoidosis, Infectious:, Tuberculosis, Mycoplasmosis, Histoplasmosis, Blastomycosis, Coccidiomycosis, Cat, scratch, disease, Malignancy:, Lymphangiosis, carcinomatosa, Lymphoma, Cancer, Inorganic, dust, diseases:, Berylosis, Silicosis, Other:, Hypersensivity, pneumonitis, Drug, reactions, Amyloidosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014838/000001.jpg?itok=EY_Xgp7b",
            "caption": "There is a moderate bilateral hilar lymphadenopathy. There are diffused, multiple small nodular opacities predominantly located in the upper lung lobes"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014838/000002.jpg?itok=buSPOSOT",
            "caption": "There is a moderate bilateral hilar lymphadenopathy. There are diffused, multiple small nodular opacities predominantly located in the upper lung lobes"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014838/000003.jpg?itok=fzvfK6bH",
            "caption": "Mediastinal window axial scan. There is hilar node enlargement. There are  disseminated small pulmonary consolidations."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014838/000004.jpg?itok=ej_gJWRM",
            "caption": "Pulmonary window axial scan. There are multiple small, well-defined nodules presenting perilymphatic distribution. They locally coalesce together forming bigger consolidations. Galaxy sign can be seen."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014838/000005.jpg?itok=m76qRWCq",
            "caption": "Pulmonary window coronal reconstruction. There are multiple small, well-defined nodules primarily seen in upper and middle lung zones. Locally they coalesce together forming bigger consolidations."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014838/000006.jpg?itok=Z_UlYtCV",
            "caption": "Sarcoidosis staging on the basis of the chest radiograph"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014838/000007.jpg?itok=R3caq-yj",
            "caption": "1) Hilar lymph nodes 95% 2) Right superior mediastinal (paratracheal) lymph nodes 75% 3) Left superior mediastinal (aortopulmonary window) lymph nodes 50% 4) Subcarinal lymph nodes 20%"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Mediastinum",
      "Lymph nodes"
    ],
    "imaging_technique": [
      "Digital radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/14838",
    "time": "06.07.2017"
  },
  "14847": {
    "case_id": 14847,
    "title": "Pulmonary Nocardiosis - a case report",
    "section": "Chest imaging",
    "age": "63",
    "gender": "male",
    "diagnosis": "Pulmonary nocardiosis",
    "history": "A 63-year-old male patient presented to the outpatient department with history of low-grade fever, cough and mild dyspnoea for one week. Diagnosed case of dermatomyositis on immunosuppressants for a few months.",
    "image_finding": "Chest radiograph: A region of wedge-shaped consolidation with internal cystic lucencies in left upper zone. Also patchy consolidation noted in left retrocardiac region and mild peribronchial thickening in left lower zone.HRCT (high resolution computed tomography) chest: A (5.1 x 3.4 x 4.5 cm) relatively well-defined mass-like consolidation with internal ill-defined small cavities and an ill-defined halo of ground glass opacity noted in the subpleural aspect of anterior segment of left upper lobe. Focal mass-like consolidation and ill-defined consolidation with adjacent ground glass opacities and fine interstitial septal thickening in the posterior basal segments of bilateral lower lobes. No lymphadenopathy.",
    "discussion": "BACKGROUND: Pulmonary involvement is the most common manifestation of nocardiosis [3]. It is caused by Nocardia species which is a gram positive, weakly acid-fast positive bacteria found in soil [1]. It is an uncommon opportunistic infection commonly occurring in immunocompromised subjects like HIV/AIDS, organ transplant, steroid therapy and uncommonly in immunocompetent subjects as well [4]. CLINICAL PERSPECTIVE: Clinical features are non-specific, which ranges from acute pulmonary disease to disseminated disease course [1]. Common pulmonary symptoms include cough, dyspnoea, chest pain, fever etc. Complications like empyema, chest wall extension of the pulmonary disease are uncommon. Imaging (chest radiograph, HRCT chest) is advocated in cases where the symptoms are not amenable to resolution by the empirical antibiotic therapy and worsening clinical picture. IMAGING PERSPECTIVE: Usually chest radiography is the first modality offered, whereas high resolution CT (HRCT) chest is performed later on when the radiographic findings are progressing and clinical picture is not improving. Radiological findings in pulmonary nocardiosis are usually non-specific, which include nodules, consolidation, cavitation, septal thickening, ground glass opacity, crazy paving etc. [2]. Cavitation is usually observed in immunocompromised cases. Usually there is no lymphadenopathy. Thus microbiological analysis is imperative for confirmation of Nocardia infection using samples like sputum, bronchoalveolar lavage (BAL) to isolate the microorganism [4]. OUTCOME: Usually medical management is done with antibiotics like sulfonamides, cotrimoxazole. This may be complemented by the temporary cessation of the immunosuppressive therapy. However surgical intervention is needed for drainage of empyema, chest wall abscess. Prognosis depends on the immune status of the patient, extent of systemic involvement with disseminated infections carrying poor prognosis, effectiveness of antibiotic treatment [1]. Improvement in the imaging findings on follow up is usually resonated in the clinical status of the patient suggesting adequate treatment. TAKE HOME MESSAGE: - Pulmonary Nocardiosis is a rare manifestation and should always be considered as one of the differential diagnoses in cases of immunocompromised subjects presenting with respiratory complaints. - Imaging is usually non-specific, therefore microbiological analysis is most important.",
    "differential_diagnosis": "Pulmonary, nocardiosis, Tuberculosis, Actinomycosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014847/000001.jpg?itok=VqJsRmA0",
            "caption": "Frontal chest radiograph shows wedge-shaped consolidation with internal cystic lucencies in left upper zone. Also patchy consolidation noted in left retrocardiac region and mild peribronchial thickening in left lower zone."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014847/000002.jpg?itok=2IZ_YXMq",
            "caption": "Axial HRCT chest demonstrates mass-like consolidation with internal small cavities and an ill-defined halo of ground glass opacity in the subpleural aspect of anterior segment of left upper lobe."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014847/000003.jpg?itok=SxZ_IZKB",
            "caption": "Coronal HRCT chest demonstrates mass-like consolidation with internal small cavities and an ill-defined halo of ground glass opacity in the left upper lobe."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014847/000004.jpg?itok=QyC-Peqw",
            "caption": "Axial HRCT chest demonstrates right focal mass-like consolidation and left ill-defined consolidation with adjacent ground glass opacities and fine interstitial septal thickening in the posterior basal segments of bilateral lower lobes."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Respiratory system"
    ],
    "imaging_technique": [
      "CT-High Resolution"
    ],
    "link": "https://www.eurorad.org/case/14847",
    "time": "15.07.2017"
  },
  "14858": {
    "case_id": 14858,
    "title": "The vanishing azygos vein",
    "section": "Chest imaging",
    "age": "62",
    "gender": "female",
    "diagnosis": "Luxation of the azygos lobe following pneumothorax",
    "history": "The here presented patient is a 66-year-old woman with a history of severe chronic obstructive pulmonary disease, candidate for lung transplantation. Pre-interventional assessment included chest radiography and CT that showed multiple nodules, warranting CT-guided biopsy. Following biopsy the patient developed a pneumothorax, necessitating thoracostomy tube placement.",
    "image_finding": "The initial chest radiograph (Fig. 1a) and CT (Fig. 1b) showed a typical variant azygos fissure with a teardrop-shaped opacity at its lower end (Fig. 1a), corresponding to the laterally and intrapulmonary displaced arch of the azygos vein. Following needle biopsy of a right upper lobe lung nodule (Fig. 1c), a pneumothorax occurred (Fig. 2), with partial collapse of the right lung and caudal displacement of the azygos lobe. The follow-up images after placement of a right-sided chest tube documented rapid resorption of the pneumothorax and reexpansion of the right upper lobe, including the azygos lobe. However, the azygos lobe reexpanded laterally to the arch of the azygos vein, resulting in an empty azygos fissure on the radiograph, without the typical teardrop-shaped opacity at its caudal end (Fig. 3a). CT confirmed the displacement of the arch of the azygos vein, now adjacent to the right mediastinal wall (Fig. 3b).",
    "discussion": "The azygos lobe is an anatomic variant with an incidence of 0.4-1.2% [1-4]. During fetal development, the right posterior cardinal vein, precursor of the upper segment of the azygos vein, does not migrate over the right lung's apex to its normal paratracheal position, but rather penetrates into the right upper lobe's apical segment [5, 6]. Two layers of parietal and visceral pleura form the azygos fissure (mesoazygos) extending cranially to the displaced vein. Contrarily, fissures between ordinary lung lobes are covered by two sheaths of visceral pleura only. The azygos fissure delineates laterally the so-called azygos lobe, without independent bronchovascular tree segments, not a lung lobe in the strict sense [7]. The azygos lobe is a benign and asymptomatic anatomic variant. Due to its sagittal orientation, the azygos fissure is perceptible on frontal radiographs as a thin line, similar to the small fissure. The azygos vein is seen end on at its lower end as a teardrop-shaped opacity. At the upper end of the fissure, a triangular opacity (trigone) represents a pleural reflection towards the chest wall [2]. The Boyden classification differentiates between three types of azygos lobes, A, B and C, depending on the length of the mesoazyos [8]. In type A, the trigone is situated on the lateral aspect of the pulmonary apex, in type B at its midpoint, and in type C even more medially. In cases of pneumothoraces the azygos lobe may disappear from its usual location medial to the azygos fissure, and displace it medially after reexpansion, leaving an empty azygos fissure now composed of visceral pleural only. Other causes for lateral luxation of the azygos lobe are increased intrathroacic pressure (cough, vomiting), vertebral collapse [9], fibrosis [6], and pleural effusion [10]. A short mesoazygos predisposes to azygos lobe luxation [4]. Following azygos lobe luxation, the fissure may disappear [6)]. Some conditions may mimic an azygos fissure, such as lung scars, or the wall of a dilated oesophagus [10]. The azygos vein's arch should be searched for if an azygos fissure is suspected. Discovery of an empty azygos lobe may indicate a former pneumothorax having occurred unnoticed, but the finding has no functional repercussion. Azygos lobe anatomy is important in biopsy or surgical planning (upper lobe resection, bullectomy) to avoid any unnecessary complications [4, 9, 11].In conclusion, the azygos lobe is a benign variant adjacent to an azygos fissure. The fissure may remain empty after a pneumothorax.",
    "differential_diagnosis": "Luxation, of, the, azygos, lobe, following, pneumothorax, Lung, scar, Bandlike, atelectasis, Right, oesophageal, wall, in, oesophageal, dilation",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014858/000023.jpg?itok=g4uNtBxF",
            "caption": ""
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014858/000013.jpg?itok=xHC1B4Yv",
            "caption": "Axial image of contrast-enhanced CT scan shows azygos vein coursing postero-anteriorly through the lowermost portion of the fissure (arrow)."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014858/000014.jpg?itok=ukzMgalq",
            "caption": "Nodule of the right upper lobe to be biopsied (arrow). The azygos fissure can be seen (arrowhead), separating the azygos lobe from the rest of the right upper lobe."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014858/000015.jpg?itok=dYSkjsPq",
            "caption": "Axial non-enhanced CT image shows right pneumothorax following fine needle biopsy. The azygos vein is now freely exposed, covered only by parietal pleura (arrowhead), whereas the azygos scissure is empty (arrow)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014858/000024.jpg?itok=Gq1dfgIr",
            "caption": "Radiograph after chest tube placement shows reexpansion of the right lung, including the azygos lobe. The arch of the azygos vein is medially displaced in a paramediastinal position (not seen), the azygos fissure empty (arrow)."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014858/000025.jpg?itok=uqTEzlGM",
            "caption": "CT image after chest tube placement and reexpansion of right lung. The azygos lobe displaces the azygos vein now medially (arrowhead), the azygos fissure (arrow) remains empty. Note small residual pneumothorax."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/14858",
    "time": "31.07.2017"
  },
  "14900": {
    "case_id": 14900,
    "title": "Achalasia mimicking large paraesophageal hiatal herni",
    "section": "Chest imaging",
    "age": "67",
    "gender": "male",
    "diagnosis": "Achalasia",
    "history": "An outpatient was referred for an oesophagram (barium swallow) because of worsening symptoms including reflux, daily vomiting, meal-related pain, and weight loss. Relevant medical history with onset ten years ago included reflux and aspiration pneumonias. Dysphagia had only recently been described in his medical chart.",
    "image_finding": "The oesophagram shows a straight, centrally located and moderately dilated oesophagus with tertiary contractions (Fig. 1-3). There is unimpeded contrast passage into a spherical intrathoracic cavity with an air/fluid/contrast level (Fig. 2-5), located above the diaphragm to the right. Contrast moves swiftly to the intra-abdominally located ventricle (Fig. 2-4). The measurements of the cavity are stationary compared to the only previous oesophagram five years ago. Due to slow passage from ventricle to duodenum, an image was recorded 1 hour post contrast (HPC, Fig. 6). This shows contrast retention within the intrathoracic cavity, and normal passage from ventricle to duodenum. The description concluded with para-oesophageal hiatal hernia with reduced passage to the ventricle, severe passive reflux in recumbent position (Fig. 7), and tertiary oesophageal contractions.CT-examinations and chest X-rays (Fig. 8-10) also concluded with hiatal hernia. Manometry showed mixed peristalsis, and gastroscopy at symptom onset found undigested food in an intrathoracic cavity.",
    "discussion": "Based on symptoms and imaging findings, the patient was referred to subacute laparoscopic operation for para-oesophageal hernia. Surprisingly, during surgery the entire ventricle was found intra-abdominally, thus refuting the diagnosis. Instead, the lower oesophageal sphincter (LES) was found severely stenotic in the midst of the cavity. A diverticulum was considered, but disproved by a simultaneously performed gastroscopy. Hence, the diagnosis of achalasia was reached perioperatively. A thorough read through the patient chart revealed that biopsies were taken from abnormal mucosa in what was believed to be a para-oesophageal hiatal hernia during onset of symptoms. The biopsies consisted of oesophageal mucosal and muscular layers, and specified the absence of cylindrical epithelium otherwise expected to be found in ventricular mucosa. Primary achalasia is a progressive motility disorder of the oesophagus, characterised by abnormal or absent peristalsis, and insufficient relaxation of the LES due to a loss of inhibitory innervation of smooth muscle [1]. The incidence is 1 per 100 000, and the prevalence is 10 per 100 000 [2]. The aetiology remains unknown, although auto-antibodies have been detected which supports the hypothesis of an autoimmune component [3].Clinically, the cardinal symptom of achalasia is dysphagia for solids and liquids. It also presents with regurgitation or vomiting of undigested food, and occasionally chest discomfort and weight loss. Symptoms are initially mild and intermittent, but progress in severity and frequency [1, 4]. Complications include aspiration pneumonia and the feared albeit rare oesophageal squamous cell carcinoma. The latter has a low absolute risk with a yearly incidence rate of 0.34%, but a high relative risk with a hazard ratio of 28 [5].Manometry is the golden standard among diagnostic tests, and is used to detect increased pressure over LES. It usually relies on support from an oesophagram where typical imaging findings include \"bird beak\"-configuration of the distal oesophagus, dilated oesophagus, tertiary contractions and failure of normal peristalsis in supine position, resulting in contrast retention. Gastroscopy can show a dilated oesophagus with retention of content [1, 4].There is no cure for achalasia, only symptomatic treatment which often needs to be repeated [1]. This patient awaits a laparoscopic Heller myotomy. Meanwhile, botox injections give immediate but temporary relief of symptoms [4]. Clinical signs of achalasia can overlap with reflux and hiatal hernia [1]. The purpose of this clinical case is to focus on the atypical presentations of achalasia on oesophagrams. Food regurgitation, dilated oesophagus with contrast retention and tertiary contractions should always lead us to consider achalasia.",
    "differential_diagnosis": "Achalasia, Hiatal, hernia, Epiphrenic, diverticulum, Oesophageal, cancer, Ventricular, cancer",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014900/000001.jpg?itok=e-TbyoD-",
            "caption": "Supine position, AP view, 1 HPC."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014900/000002.jpg?itok=sKb1RuiH",
            "caption": "Right recumbent position, lateral view, 10 MPC."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014900/000003.jpg?itok=jlA1vUew",
            "caption": "Standing position, lateral view."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014900/000004.jpg?itok=XEAoj95a",
            "caption": "Standing position, AP view."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014900/000005.jpg?itok=y2aBYVAT",
            "caption": "Standing position, AP view, 1 minute past contrast (MPC)."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014900/000006.jpg?itok=iTzcE3Hd",
            "caption": "Standing position, lateral view, 2 MPC."
          }
        ]
      },
      {
        "number": "Figure 7",
        "subfigures": [
          {
            "number": "Figure 7",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014900/000007.jpg?itok=ZZddMOy8",
            "caption": "Standing position, AP view."
          }
        ]
      },
      {
        "number": "Figure 8",
        "subfigures": [
          {
            "number": "Figure 8",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014900/000008.jpg?itok=eZiCvF_L",
            "caption": "Standing position, AP view, showing intrathoracic cavity with air/fluid level, interpreted as hiatal hernia."
          }
        ]
      },
      {
        "number": "Figure 9",
        "subfigures": [
          {
            "number": "Figure 9",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014900/000009.jpg?itok=k2HAePDL",
            "caption": "Dilated oesophagus (arrows) and intrathoracic cavity to the right."
          }
        ]
      },
      {
        "number": "Figure 10",
        "subfigures": [
          {
            "number": "Figure 10",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014900/000010.jpg?itok=8NpdSpFQ",
            "caption": "Intrathoracic cavity (arrows), believed to be hiatal hernia, but proved to be dilated oesophagus due to achalasia."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Gastrointestinal tract",
      "Oesophagus"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "Fluoroscopy",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/14900",
    "time": "10.10.2017"
  },
  "14923": {
    "case_id": 14923,
    "title": "Giant solitary fibrous tumour of the ple",
    "section": "Chest imaging",
    "age": "35",
    "gender": "female",
    "diagnosis": "The mass was resected and pathologic examination revealed a solitary fibrous tumour of the pleura.",
    "history": "A 35-year-old asymptomatic woman was referred for a Chest Radiograph (CR) due to a suspected anomaly found incidentally in a previous CR while abroad.",
    "image_finding": "Contrast-enhanced CT was performed revealing a large and lobulated solid soft-tissue mass, occupying almost two thirds of the right hemithorax, with arterial phase heterogeneous enhancement and progressively more intense centripetal enhancement in the venous phase (Fig. 2). The mass displaced the diaphragm inferiorly and the mediastinum to the left, maintaining strict contact with the latter. Because infiltrative growth into mediastinal structures could not be discarded, MRI was performed (Fig. 3), showing low overall signal in both T1 and T2, suggestive of fibrous component. Diffusion-weighed MRI showed little diffusion restriction, indicative of a probably benign lesion. There were no signs of invasion of mediastinal structures.",
    "discussion": "Solitary Fibrous Tumours of the Pleura (SFTP) are rare mesenchymal tumours accounting for <5% of all pleural tumours [1], usually discovered incidentally and with generally benign behaviour. Only around 12% are malignant [2].Around 800 cases of such tumour types have been reported [2]. Affecting males and females equally, the highest incidence is between 60 and 70 years of age [2].Recent findings have suggested that SFPT may arise from perivascular multipotent mesenchymal elements displaying features akin to pericytes and submesothelial fibroblasts [3]. SFTP most commonly develop in the lower part of the pleural cavity, specifically from the visceral pleura in around 80% [2]. Even though there is no specific size threshold for a SFTP to be considered \"giant\", existing literature is consistent with this terminology when describing tumours larger than 10cm [2, 4]. Initially they are usually asymptomatic but may cause chest pain, cough and dyspnoea as they grow due to increased pressure on surrounding structures. Rarely may they compress mediastinal structures. Diagnostic radiology plays an important role in the study of SFTP since many are found incidentally in routine chest radiographs. A CT scan can provide further valuable information regarding the location of SFTP, its relation to surrounding structures, tumour homogeneity/heterogeneity or potential bleeding or necrotic areas [2]. Nevertheless, CT alone cannot differentiate between a benign and a malignant SFTP. As the tumour grows, the likelihood of malignancy also increases, as does its heterogeneity, with increasingly undefined cleavage planes with surrounding structures. MRI or angiography are often performed to evaluate tumour infiltration into mediastinal structures and to evaluate feeding arteries, respectively. Resection is generally considered curative [2]. Neoadjuvant therapy is not indicated since the biological potential of SFTP is rarely histologically confirmed preoperatively [2]. After tumour resection, in histologically proven tumours adjuvant therapy may be indicated [2].",
    "differential_diagnosis": "The, mass, was, resected, and, pathologic, examination, revealed, a, solitary, fibrous, tumour, of, the, pleura., Sarcomatoid, mesothelioma, Primary/metastatic, spindle, cell, carcinoma, Spindle, cell, melanoma, Other, primary/metastatic, soft, tissue, noeplasms",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014923/000010.png?itok=wS7P_04V",
            "caption": "Chest Radiograph (CR) PA view showing a well-defined, rounded mass occupying the lower half of the right hemithorax."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014923/000013.png?itok=lsY4iZFQ",
            "caption": "A. Axial view T1 and B. Coronal view T2-weighed MR showing overall low signal with areas of high signal in T2 suggestive of areas of necrosis/myxoid degeneration."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014923/000014.png?itok=gX4JDDWL",
            "caption": "A. Axial view T1 and B. Coronal view T2-weighed MR showing overall low signal with areas of high signal in T2 suggestive of areas of necrosis/myxoid degeneration."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014923/000017.jpg?itok=7IuGSGOC",
            "caption": "Arterial phase contrast-enhanced CT (axial view)"
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014923/000016.jpg?itok=tPNk2ZYM",
            "caption": "Venous phase contrast-enhanced CT (coronal view)"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax",
      "Thoracic wall"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT",
      "MR"
    ],
    "link": "https://www.eurorad.org/case/14923",
    "time": "22.08.2017"
  },
  "14941": {
    "case_id": 14941,
    "title": "Idiopathic pulmonary haemosiderosis",
    "section": "Chest imaging",
    "age": "6",
    "gender": "female",
    "diagnosis": "Idiopathic pulmonary haemosiderosis.",
    "history": "A 6-year-old African American female patient presented with a 3-week history of cough unresponsive to treatment with antibiotics. The patient was born prematurely at 28 weeks and was below the 5th percentile for height and weight at presentation. She has a history of gastro-esophageal reflux disease, aspiration, and recurrent colds.",
    "image_finding": "A frontal chest radiograph (Fig.1) demonstrates bilateral middle and lower lung predominant airspace opacities. Non-contrasted axial CT-images (Fig. 2) obtained a few days later demonstrated multifocal ground glass opacities with denser areas of airspace consolidation scattered throughout the bilateral lungs.",
    "discussion": "Background:\nIdiopathic Pulmonary Haemosiderosis (IPH) is a rare condition in which the patient suffers from recurrent episodes of diffuse alveolar haemorrhage of unknown aetiology [1]. The pulmonary system responds to haemorrhage via activation of alveolar macrophages. These specialised macrophages phagocytose erythrocytes at a rate six times slower than systemic macrophages [2]. This reduced ability to metabolise the haemorrhaged blood ultimately leads to a build-up of haemosiderin [2].\n\nClinical Perspective:\nThe pulmonary haemorrhage of IPH gives rise to the symptoms commonly seen in this condition. The clinical course is defined by unpredictable alternations between acute and chronic phases. In the acute phase, alveolar haemorrhage presents as dyspnoea, cough and haemoptysis and is sometimes referred to as an IPH exacerbation. Patients in the chronic phase have similar but slowly resolving symptoms [1].\n\nThis patient suffered from all symptoms except for haemoptysis. Imaging is ordered as a non-invasive means of discovering whether the symptom profile is derived from bleeding within the lung tissue [3]. Serology is used in order to exclude autoimmunity, vasculitides, and other potential causes [1]. Pathology is used to confirm the diagnosis of IPH [1].\n\nImaging Perspective:\nThoracic radiographs are ordered to evaluate for lung opacities that may indicate pulmonary haemorrhage [3]. A thoracic CT is ordered to better characterise and localise the suspected bleed [3]. CT shows ground glass opacities often predominating in the lower lobes [3]. Imaging is paramount to reaching the diagnosis of IPH because it rules out causes of haemorrhage apparent on imaging and allows the surgeon to target the correct pathologic sites for bronchoalveolar lavage (BAL) and peripheral wedge biopsy. The BAL revealed haemosiderin-laden macrophages. The open lung biopsy also showed haemosiderin-laden macrophages with minimal lymphocytic infiltrate and scattered alveolar wall fibrosis. Serologic testing was negative.\n\nOutcome:\nIPH is commonly treated with glucocorticoids plus or minus addition of immunosuppressants [4]. She was given oral prednisone and iron supplementation and nutritional advice for the anaemia and low weight, albuterol and fluticasone for asthma, omeprazole for her GERD. The rarity of IPH makes the prognosis difficult to determine although it is believed that children suffer a more aggressive course compared to adults [5]. In conclusion, this patient presented at the peak incidence of childhood with all 3 of the key symptoms of IPH, serology was negative, and pathology confirmed the diagnosis. The patient is doing well with treatment 10 years after diagnosis.",
    "differential_diagnosis": "Idiopathic, pulmonary, haemosiderosis., Mitral, stenosis, Polyarteritis, nodosa, Systemic, lupus, erythemotosus, Systemic, vasculitis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014941/000001.png?itok=qLgV1OE0",
            "caption": "Frontal chest radiograph demonstrates bilateral airspace opacities predominantly within the mid and lower lungs."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014941/000002.jpg?itok=AkphyF1T",
            "caption": "Non-contrasted axial CT demonstrates bilateral ground glass opacities within the right greater than left upper lobes. Denser airspace opacification is present within the posterior right upper lobe."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014941/000008.png?itok=zcauPRFe",
            "caption": "Non-contrasted axial CT demonstrates bilateral ground glass opacities within the right greater than left upper lobes. Denser airspace opacification is present within the posterior right upper lobe."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014941/000009.png?itok=_DuaiL9X",
            "caption": "Non-contrasted axial CT demonstrates bilateral ground glass opacities within the right greater than left upper lobes. Denser airspace opacification is present within the posterior right upper lobe."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014941/000005.jpg?itok=dPM1i_V4",
            "caption": "H&E staining at low power demonstrates the presence of hemosiderin laden macrophages."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014941/000010.png?itok=vGiI7VMh",
            "caption": "H&E staining at medium power demonstrates the presence of hemosiderin laden macrophages."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014941/000011.png?itok=P8JY0xjq",
            "caption": "H&E staining at high power demonstrates the presence of hemosiderin laden macrophages."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT-High Resolution",
      "Experimental"
    ],
    "link": "https://www.eurorad.org/case/14941",
    "time": "17.09.2017"
  },
  "14959": {
    "case_id": 14959,
    "title": "Pulmonary contusions located exclusively in upper lobes.",
    "section": "Chest imaging",
    "age": "20",
    "gender": "female",
    "diagnosis": "Pulmonary contusions located exclusively in upper lobes.",
    "history": "Driver who suffers a traffic accident, with collision against the front car. The patient reports a strong blow to the top of the chest against the steering wheel. She was transported to the hospital. Clinically, the patient had hypoxemia, hypercarbia and increase in laboured breathing.",
    "image_finding": "On chest radiograph: Although the quality of the image is not optimal, subtle interstitial-alveolar opacities are visualised in both upper lobes (Figure 1). On CT: Geographic, non-segmental areas of ground-glass densities that do not respect thelobar boundaries in both upper lobes. In some of them, there is subpleural sparing of 1\u20132 mm (Figure 2, 3 and 4). The rest of the lung parenchyma does not present pathological findings (Figure 5). There were no other significant findings related to the trauma.",
    "discussion": "Lung contusion is a focal parenchymal injury caused by disruption of the capillaries of the alveolar walls and septa, and leakage of blood into the alveolar spaces and interstitium [1]. It is the most common type of lung injury in blunt chest trauma with a reported prevalence of 17\u201370% [2]. They are most frequently bilateral and multiple, particularly in young patients, both in the impact and \"contrecoup\" areas. The main mechanism is compression and tearing of the lung parenchyma at the site of impact against osseous structures, rib fractures or pre-existing pleural adhesions [3].The timing of the development of pulmonary contusion is often helpful in determining thecause of areas of pulmonary opacity in trauma patients. Focal areas of pulmonary opacity appearing 24 hours or more after injury suggest diagnoses other than contusion, including aspiration, pneumonia, and fat embolism. The accumulation of blood and edema becomes apparent at 24 h, making contusion radiographically more evident, although it is detected by CT from the initial imaging [5].On chest radiography, pulmonary contusions feature patchy, ill-defined, coarse opacities. They do not respect anatomical segmental or lobar boundaries and usually do not present any air bronchograms. Pulmonary contusions have apredominantly subpleural distribution. They have no gravitational distribution. On a chest X-ray sometimes contusions may not become apparent for >24 hours [4]. CT findings of contusion consist of non-segmental areas of consolidation and groundglassopacification that predominantly involve the lung and are directed deeply into the area of trauma (more common posteriorly and in lower lobes), often sparing 1 to 2 mm of sub-pleural lung parenchyma adjacent to the injured chest wall [1, 3, 4]. CT is highly sensitive in detecting pulmonary contusions and the volume of lung involvement on CT scanning correlates with clinical outcomes [1, 2].Patients who have pulmonary contusion are at an increased risk of developing pneumonia and respiratory distress syndrome [6].",
    "differential_diagnosis": "Pulmonary, contusions, located, exclusively, in, upper, lobes., Aspiration, pneumonia, Segmental, /, focal, atelectasis, ARDS, Pulmonary, haemorrhage, Fat, embolism",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014959/000001.png?itok=hVO5nCSC",
            "caption": "Patchy ill-defined areas of parenchymal density in both upper lobes, predominantly right (performed 2h after accident)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014959/000002.png?itok=1YTcSYmc",
            "caption": "Patchy airspace opacities/consolidations\nwith ill-defined borders that are distributed\nirrespective of bronchopulmonary segmental anatomy (non-segmental distribution). Some of them have a subpleural sparing (1\u20132 mm of clear parenchyma\nbeneath the pleural surface)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014959/000003.png?itok=g-ul2AhV",
            "caption": "Patchy airspace opacities/consolidations with ill-defined borders that are distributed irrespective of bronchopulmonary segmental anatomy (non-segmental distribution). Some of them have a subpleural sparing (1\u20132 mm of clear parenchyma beneath the pleural surface)."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014959/000004.png?itok=15BFdGQA",
            "caption": "Patchy airspace opacities/consolidations with ill-defined borders that are distributed irrespective of bronchopulmonary segmental anatomy."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014959/000005.png?itok=IPrvM_sw",
            "caption": "In the middle lobe and lower lobes there are not pulmonary consolidations suggestive of contusions."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/14959",
    "time": "31.08.2017"
  },
  "14980": {
    "case_id": 14980,
    "title": "Hypervascular pulmonary nodule",
    "section": "Chest imaging",
    "age": "61",
    "gender": "male",
    "diagnosis": "Late pulmonary metastasis from RCC.",
    "history": "A 61-year old man had his left kidney transplanted in 1999 due to nephropathy and underwent right nephrectomy in 2006 due to kidney neoplasia, from which he fully recovered. During a follow-up abdominal magnetic resonance (MR) in 2015 a pulmonary nodule in right inferior lobe was detected, therefore computed tomography (CT) examination was requested.",
    "image_finding": "CT detected a well-defined pulmonary nodule of 1.3 cm in the posterior-basal segment of the right inferior lobe (Figure 1). Neither calcifications nor fat were found within the lesion. No pathological lymphnodes were detected. PET-CT performed after 4 months showed low to mild metabolic activity of the nodule (SUV 1.5) (Figure 2). A follow-up CT, performed with intravenous contrast medium after 3 months, highlighted a slight dimensional increase (2 cm) of the nodule which showed intense arterial contrast enhancement (Figure 3).During a third follow-up CT, the radiologist was asked a differential diagnosis between a pulmonary nodule or a pulmonary arterio-venous malformation (PAVM). A third differential diagnosis, carcinoid, was taken into account, due to CT morphological and contrast enhancement characteristics (Figure 4). Moreover the nodule showed volumetrical increase, from 1.8 cm^3 to 4.5 cm^3 (Figure 5).Atypical resection of the right inferior lobe led to the diagnosis of metastasis from clear-cell renal carcinoma (RCC), positive to CD10 antigen.",
    "discussion": "RCC tends to metastasize to the lungs in 70-76% of patients, lymphnodes in 50%, skeleton in 40% and to the liver in 20% [1, 2]. The majority (78%) of recurrent RCC occurs within the first 5 years post-operatively, although recurrences have been reported as late as 30 years following nephrectomy [3]. There are many different types of hypervascular pulmonary nodules, both benign and malignant, which show low uptake of FDG at PET-examination, and RCC is one of that. Nodular enhancement of less than 15 HU after contrast material administration is strongly predictive of a benign lesion, whereas enhancement of more than 20 HU typically indicates malignancy (sensitivity, 98%; specificity, 73%; accuracy, 85%) [4].Among benign conditions PAVM, that are an abnormal communication between the pulmonary artery and the pulmonary vein, are often unilateral, with predilection towards the lower lobes (50-70%). On non-contrast CT these lesions are either homogeneous, well-circumscribed, non-calcified nodules measuring up to several centimeters in diameter or present as serpiginous masses connected with blood vessels. Contrast injection demonstrates enhancement of the feeding artery, the aneurysmal part, and the draining vein on early-phase sequences [5].Malignancies such as prostate cancer, renal cell carcinoma, low malignant potential and early-stage ovary carcinoma, bronchioalveolar cell carcinoma and carcinoid tumors are several examples of tumors that have demonstrated low 18F-FDG uptake [6, 7, 8]. Carcinoids have high attenuation, enhance significantly on contrast enhanced CT, and show direct or indirect airway involvement on thin-section analysis; this value clearly reflects the hypervascularity seen pathologically in these lesions, even those presenting as incidental pulmonary nodules; calcification may be present, less common in small and pheripheral lesions [9]. There is a higher false-negative rate of FDG PET for carcinoid tumors (~ 25%) [10] than for malignant nodules resulting from bronchogenic carcinoma.In our present case, among all these differential diagnosis, carcinoid was first taken into account, whilst the hypothesis of late pulmonary metastasis from RCC recurring after 10 years was not immediately thought of.When the radiologic features of a pulmonary nodule are not diagnostic, transthoracic needle aspiration biopsy, bronchoscopy, video-assisted thoracoscopic surgery, or thoracotomy may be performed [11].",
    "differential_diagnosis": "Late, pulmonary, metastasis, from, RCC., Carcinoid, Pulmonary, Arteriovenous, Malformations, Metastases, of, clear-cell, renal, carcinoma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014980/000006.jpg?itok=6l88beXH",
            "caption": "a) soft tissue window"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014980/000007.jpg?itok=6W2RaJWv",
            "caption": "b) lung window"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014980/000009.jpg?itok=bysegW26",
            "caption": "a) soft tissue window"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014980/000010.jpg?itok=dXLUajAs",
            "caption": "b) lung window"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014980/000011.jpg?itok=ZKj6Cwfm",
            "caption": "a) lung window"
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014980/000012.jpg?itok=ag1WZoK6",
            "caption": "b) soft tissue window (basal acquisition)"
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014980/000013.jpg?itok=0kEOuZvL",
            "caption": "c) soft tissue window (acquisition after medium contrast material injection)"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014980/000014.jpg?itok=DvvWQUOt",
            "caption": "a) maximum volume of the nodule in 2015 : 1.8 cm^3"
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014980/000015.jpg?itok=5FfPWjZB",
            "caption": "b) CT 3D-reconstruction in 2017 shows volumetrical increase of about 2.7 cm^3"
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000014980/000016.jpg?itok=kzGafbLh",
            "caption": "On PET-examination the nodule showed low uptake of FDG (SUV 1.5)."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT",
      "PET-CT"
    ],
    "link": "https://www.eurorad.org/case/14980",
    "time": "31.08.2017"
  },
  "15032": {
    "case_id": 15032,
    "title": "Pulmonary inflammatory pseudotum",
    "section": "Chest imaging",
    "age": "62",
    "gender": "female",
    "diagnosis": "Pulmonary inflammatory pseudotumour IgG4-related disease.",
    "history": "A 62-year-old female patient with a diagnosis of SAPHO was hospitalised at the rheumatology department. She presented persistent fever, cough, pain in the left hemithorax, enlarged palpable lymph nodes and weight loss.",
    "image_finding": "The chest radiograph showed multiple coarse nodules, with irregular margins in the apical and medial regions of the lungs.\nA chest CT showed multiple nodular parenchymal consolidations, partially confluent with irregular margins. At the periphery of the consolidations, there were ground-glass opacities, while limited pleural thickening and areas of ground were localised in the basal region of the left lung.\nEnlarged mediastinal lymph nodes were also present.\nPET/CT showed evidence of glucid hyper-metabolism with some of the known pulmonary parenchymal nodularities, the greatest localised in the upper lobe of left lung (SUV max 4.5).\nGiven the unclear nature of the findings, the patient underwent an atypical superior left lobe resection in VATS. The histological sample showed a nodular mass characterised by a lymphoplasmacellular infiltration, eosinophils and myofibroblasts. An immunohistochemical staining revealed IgG4+ plasmacells (with 100 cells/high power field, IgG4+/IgG+ plasmacell > 40%).",
    "discussion": "The IgG4-related disease is a chronic fibrotic inflammatory disease [1] characterised by: an infiltration of lymphocytes in the tissue, IgG4-positive plasma cells, a high serum IgG4 concentration and fibrosis [3].\n\nIt may affect one or more organs, and the spectrum of symptoms depends on localisations and the grade of fibrosis [1].\n\nThe disease also may affect the lung and the pleura. The patient can present cough, haemoptysis, dyspnoea, fever and chest pain [2].\nIt is possible to recognise four types of pulmonary involvement [2, 5]:\n1) Solid nodular/mass lesions, sometimes with spiculations;\n2) Thickening of the bronchovascular bundles and interlobular septa;\n3) Alveolar interstitial disease, with a diffuse reticular shadow and bronchiectasia;\n4) Round-shaped, ground-glass opacities.\n\nPlus mediastinal lymphadenopathy, and/or pleural involvement [1].\n\nComprehensive clinical diagnostic criteria for IgG4-RD are [6]:\n(1) Clinical examination reveals a particular diffuse/localised swelling or mass in a single or in multiple organs.\n\n(2) Elevated serum IgG4 concentrations (\u2265135 mg/dL).\n\n(3) Histological examination presents:\n(a) Fibrosis and marked lymphocyte and plasmacyte infiltration;\n(b) Infiltration of IgG4-positive plasma cells: a ratio of IgG4/IgG positive cells greater than 40% and greater than 10 IgG4-positive plasma cells/HPF.\nDefinite: condition (1), condition (2) and condition (3) have to be satisfied.\nProbable: condition (1) and condition (3) have to be satisfied.\nPossible: condition (1) and condition (2) have to be satisfied.\n\nIgG4RD has a very good response to corticosteroid therapy but relapses are common [1, 4, 5].\n\nA lung needle biopsy revealed an inflammatory infiltration rich of lymphocytes.\nA clear diagnosis was needed before an immunosuppressive treatment could be started. Consequently, the patient underwent an atypical superior left lobe resection in VATS. This approach was preferred to a lobectomy, because it is less demolitive in a context of multiple lesions. The histological sample showed a nodular mass characterised by a lymphoplasmacellular infiltration, eosinophils and myofibroblasts. An immunohistochemical staining revealed IgG4+ plasmacells (with 100 cells/high power field, IgG4+/IgG+ plasmacell > 40%).",
    "differential_diagnosis": "Pulmonary, inflammatory, pseudotumour, IgG4-related, disease., Adenocarcinoma, or, bronchioloalveolar, carcinoma, Inflammatory-myofibroblastic, tumour",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015032/000001.jpg?itok=2T0QPXCL",
            "caption": "PA and LL plain film shows nodular opacities in the upper lobe of the right and left lung"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015032/000002.jpg?itok=2oLA-cCU",
            "caption": "PA and LL plain film shows nodular opacities in the upper lobe of the right and left lung"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015032/000003.jpg?itok=sXZh4SeL",
            "caption": "CT image shows solid nodule in right upper lobe accompanied by peripheral ground glass opacity.\nDiffuse pseudo-nodular area of ground glass"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015032/000004.jpg?itok=jlyP10by",
            "caption": "CT image shows peribronchial spread of inflammation"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015032/000005.jpg?itok=SyWFcCBo",
            "caption": "Multiple small nodules, with non defined margin and ground glass opacities"
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015032/000011.png?itok=tAS5VqaD",
            "caption": "Images show increased FDG uptake in lung nodule of the upper lobe of the right lung"
          },
          {
            "number": "Figure 5b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015032/000007.png?itok=n-A7l2Qu",
            "caption": "Images show increased FDG uptake in lung nodule of the upper lobe of the right lung"
          },
          {
            "number": "Figure 5c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015032/000009.png?itok=ygjG9s5Z",
            "caption": "Images show increased FDG uptake in lung nodule of the upper lobe of the right lung"
          },
          {
            "number": "Figure 5d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015032/000010.png?itok=FSnFm99e",
            "caption": "Images show increased FDG uptake in lung nodule of the upper lobe of the right lung"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Thorax"
    ],
    "imaging_technique": [
      "CT",
      "Digital radiography",
      "PET-CT"
    ],
    "link": "https://www.eurorad.org/case/15032",
    "time": "13.10.2017"
  },
  "15062": {
    "case_id": 15062,
    "title": "Bleomycin-induced pneumonitis",
    "section": "Chest imaging",
    "age": "60",
    "gender": "male",
    "diagnosis": "Bleomycin-induced pneumonitis",
    "history": "Our 60-year-old patient was diagnosed with stage IIIB nodular sclerosing Hodgkin\u2019s lymphoma and after completion of cycle 3 of ABVD (adriamycin, bleomycin, vinblastine & dacarbazine), he presented with a one-week history of exertional dyspnoea, fever and non-productive cough with oxygen saturation circa 90% in room air.",
    "image_finding": "PET with FDG showed increased avidity in the mid-zone to base of the lung during acute phase of bleomycin-induced pneumonitis (clinical event). CT Thorax similarly showed ground glass opacification of the mid to lower zone of the lung. Follow-up scan for re-staging and coincidentally matching 3 months after steroidal treatment for bleomycin-induced pneumonitis showing complete resolution of the disease.",
    "discussion": "Clinical Perspective: Suspecting an infectious aetiology, he was initially started on broad spectrum antibiotics (piptazobactam) and trimethoprim-sulfamethoxazole added when the clinical condition failed to improve. Poor response to antimicrobials led to a suspicion of bleomycin-induced pneumonitis (BIP) which was further supported by PET with FDG findings [1]. High dose steroid treatment (100mg Prednisolone) was commenced with significant resolution of respiratory symptoms within 48hours. Antibiotics were stopped and a tapering dose of steroids over 3 months continued.Imaging Perspective: PET images attached show initial staging, clinical event (BIP) and post-treatment resolution images. At presentation with the clinical event (BIP), there was increased FDG avidity affecting the middle and lower lobes of the lung in comparison to the initial staging scan. CT Thorax similarly showed ground glass opacification of the mid to lower zone of the lung. This imaging feature coupled with a pulmonary function test showing a restrictive ventilatory pattern led to a clinical diagnosis of bleomycin-induced pneumonitis. Interestingly, this gentleman\u2019s re-staging PET scan provided useful information both on treatment response (Hodgkin\u2019s lymphoma) and resolution of pneumonitis [2]. Teaching Points: BIP is a major pulmonary toxicity issue and significantly reduces 5-year overall survival in patients treated with the ABVD regimen for Hodgkin\u2019s lymphoma [3]. The gold standard in making a diagnosis remains tissue biopsy and histological analysis. However, these patients are almost always acutely unwell, thus a challenge to any invasive diagnostics. Characteristic CT findings of BIP include ground glass opacification of the posterobasal region with bilateral peripheral infiltrates [4]. However, other differentials with similar CT findings and clinical presentation such as opportunistic infection, radiation toxicity and cardiogenic interstitial oedema need to be systematically ruled out. PET scanning with FDG has shown promise in detecting BIP and differentiating active inflammation from chronic scarring [5]. Combining clinical presentation, PET imaging findings and respiratory function test as with our case could potentially allow early recognition and treatment of bleomycin-induced pneumonitis.",
    "differential_diagnosis": "Bleomycin-induced, pneumonitis, Respiratory, tract, sepsis, (opportunistic, infections), Lymphangitic, carcinomatosis, Radiation, pneumonitis, Cardiogenic, interstitial, oedema",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015062/000001.jpg?itok=MbgXJ08e",
            "caption": "Staging PET scan showing initial diagnosis of stage IIIB nodular sclerosis Hodgkin's lymphoma."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015062/000002.jpg?itok=QjwohUXT",
            "caption": "PET scan at presentation with respiratory symptoms post cycle 3 of ABVD showing diffuse FDG uptake in mid and lower zones of the lung."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015062/000003.jpg?itok=0L9lWLfI",
            "caption": "PET scan post completion of steroid treatment showing resolution of pneumonitis and FDG avid foci in spleen of Hodgkin's lymphoma."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015062/000005.jpg?itok=h3-wOJj2",
            "caption": "CT Thorax at presentation with respiratory symptoms post cycle 3 ABVD showing ground glass opacification of the mid zone of the lung."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015062/000006.jpg?itok=xPEGOxIJ",
            "caption": "CT Thorax at presentation with respiratory symptoms post cycle 3 ABVD showing ground glass opacification of the lower zone of the lung."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015062/000007.jpg?itok=jpA2y64i",
            "caption": "CT Thorax post completion of steroid treatment showing resolution of pneumonitis in the mid zone of the lung."
          }
        ]
      },
      {
        "number": "Figure 7",
        "subfigures": [
          {
            "number": "Figure 7",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015062/000008.jpg?itok=FvuQ4KeE",
            "caption": "CT Thorax post completion of steroid treatment showing resolution of pneumonitis in the lower zone of the lung."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "PET",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/15062",
    "time": "16.11.2017"
  },
  "15140": {
    "case_id": 15140,
    "title": "An unexpected posterior mediastinal mass",
    "section": "Chest imaging",
    "age": "67",
    "gender": "male",
    "diagnosis": "Poorly-differentiated sarcoma of the posterior mediastinum.",
    "history": "An elderly male patient complained of intermittent right flank and upper quadrant pain accompanied by anorexia and dyspnoea on exertion for three months. There was no febrile episode or jaundice. The patient is currently undergoing treatment for pulmonary tuberculosis. He has a chronic smoking history and was a previous alcoholic beverage drinker.",
    "image_finding": "The chest radiograph shows nodular and hazed infiltrates with a honeycombed pattern in both upper lobes, likely tuberculous changes, with possible bronchiectasis and volume loss in the right upper lobe. There is also scalloping of the right hemidiaphragm.\n\nOn ultrasound, a heterogeneous iso- to hyperechoic lesion is noted above the right hemidiaphragm, showing no increased vascularity.\n\nThe patient subsequently underwent a CT examination wherein a large, lobulated mass was identified at the right side of the posterior mediastinum, from T8 down to L3, showing heterogeneous enhancement. On an unenhanced study, the mass was almost isodense to the liver with no definite calcification. Non-enhancing regions were demonstrated within, which may represent necrosis or haemorrhage. Due to its size, mass effects to the adjacent structures were appreciated.\n\nA CT-guided percutaneous fine needle aspiration biopsy of the mass showed anaplastic malignancy, positive for vimentin and negative for cytokeratin. These findings are consistent with poorly-differentiated sarcoma.",
    "discussion": "Posterior mediastinal tumours can come from different organs but most often are neurogenic in nature. As illustrated above, we encountered the uncommon sarcoma as a large posterior mediastinal mass. And because they are rare, few literature is available regarding the nature of these tumours and how they are managed. [1]\n\nPrimary mesenchymal tumours of the mediastinum are extremely uncommon and can arise from any structure in the chest. [2] They are usually located in the anterior mediastinum, commonly sporadic and are often asymptomatic until they reach a considerable size, causing symptoms of compression or invasion of the surrounding structures. [3]\n\nThe role of imaging is huge in the proper assessment of the characteristics, extent of involvement, potential resectability and probable response to treatment of these lesions. [2] Radiography is usually the first step and the most helpful one in identifying the presence of a mediastinal mass. However, in this case, the discrete location of the posterior mediastinal mass at the level of the diaphragm and its unique growth inferiorly made CT a key in the evaluation.\n\nRegardless of location and type, sarcoma should be included as a major differential diagnosis in an intrathoracic mass that is large in size (>70 mm), showing well-defined smooth or lobulated margins, associated pleural effusion, and no significant lymphadenopathy. [2] They also show large areas of low-density suggestive of necrosis, and exhibit variable heterogeneous enhancement. [2] Calcifications as well as pleural tags or ground glass opacities are not commonly seen. Some that have calcifications are possibly teratoma, osteosarcoma or chondrosarcoma. [4] Presence of bone, vessels, or muscle invasion, or intrathoracic extension may be a clue to the malignant nature of a chest wall sarcoma. [5] In MRI, sarcomas show heterogeneous but predominantly T1 hypointense and T2 hyperintense signals with areas of haemorrhage and necrosis as well as some with neovascularity. [3] However, benign and malignant features are often overlapping. Hence, histopathologic analysis is necessary.\n\nComplete surgical resection is the only curative treatment for soft-tissue sarcomas. [1, 6] Local recurrence is high and this signifies short survival (median of 3 months). [4] Chemotherapy and radiotherapy are being looked into as potential adjunct treatments to help improve prognosis and survival.\n\nThis rare tumour poses a diagnostic challenge to the clinicians, making imaging a vital part in the proper recognition and characterisation of these lesions, together with tissue analysis.",
    "differential_diagnosis": "Poorly-differentiated, sarcoma, of, the, posterior, mediastinum., Malignant, peripheral, nerve, sheath, tumours, Neurogenic, tumours",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015140/000001.jpg?itok=KDDpS1ng",
            "caption": "PA view shows nodular and hazed infiltrates with honeycombed changes in both upper lobes, likely tuberculous changes, with possible bronchiectasis and volume loss in the right upper lobe. The right hemidiaphragm is scalloped."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015140/000002.png?itok=KY0QjY6B",
            "caption": "Sonogram of the hepatic region shows a large heterogeneous iso- to hyperechoic lesion (arrow) above the right hemidiaphragm (*). Color Doppler study shows no increased vascularity."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015140/000003.png?itok=R8q6yunm",
            "caption": "Axial image shows a large, heterogeneously-enhancing lobulated mass (arrow) at the right side of the posterior mediastinum. Non-enhancing areas are appreciated within which may represent necrosis or haemorrhage. No calcification is noted."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015140/000004.png?itok=3FrAnJtU",
            "caption": "This large mass from the level of T8 to L3 causes significant mass effect seen as inferior displacement of the right hemidiaphragm (arrow), kidney, adrenal gland and bowel segments."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Mediastinum",
      "Abdomen"
    ],
    "imaging_technique": [
      "Ultrasound",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/15140",
    "time": "20.10.2017"
  },
  "15144": {
    "case_id": 15144,
    "title": "Pulmonary Langerhans cell histiocytosis: Imaging findings and differential diagnosis",
    "section": "Chest imaging",
    "age": "53",
    "gender": "female",
    "diagnosis": "Pulmonary Langerhans cell Histiocytosis",
    "history": "A 53-year-old woman presented with symptoms of dyspnoea and non-productive cough, persistent for 7 weeks and not improving despite antibiotic therapy. She has been smoking for at least 35 years. Laboratory findings were normal. Initially Chest X-ray was performed.",
    "image_finding": "Chest X-ray showed symmetric upper lung zone predominant reticulonodular opacities with multiple ill-defined nodules of 1-10 mm in diameter (Figure 1).Further evaluation with CT confirmed this pattern and showed that some of these nodules presented with a central cavitation. These solid nodules showed stellate borders and were distributed in a peribronchiolar pattern. Furthermore, some small (< 10 mm) thick and thin walled irregular cysts were seen in the upper lobes (Figure 2). There were no signs of lung fibrosis and no lymphadenopathy or pleural fluid was present. A lung biopsy was performed and pathologic examination revealed eosinophilic granulomas in the context of pulmonary Langerhans cell histiocytosis.",
    "discussion": "Pulmonary Langerhans cell histiocytosis (PLCH) is an uncommon smoking-related granulomatous interstitial lung disease which is an isolated form of the multisystem disease of Langerhans cell histiocytosis. Most common presenting symptoms are non-productive cough and dyspnoea. On imaging, the elementary lesion is that of a bronchiolocentric evolving granuloma in the walls of the airways which is seen on HRCT as a peribronchiolar nodule. These solid nodules are usually smaller than 10 mm, have irregular borders and predominantly involving the middle and upper lung zones with relative sparing of the costophrenic angles [1].Cavitation results from bronchiolar dilatation resulting from inflammation and fibrosis of the bronchiolar wall [2]. In its later stages, these cavitated nodules are replaced by thick walled cysts and finally by thin walled cysts. These cysts are also usually less than 10 mm in diameter and they can appear round or show more bizarre shapes.PLCH can be strongly suggested in cases of a nodular pattern in presence of cavitated nodules and small cysts. But in early stage of disease, when nodules are the only HRCT abnormality, differential diagnosis is extensive. Differentiation should be especially made with sarcoidosis, silicosis, tuberculosis and lung metastasis. Nodules in PLCH have a peribronchial and peribronchiolar distribution whereas perilymphatic nodules are typically seen in sarcoidosis, silicosis and lymphangitic carcinomatosis. A tree-in-bud pattern raises the possibility of endobronchial spread of tuberculosis.When there are also cavitated nodules differentiation should be further made with Wegener granulomatosis, septic emboli and lung metastasis. Nodules in Wegener granulomatosis are usually larger, more delineated, have a more random distribution and cavitate in up to 50% of cases. In addition, presence of concomitant ground glass and consolidation favour the diagnosis of Wegener granulomatosis. Nodules seen in septic emboli show also stellate borders but they are more seen in the periphery of the lung bases. Metastatic nodular cavitation may occur in the squamous, sarcomatous or transitional cell carcinomas. They are better delineated and have a random vascular distribution [2, 3].In the late chronic stadium of PLCH when lung cysts are the only abnormality differentiation should be made with centrilobular emphysema, desquamative interstitial pneumonia (DIP), Lymphangioleiomyomatosis (LAM) and Lymphocytic interstitial pneumonitis (LIP). In centrilobular emphysema focal areas of lung destruction lack visible walls. Concomitant patchy ground-glass opacity favours diagnosis of DIP. In women with LAM cyst have a round shape and no lung zone is spared. Cysts in patients with LIP have a lower lobe predominance [1].",
    "differential_diagnosis": "Pulmonary, Langerhans, cell, Histiocytosis, Sarcoidosis, Silicosis, Tuberculosis, Wegener, granulomatosis, Centrilobular, emphysema",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015144/000002.jpg?itok=CV5qBb-r",
            "caption": "Symmetric upper lung zone predominant reticulonodular opacities with multiple ill-defined nodules of 1-10 mm in diameter."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015144/000004.png?itok=ewGqHD-z",
            "caption": "Small ill-defined bronchiolocentric solid nodules, cavitating nodules and cysts in middle and upper lung zone predominance."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015144/000005.png?itok=nMePGGaC",
            "caption": "Small ill-defined bronchiolocentric solid nodules, cavitating nodules and cysts in middle and upper lung zone predominance."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "Digital radiography",
      "CT-High Resolution"
    ],
    "link": "https://www.eurorad.org/case/15144",
    "time": "02.11.2017"
  },
  "15154": {
    "case_id": 15154,
    "title": "Case report: Radiological presentation of pulmonary sporotrichosis",
    "section": "Chest imaging",
    "age": "35",
    "gender": "male",
    "diagnosis": "Primary pulmonary sporotrichosis",
    "history": "A 35-year-old male patient, resident of Rio de Janeiro, smoker (32 packs per year), with hyporexia, dyspnoea, chest pain and weight loss. Respiratory examination showed reduced vesicular sounds in the right lung apex and crackles in the middle third of the left lung and apexes. No skin lesions or lymphadenopathy.",
    "image_finding": "Chest computed tomography performed within a few hours of admission to our hospital showed multiple bilateral centrilobular nodules, which reflected filling of small airways, traction bronchiectasis and irregular excavations with thickened walls in the right upper lobe, lingula and right lower lobe superior segment. Ground-glass opacities were adjacent to excavated lesions and no lymphadenopathy was present.",
    "discussion": "Sporotrichosis is the most prevalent subcutaneous mycosis worldwide, caused by the fungus Sporothrix. It has an estimated annual incidence of 48-98 cases per 100,000 inhabitants in endemic areas (tropical/subtropical countries). The incidence in non-endemic areas are not well estimated, but there are few reports of accidental exposure, where clinical diagnosis may be difficult particularly due to the heterogeneous morphology of lesions [1].Pulmonary sporotrichosis is an uncommon condition that usually presents as a chronic pulmonary disease. It is divided into two distinct radiological presentations, due to the types of inoculation of the pathogen [2, 3, 4, 13]. Primary pulmonary sporotrichosis results of direct inhalation of Sporothrix schenckii. It is an extremely rare disease, affecting less than 1% of the patients infected by the fungus [3, 7, 13]. In general, it affects middle-aged men, with chronic obstructive pulmonary disease, alcoholism, chronic use of corticosteroids and immunosuppressive diseases. The main sites of involvement are the upper lobes, where a granulomatous inflammatory reaction is initiated, resulting in central caseous necrosis and pulmonary excavation. When multiple cultures for tuberculosisare negative or when anti-tuberculous therapy fails, pulmonary sporotrichosisshould be considered [3, 5, 10, 13].Other cases of disseminated infection are usually secondary to traumatic inoculation through the skin, with haematogenous or lymphatic spread [3, 4, 7]. We report a case with multiple excavated areas, the largest one in the right upper lobe, and multiple bilateral centrilobular nodules, predominantly located adjacent to the excavated lesions. These findings were consistent with primary pulmonary sporotrichosis [3, 4, 5].Laboratory confirmation is necessary due to the non-specific clinical-radiological findings, including direct examination of tissue biopsy specimens, bronchoalveolar lavage or pus in localised disease, or sputum, urine, blood, cerebrospinal and synovial fluids in disseminated infections, depending on the affected organs. In pulmonary involvement, high serologic titers or skin-test positivity, with positive sputum/pleural fluids culture, or lung biopsy can confirm the disease. In this case, after empirical treatment failure for tuberculosis, positive sputum culture and serology for sporotrichosis were required [4, 7, 13], followed by itraconazole therapy.The treatment of choice is itraconazole 400mg/day/year. Liposomal amphotericin B is reserved for refractory or severe cases [2, 3, 6, 8, 9]. In localised disease, early surgery is recommended. In this case, Liposomal amphotericin B was necessary after treatment failure with itraconazole [3].Therefore, it is important to recognise the radiological patterns of pulmonary sporotrichosis, since it can be confused with other causes of excavated lesions, especially tuberculosis, another Brazilian endemic disease.",
    "differential_diagnosis": "Primary, pulmonary, sporotrichosis, Tuberculosis, Histoplasmosis, Paracoccidioidomycosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015154/000001.jpg?itok=Z7BG8UMg",
            "caption": "Cavity with thickened walls in the right upper lung and bilateral reticular interstital pattern.\nThe hilar structures are distorted due to volume loss of the right upper lobe.\nNo lymphadenopathy was seen.\n(posteroanterior view)"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015154/000002.jpg?itok=9As7Z6oQ",
            "caption": "Cavity with thickened walls in the right upper lung and bilateral reticular interstital pattern.\nThe hilar structures are distorted due to volume loss of the right upper lobe.\nNo lymphadenopathy was seen. (lateral view)"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015154/000003.jpg?itok=Xe6fH8wQ",
            "caption": "Multiple bilateral foci of bronchiolar filling, bronchiectasis and irregular excavations with thickened walls in the right upper lobe, lingula and right lower lobe superior segment."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015154/000004.jpg?itok=N4kA2lgH",
            "caption": "Multiple bilateral foci of bronchiolar filling, bronchiectasis and irregular excavations with thickened walls in the right upper lobe, lingula and right lower lobe superior segment."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015154/000005.jpg?itok=Mbg-S2ET",
            "caption": "Multiple bilateral foci of bronchiolar filling, bronchiectasis and irregular excavations with thickened walls in the right upper lobe, lingula and right lower lobe superior segment."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015154/000007.jpg?itok=WHzJ68F8",
            "caption": "Multiple bilateral foci of bronchiolar filling, bronchiectasis and irregular excavations with thickened walls in the right upper lobe, lingula and right lower lobe superior segment."
          },
          {
            "number": "Figure 2e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015154/000008.jpg?itok=nqXaWSoQ",
            "caption": "Excavations with irregular thickened walls in the right upper lobe right and lower lobe superior segment, with multiple bilateral foci of bronchiolar filling."
          },
          {
            "number": "Figure 2f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015154/000009.png?itok=M2NH3HzD",
            "caption": "Excavation with irregular thickened wall in the right upper lobe, and multiple bilateral foci of bronchiolar filling (MIP)."
          },
          {
            "number": "Figure 2g",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015154/000010.png?itok=2Eq763oO",
            "caption": "Excavation with irregular thickened wall in the right upper lobe, and multiple bilateral foci of bronchiolar filling.\n(MinIP)."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/15154",
    "time": "31.01.2018"
  },
  "15157": {
    "case_id": 15157,
    "title": "ndobronchial spread in pulmonary adenocarcinom",
    "section": "Chest imaging",
    "age": "72",
    "gender": "female",
    "diagnosis": "Pulmonary adenocarcinoma (papillary subtype), with likely aerogenous metastasis",
    "history": "A patient with history of asthma presented with general malaise and worsening of wheezing during the night in the former 2 months. Chest radiography was initially ordered, with CT being ordered on follow-up.",
    "image_finding": "Figure 1: Chest radiography (front and profile): opacity in the upper lobe of the right lung, apparently respecting the fissure.Figure 2: CT six weeks after (lung window, sagittal and coronal reformat) - persistent consolidation with slight air bronchogram, and apparent transfissural spread.Figure 3: Axial CT (lung and soft tissue window), post e.v. contrast. Multiple well-defined nodes (circle) in the same lobe. Consolidation shows homogeneous enhancement and tapered air bronchogram (arrow).",
    "discussion": "Adenocarcinoma is the most common histologic type of lung cancer, and may present with different types of macroscopic presentation, including pneumonia-like consolidation, especially in invasive mucinous adenocarcinoma (formerly mucinous bronchioloalveolar carcinoma). [1]Air-space consolidation is represented in imaging by homogeneous opacity obscuring vessels, with air bronchogram, preserved lung volume, and fissures.Classical differential diagnosis for this pattern of long pathology consist of the classical four substances [2]:-Water (e.g. oedema)-Blood (e.g. pulmonary haemorrhage)-Pus (e.g. pneumonia)-Cells (e.g. adenocarcinoma in-situ, organising pneumonia, etc).Temporal persistence of lung consolidation despite therapy should prompt suspicion for oncologic pathology. Despite adenocarcinoma in-situ being the most commonly recalled sub-type of cancer with this presentation, papillary sub-types may also present in such fashion. In some series, this latter type is the most common lung cancer presenting with consolidation. [2, 3]Multiple lung nodules were the other significant finding. Differential diagnosis of multiple lung nodules includes metastasis almost universally, and in this case further suspicion should be added by the well-defined contours seen.The most commonly acknowledged cancer spread pathways are lymphatic, haematogenous, local direct invasion and through the serosal cavities (pleural). In this case, ipsilateral and the same lobe distribution of nodules suggest aerogenous dissemination, which is also a possible cancer spread pathway particularly described for adenocarcinoma. Aerogenous dissemination is also thought to account for possible multricenticity of adenocarcinoma in-situ of the lung. [4]In this case, bronchioloalveolar lavage was performed with fluid being processed in cell-block technique and imunnohistochemistry having been performed. Final diagnosis was consistent with adenocarcinoma of the micropapillary subtype, with imunohistochemistry indicating primary lung origin. Micropapillary predominant adenocarcinoma has tumour cells growing in papillary tufts, which lack fibrovascular cores. [1] This type of tumour has a reported poor prognosis. [1] The authors believe that this type of lung cancer architecture, with lack of a fibrovascular core, may be associated with aerogenous metastisation.Important learning points for this case are to consider the possibility of malignancy for persistent lobar changes. In the event of an endobronchial spread pattern being detected, neoplastic disease should not be immediatly discarded, as this has been described as a potentially underrecognised form of lung cancer spread [4, 5].",
    "differential_diagnosis": "Pulmonary, adenocarcinoma, (papillary, subtype),, with, likely, aerogenous, metastasis, Lung, carcinoma, Lymphoma, Pneumonia, (infectious, disease)",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015157/000004.png?itok=sscA_Pzc",
            "caption": "Chest radiography (front and profile): opacity in the upper lobe of the right lung, apparently respecting the fissure."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015157/000005.png?itok=3aMJoWkv",
            "caption": "Chest radiography (front and profile): opacity in the upper lobe of the right lung, apparently respecting the fissure."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015157/000006.png?itok=fzNtnpph",
            "caption": "CT six weeks after (lung window, coronal reformat) with baseline radiograph for comparison to the left - persistent right upper lobe consolidation with tapered air bronchogram."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015157/000007.png?itok=QqFeA9Hz",
            "caption": "CT six weeks after (lung window, sagittal reformat) with baseline radiograph for comparison to the left - persistent right upper lobe consolidation in the posterior segment, and apparent transfissural spread."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015157/000009.png?itok=KqIfob99",
            "caption": "Axial CT (lung window). Multiple well-defined nodes (circle) in the same lobe of upper lobe consolidation involving mainly the posterior segment."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015157/000008.png?itok=l_6YfcDN",
            "caption": "Axial CT (soft tissue window), post e.v. contrast. Consolidation shows homogeneous enhancement and tapered air bronchogram (arrow)."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/15157",
    "time": "18.01.2018"
  },
  "15185": {
    "case_id": 15185,
    "title": "Pilomatricom",
    "section": "Chest imaging",
    "age": "47",
    "gender": "male",
    "diagnosis": "Pilomatricoma",
    "history": "We present a 47-year-old male patient with an enlarging mass in the right thoracic wall for about 1 year. There was no relevant medical history and no trauma. A Computed Tomography (CT) study was requested for characterisation.",
    "image_finding": "A Computed Tomography (CT) was performed without (Fig. 1a and 1b) and with intravenous contrast (Fig. 2a and 2b).\nThe (CT) non-enhanced images (Fig. 1a and 1b) showed a large superficial mass in the right thoracic wall. The mass was heterogeneous, predominantly hypodense with small hyperdense content, probably calcification or haemorrhagic foci.\nThe administration of intravenous iodated contrast agent (Fig. 2a and 2b) revealed solid (enhanced) and cystic/necrotic (non-enhanced) components. The right pectoralis major muscle had normal imaging characteristics.\nThe 3D reformation image revealed the macroscopic aspect of the mass (Fig. 3).\nThe mass had nonspecific characteristics on CT but it seemed that there was no muscle invasion.\nThe patient underwent surgery and the histological study was consistent with pilomatricoma (Fig. 4).",
    "discussion": "Pilomatricoma is a benign cutaneous neoplasm with differentiation of hair matrix cells [1]. It is more common in children and young adults with a second peak of onset in the 6th and 7th decades of life [1]. Pilomatricomas occur predominantly in the head and neck region, followed by the upper extremities, the lower extremities, and rarely the trunk [1].\n\nOn ultrasound studies pilomatricomas appear as superficial ovoid complex nodules that may have a heterogeneous echotexture, internal echogenic foci in scattered-dot pattern and a hypoechoic rim or posterior shadowing [2].\n\nThe computed tomography (CT) characteristics are nonspecific: subcutaneous tumours sharply demarcated with a soft tissue density, calcifications and a variable degree of enhancement [2, 3].\n\nOn MRI pilomatricomas have a homogeneous intermediate signal intensity on T1-weighted images and a heterogeneous intermediate signal intensity on T2-weighted images. The fat-suppressed T2-weighted images shows hyperintense reticulations that can also be seen on gadolinium-enhanced T1-weighted images [3]. A capsule is usually seen: hyperintense on fat-suppressed T2-weighted images and with enhancement on contrast-enhanced T1-weighted images. Peritumural subcutaneous oedema can also be present [3].\n\nThere aren no pathognomonic aspects of pilomatricomas on imaging studies, so a pathological evaluation of the lesion is necessary in order to make the diagnosis. The classic histology is the presence of ghost or shadow cells and basophilic cells.\nThe basophilic cells have relatively uniform nuclei and scanty basophilic cytoplasm. The shadow cells are in masses and show ghost outlines. They appear eosinophilic and may be keratinised [2, 4].\nTreatment is surgical resection with wide margins of 1-2 cm. Following excision, pilomatricoma recurrences are relatively rare, with an overall rate of 2.6% [2].\n\nTeaching points:\nPilomatricomas are cutaneous lesions more frequent in children and young adults in the head and neck region.\nPilomatricomas present as superficial tumours with nonspecific characteristics on imaging: soft tissue density and calcifications on CT, intermediate signal intensity on T1-weighted images and intermediate signal intensity on T2-weighted images.\nDefinitive diagnosis is made with the histhologic evaluation.",
    "differential_diagnosis": "Pilomatricoma, Sebaceous, cyst, Dermoid, cyst, Giant, cell, tumour, Chondroma, Ossifying, haematoma, Foreign, body, reaction, Metastatic, bone, formation",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015185/000001.png?itok=bc0DqZQW",
            "caption": "Axial unenhanced CT shows a large superficial mass (large arrows) in the right thoracic wall. The mass is hypodense with small hyperdense foci (small arrows)."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015185/000005.png?itok=kyxFdqnd",
            "caption": "Sagittal unenhanced CT image shows a large superficial mass in the right thoracic wall (large arrows)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015185/000006.png?itok=Pcp6bNkP",
            "caption": "The 3D reformation image reveals the macroscopic aspect of the\r\nmass"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015185/000007.jpg?itok=rQUc8sQF",
            "caption": "Lobulated mass of epithelial cells and connective tissue stroma with inflammatory cell infiltrate, some foreign-body giant cells and a keratin pearl. (H&E)"
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015185/000008.jpg?itok=70RcWcFZ",
            "caption": "Basophilic cells, one of the cell types, have scanty cytoplasm, indistinct cell borders, hyperchromatic nuclei and several mitoses. (H&E)"
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015185/000009.jpg?itok=MhCRkg6W",
            "caption": "Shadow (mummified) eosinophilic cells, the other cell type, have more cytoplasm, distinct cell borders and no nuclear staining. (H&E)"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015185/000010.png?itok=IsHSEbQP",
            "caption": "Axial CT after administration of contrast agent shows a superficial mass with solid and cystic/necrotic components."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015185/000011.png?itok=qot9f1h3",
            "caption": "Sagittal CT after administration of contrast agent shows a superficial mass with solid and cystic/necrotic components."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thoracic wall"
    ],
    "imaging_technique": [
      "CT",
      "Percutaneous"
    ],
    "link": "https://www.eurorad.org/case/15185",
    "time": "22.05.2018"
  },
  "15189": {
    "case_id": 15189,
    "title": "Intrathoracic lipom",
    "section": "Chest imaging",
    "age": "45",
    "gender": "female",
    "diagnosis": "Intrathoracic lipoma",
    "history": "A 42-year-old asymptomatic female patient was referred for a chest radiograph and HRCT due to a suspected systemic sclerosis.",
    "image_finding": "The PA projection of chest X-ray (Fig. 1a) shows a widening of the mediastinal para-oesophageal line, in the lower left part; the LL projection (Fig. 1b) shows a bulging of the retrocardiac space, with a presence of opacity with density of soft tissues.\nThe Chest CT (Fig. 2) demonstrates the absence of lung involvement, but it shows in the middle and lower mediastinum, predominant on the left side and disposed around the oesophagus and aorta, the presence of tissue with a density of -100 / -110 HU and subtle hyperdense septa in its interior.\nA double MDC Oesophagus X-ray (Fig. 3) performed for screening of systemic sclerosis, shows a hypotonic and hypokinetic oesophagus in absence of compression phenomena.\nThe Chest MR (Fig. 4, 5, 6) confirms the presence of intrathoracic lipoma extended from the plane passing through pulmonary trunk to the diaphragmatic hiatus. The mass is encapsulated, well-clotted by the mediastinal organs.",
    "discussion": "Lipomas are a benign tumours that originate from fatty tissue. [1, 3]. They can appear anywhere in the body; thoracic lipomas are rare. [1, 2, 3]\n\nGenerally, the majority of lipomas become apparent in patients at 40 to 60 years of age, and they tend to be more common in obese persons. [6]\n\nThe lipomas that involve the thorax can be divided into two groups:\n- Subcutaneous: usually appears in the upper back, neck, and shoulder regions.\n- Deeply seated: intrathoracic (or mediastinal) lipoma. This group can be classified into two classes:\n\u2022 pure intrathoracic: located completely within the thoracic cavity\n\u2022 mediastinal lipoma that have intra-and/or extra-thoracic lesions. In particular:\n- cervico-mediastinal type which extends to the neck\n- transmural type which penetrates the chest wall. [1, 2, 3, 6]\n\nDeeply seated intrathoracic lipomas usually tend to have a big size and their detection is often late and incidental, e.g. while the patient is performing routine examinations or imaging investigations for mild symptoms [1]. Generally they are characterised by slow growth; for this reason, usually they are asymptomatic. [1, 5] The symptoms are often due to mass effect and depend on the site and size of the lesion. [5 and 6] The patient can have: dysphagia, dyspnoea, dry cough, jugular distention, and cardiac arrhythmias or even death. [4, 5, 6]\n\nAt a X-ray examination, a lipoma can appear like a well-defined rounded nodul/mass that presents soft tissue density. [3, 6]\nOn a Chest CT, lipomas show homogeneous fat attenuation of approximately (- 50 to -150 HU). [2, 4, 6]\nMRI is useful to describe the extent of the mass, and the relationship between this and the adjoining organs. [3, 4] Also, it can be of help to identify the fatty nature of the lesion [4]; it presents a high signal intensity on both T1- and T2-weighted images. [6]\nUsually radiologic investigations are useful for diagnosis, but can\u2019t exclude the malignancy. [2]\n\nIn general, surgical resection is necessary to:\n-prevent:\no increasing in size\no infiltrating development\no local recurrence\no malignant degeneration\n- avoid a mass effect on adjacent structures and/or alleviate symptoms\n- pathologic examinations and verification of the diagnosis [1, 2, 6]\n\nMR is performed to exclude a possible suspicious mass not seen in CT; in this way the liposarcoma is excluded.\nThe clinicians decide to avoid a biopsy or a surgical resection because the patient is asymptomatic and prefers a clinical follow-up.",
    "differential_diagnosis": "Intrathoracic, lipoma, Liposarcoma, Lipoblastoma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015189/000002.jpg?itok=7ENpWHwu",
            "caption": "The Chest TC shows the presence of tissue with a density of -100 / -110 HU and subtle hyperdense septa in its interior."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015189/000005.jpg?itok=8xYqEwS6",
            "caption": "RM Cor T2W: intrathoracic lipoma is extended from the plane passing through pulmonary trunk to the diaphragmatic hiatus."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015189/000006.jpg?itok=_M3FbTYk",
            "caption": "The sagittal projection shows that the mass is well-clotted by the mediastinal organs."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015189/000007.jpg?itok=2IK7X34F",
            "caption": "The Chest RM (RM Ax 3D) confirms the presence of intrathoracic lipoma."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015189/000009.jpg?itok=nFobbEfP",
            "caption": "The PA projection of Chest RX shows a widening of the mediastinal para-oesophageal line, in the lower left part."
          },
          {
            "number": "Figure 5b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015189/000008.jpg?itok=Dh5Wdg30",
            "caption": "The LL projection shows a bulging of the retrocardiac space, with a presence of opacity with density of soft tissues."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015189/000010.jpg?itok=SRZyH_YA",
            "caption": "A double MDC oesophagus RX shows a hypotonic and hypokinetic oesophagus in absence of compression phenomena."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Mediastinum"
    ],
    "imaging_technique": [
      "Digital radiography",
      "CT",
      "Fluoroscopy",
      "MR"
    ],
    "link": "https://www.eurorad.org/case/15189",
    "time": "20.12.2017"
  },
  "15215": {
    "case_id": 15215,
    "title": "Healed varicell",
    "section": "Chest imaging",
    "age": "56",
    "gender": "female",
    "diagnosis": "Multiple random nodules were related with healed varicella.",
    "history": "A 56-year-old female patient complaining of cough and dyspnoea for many weeks. No complaints of weight loss. She was a heavy smoker and had chickenpox at 33 years.Chest radiograph (Fig. 1) was performed followed by thoracic CT examination (Fig. 2).",
    "image_finding": "Chest radiograph (Fig. 1) revealed diffuse, multiple small nodular opacities, with random distribution. Some of them were dense suggesting calcification. In the right perihilar region a spiculated nodule was observed and CT was suggested.Computed tomography (Fig. 2a, Fig.2b and Fig.2c) showed multiple pulmonary nodules with random distribution, and well-defined edges. They varied from 2 to 5 mm in diameter and they were not cavitated. In the inferior right lobe there was a subpleural spiculated nodule with 30 x 18 x 29 mm, with some calcifications (Fig.2d). It was considered a suspicious lesion and biopsy was suggested.",
    "discussion": "Varicella zoster virus pneumonia (VZVP) is a serious complication of an infection with varicella zoster virus, which sometimes proves fatal.[3] Risk factors for developing VZVP are contact with chickenpox, smoking and pregnancy (third trimester). Smoking has been recognised as the most important risk factor. [3] VZVP is more prevalent among young men and usually presents 1\u20136 days after onset of the skin rash. Symptoms are nonspecific and include tachypnoea, chest tightness, cough, dyspnoea, fever, pleuretic chest pain and occasionally haemoptysis. [4] The initial chest radiograph typically shows ill-defined nodular (2\u20135 mm in diameter) or reticular densities that represent interstitial pneumonitis, more evident in the periphery of the lung. Radiological abnormalities usually resolve, but may persist for weeks or months and in a few cases nodules can calcify and remain indefinitely. [2] In this case, we present a typical pattern of diffuse calcified pulmonary nodules, with random distribution, seen years after acute VZVP. This is a nonspecific finding; however, when the physician is confronted with disseminated small (< 1cm) calcified pulmonary nodules, a history of prior VZVP should be sought, since it can greatly facilitate the differential diagnosis between tuberculosis, coccidioidomycosis, histoplasmosis and pneumonoconiosis, rendering extensive diagnostic workup unnecessary. [3, 5] Definitive diagnosis in the acute phase can be provided by isolation of varicella zoster virus on vesicular fluid cultures. [2] Treatment of VZVP as well as other complications of varicella zoster virus infection in adults and children is effective by intravenous acyclovir. Recurrence of VZVP has been reported in immunocompromised patients. [3] Another clinically important finding in this patient was a spiculated lesion found in the apical segment of the right lower lobe, whose biopsy revealed an undifferentiated adenocarcinoma. The patient initiated chemotherapy, but developed multiple metastatic pulmonary lesions and died a few months later.",
    "differential_diagnosis": "Multiple, random, nodules, were, related, with, healed, varicella., Metastatic, pulmonary, calcification, Pulmonary, alveolar, microlithiasis, Amyloidosis, Silicosis, Tuberculosis, Coccidioidomycosis, Histoplasmosis, Pneumoconiosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015215/000001.jpg?itok=gUs1lJ5t",
            "caption": "Plain chest film showing multiple, diffuse, small nodular opacities, with random distribution. Some of them were dense suggesting calcification. In the right perihilar region a spiculated nodule was observed."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015215/000002.jpg?itok=AjCziATn",
            "caption": "Coronal CT examination showing multiple pulmonary nodules with random distribution, and well-defined edges. They varied from 2 to 5 mm in diameter. They were not cavitated."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015215/000006.png?itok=5kVXZGJP",
            "caption": "Axial CT examination using lung window shows multiple pulmonary nodules with random distribution, and well-defined edges. They varied from 2 to 5 mm in diameter. They were not cavitated."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015215/000008.jpg?itok=V0vk-ZPT",
            "caption": "Axial CT examination image using bone window settings shows a few calcified small nodules in the left upper lobe."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015215/000007.jpg?itok=J2fjDR0s",
            "caption": "Axial CT examination showing in the inferior right lobe a subpleural spiculated nodule with 30 x 18 x 29 mm, with some calcifications. This lesion was biopsed which revealed undifferentiated adenocarcinoma."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Thorax"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT",
      "CT-High Resolution"
    ],
    "link": "https://www.eurorad.org/case/15215",
    "time": "07.12.2017"
  },
  "15218": {
    "case_id": 15218,
    "title": "Mediastinal granulocytic sarcoma (ECR 2017 Case of the Day)",
    "section": "Chest imaging",
    "age": "48",
    "gender": "male",
    "diagnosis": "Mediastinal granulocytic sarcoma",
    "history": "A 48-year-old male patient suffered from chest pain (localised behind the sternum) for three days after a long distance flight. He underwent CT of the chest to rule out pulmonary embolism. The patient had a history of acute myelogenous leukaemia, diagnosed and treated 5 years before.",
    "image_finding": "There was no pulmonary embolism seen on CT. A soft-tissue mass was found in the lower anterior mediastinum between the sternum and the heart, abutting the contour of the mediastinum towards the right lung and the pericardium (Fig. 1 and 2). This lesion had not been present in a previous examination that had been performed one year before. In 18F-FDG-PET/CT performed two weeks later, the lesion showed increased uptake of FDG (Fig. 3). CT-guided biopsy (Fig. 4) finally revealed the diagnosis.",
    "discussion": "Granulocytic sarcoma, also known as chloroma, myeloid sarcoma or extramedullary myeloblastoma, is a rare solid tumour originating from primitive precursors of the granulocytic series of white blood cells. It can involve any part of the body. Granulocytic sarcoma is most commonly observed in patients with acute myelogenous leukaemia and less frequently with chronic myelogenous leukaemia or other myeloproliferative disorders [1, 2]. The mediastinum is the most common intrathoracic site of involvement [3]. Patients with granulocytic sarcomas are frequently asymptomatic. The imaging appearance of mediastinal granulocytic sarcomas is not specific with a wide differential diagnosis including lymphoma, thymoma, teratoma, infection/mediastinitis/abscess and haematoma. Therefore, the history of myelogenous leukaemia is an important hint towards the correct diagnosis in this case. However, even in patients with acute myelogenous leukaemia, granulocytic sarcoma is still rare (2.5-9.1% according to the literature [1]). Thus, the mediastinal soft-tissue mass found in the presented case may have other causes, such as infection or haematoma, and biopsy is required to establish the diagnosis. The presence of granulocytic sarcomas has no prognostic significance in acute leukaemia, but may be a sign of acute transformation in patients with chronic leukaemia or other myeloproliferative disorders [1]. Granulocytic sarcomas are highly sensitive to radiation and also chemotherapy, and commonly resolve after few months of treatment. Recurrence is seen in around 23% of cases [2]. Imaging with CT, MR and PET is useful in identifying granulocytic sarcomas, planning needle biopsy or radiation therapy, and evaluating therapeutic response [1, 4].",
    "differential_diagnosis": "Mediastinal, granulocytic, sarcoma, Lymphoma, Thymoma, Infection/mediastinitis, Haematoma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015218/000001.jpg?itok=fHUxaj5m",
            "caption": "CT in soft tissue kernel reconstruction showing a soft-tissue mass in the lower anterior mediastinum between the sternum and the heart, abutting the contour of the mediastinum towards the right lung and the pericardium."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015218/000002.jpg?itok=CdN65oXi",
            "caption": "CT in soft tissue kernel reconstruction showing a soft-tissue mass in the lower anterior mediastinum between the sternum and the heart, abutting the contour of the mediastinum towards the right lung and the pericardium."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015218/000003.jpg?itok=oYnrT12Z",
            "caption": "Hybrid 18F-FDG-PET/CT image showing increased uptake of FDG in the mediastinal soft-tissue mass."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015218/000004.jpg?itok=zN9TUios",
            "caption": "CT-guided biopsy revealing the final diagnosis."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Mediastinum"
    ],
    "imaging_technique": [
      "CT",
      "PET-CT"
    ],
    "link": "https://www.eurorad.org/case/15218",
    "time": "31.10.2017"
  },
  "15269": {
    "case_id": 15269,
    "title": "Pneumopericardium",
    "section": "Chest imaging",
    "age": "64",
    "gender": "female",
    "diagnosis": "Pneumopericardium resulting from fistulous communication with intra-abdominal abscess",
    "history": "A 64-year-old female patient, with the previous history of total splenectomy, total gastrectomy, partial left resection of the diaphragm and additional distal pancreatectomy for diffuse large B-cell lymphoma (DLBCL) presented at the emergency room with left quadrant abdominal pain. An abdominopelvic computed tomography (CT) examination was performed for further investigation.",
    "image_finding": "An abdominopelvic computed tomography (CT) was performed and revealed a left subdiaphragmatic abscess. A percutaneous image-guided drainage was performed with early clinical improvement. An upper gastrointestinal (UGI)\u00a0endoscopy\u00a0was performed and detected an oesophagojejunal anastomosis leakage, which was managed endoscopically with a covered metal stent.Two weeks post-admission, the patient developed sudden chest pain, and a chest-CT was requested. It revealed the presence of pneumopericardium, associated with pericardial and bilateral pleural effusion. Ancillary findings such as pericardial fluid high attenuation and enhancing of both layers of the pericardium suggested an inflammatory aetiology. We hypothesised that pneumopericardium was induced by a fistulous communication between the pericardium and the intra-abdominal abscess, apparently facilitated by prior left diaphragm resection. An iatrogenic aetiology, either during abdominal catheter or metal stent placement could not be excluded.",
    "discussion": "Pneumopericardium is a relatively rare condition, less common than isolated pneumomediastinum or pneumothorax. It was first described in 1844, and is defined by the presence of an air collection in the pericardial cavity, confined by pericardial reflections [1, 2]. In the adult population, many cases have been reported as a result of blunt or sharp trauma. Other aetiologies include iatrogenic causes related to invasive procedures such as thoracic surgery, thoracocentesis, endotracheal intubation, or positive pressure mechanical ventilation. Non-iatrogenic causes include an underlying infectious process or a fistulous communication between the pericardium and other air-containing structures such as the bronchus, gastrointestinal tract or abscess. There are also reports of spontaneous pneumopericardium in healthy adults [2, 3, 4].Clinical manifestations are variable and non-specific, and customarily includes chest pain, dyspnoea or palpitations.The symptoms are usually related to the extent of the pneumopericardium and underlying aetiology. In 37% of patients with pneumopericardium, cardiac tamponade may develop, increasing mortality to 58%. It occurs when the amount of pericardial gas is enough to impair right ventricular filling [2, 4]. As so, recognition of its imaging manifestations can be life-saving on a patient with pneumopericardium.The diagnosis of pneumopericardium is made by conventional chest radiographs or more accurately by chest CT [3]. Chest radiographs depict a continuous thin radiolucent rim of air encompassing the cardiac silhouette and outlined by a fine line, representing the pericardial sac. The main differential diagnosis includes pneumomediastinum. If present, pericardial effusion or thickening may aid in distinguishing these two entities [2, 3, 5]. In pneumomediastinum, gas doesn't surround the heart entirely and isn't confined to the heart region. It is seen as faint streaks of gas extending to the superior mediastinum and neck [2].Chest CT can efficiently confirm the diagnosis and is the mainstay of diagnosis of pneumopericardium in complex cases, easily demonstrating the heart being partially, or entirely, surrounded by air [3, 5, 6].The clinical course of pneumopericardium remains highly variable. The volume and speed of the constitution of pneumopericardium are the chief determinants that will conduct, along with the underlying aetiology, the therapeutic strategy. Although it can resolve spontaneously, in the presence of acute cardiac tamponade, an emergent pericardiocentesis is required to immediately restore haemodynamic stability, followed by pericardial fenestration/drainage [3, 5].For our patient, we hypothesised that pneumopericardium was induced by a fistulous communication between the pericardium and the intra-abdominal abscess. As clinical and ECG findings are nonspecific, recognition of its imaging manifestations can be life saving on a patient with pneumopericardium.",
    "differential_diagnosis": "Pneumopericardium, resulting, from, fistulous, communication, with, intra-abdominal, abscess, Pneumomediastinum, Pneumothorax",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015269/000001.jpg?itok=9XZYWDOT",
            "caption": "Axial CT demonstrating a left subdiaphragmatic abscess with a gas-filled cavity (arrow)."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015269/000002.jpg?itok=Xm1LNCqO",
            "caption": "Axial CT demonstrating a left subdiaphragmatic abscess with a gas-filled cavity (arrow)."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015269/000003.jpg?itok=5NlHdtit",
            "caption": "A percutaneous image-guided catheter drainage was performed (asterisk)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015269/000004.jpg?itok=0UdyN4-7",
            "caption": "Upper gastrointestinal endoscopy\u00a0detected a oesophagojejunal anastomosis leakage (arrow), which was managed endoscopically with a covered metal stent (asterisk)."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015269/000005.jpg?itok=nabGoBwH",
            "caption": "Upper gastrointestinal endoscopy\u00a0detected a oesophagojejunal anastomosis leakage (arrow), which was managed endoscopically with a covered metal stent (asterisk)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015269/000006.jpg?itok=bRS12rQv",
            "caption": "CT scanogram revealed pneumopericardium (asterisk), with air surrounding the cardiac border, that does not extend beyond the reflection of the aorta or the pulmonary artery."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015269/000007.jpg?itok=sFWpfTCT",
            "caption": "Axial CT image, lung window, showing the air surrounding the cardiac border (asterisk)."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015269/000008.jpg?itok=UxvnnWMV",
            "caption": "Axial CT image demonstrating enhancing of both layers of the pericardium (arrows) suggesting an inflammatory aetiology and bilateral pleural effusion (curved arrows)."
          },
          {
            "number": "Figure 3d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015269/000009.jpg?itok=I51oKnSD",
            "caption": "Axial CT image demonstrating enhancing of both layers of the pericardium (arrows) suggesting an inflammatory aetiology and bilateral pleural effusion (curved arrows)."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Abdomen",
      "Emergency"
    ],
    "imaging_technique": [
      "CT",
      "Fluoroscopy"
    ],
    "link": "https://www.eurorad.org/case/15269",
    "time": "03.01.2018"
  },
  "15289": {
    "case_id": 15289,
    "title": "ndobroncheal foreign body (bean)",
    "section": "Chest imaging",
    "age": "56",
    "gender": "male",
    "diagnosis": "Endobronchial foreign body (bean)",
    "history": "A patient with a history of smoking was admitted due to heavy coughing, fever and general malaise.",
    "image_finding": "The patient was initially submitted to a chest radiograph during the first clinical examination. The chest radiograph (AP) was consistent with loss of the right lung volume, with higher positioning of diaphragm and silhouette sign with the upper mediastinum, indicating upper right lobe atelectasis.A chest CT was requested. In the chest CT, on the upper bronchus, a nodular lesion with about 1 cm, well-defined and spontaneously higher density than soft tissue was detected. No enhancement of the lesion was apparent (although definite visual assessment or ROI measurements was difficult due to the small size). No hypo-enhancing areas suspicious of neoplasm were detected in the collapsed lung.",
    "discussion": "BACKGROUNDNon-asphyxiating airway foreign bodies is a problem more often associated with children, however in adults it can be difficult to diagnose as the symptoms are nonspecific. Completely obstructing lesions may lead to air resorption of the obstructed lung resulting in atelectasis (whole lung, lobar or segmental atelectasis depending on the obstruction site).Partially obstructing lesions \u2013 or when collateral air drift is possible - may mainly reduce air outflow resulting in airtrapping.Most common large airway causes of resorption atelectasis consist of neoplasia (the most common and worrisome cause in adults); inflammatory (tubercular or fungal infection); and other causes, such as mucous plugs, or foreign bodies. [1]CLINICAL PERSPECTIVEIn this case, an anomalous intraluminal lesion in a smoker raised concern for malignancy, despite some discrepant findings (such as non-enhancement and well-defined lesion).The patient was submitted to bronchoscopic assessment, for diagnosis and if possible clearance of an obstructing cause.In this case, successful retrieval of a baked bean was achieved.IMAGING PERSPECTIVEImaging findings on obstructing lesions depend on the degree of obstruction. Direct signs of atelectasis are crowded pulmonary vessels, crowded air bronchograms, and displacement of the interlobar fissures. Indirect signs of atelectasis are pulmonary opacification; elevation of the diaphragm; shift of the trachea, heart, and mediastinum; displacement of the hilus; compensatory hyperexpansion of the surrounding lung; approximation of the ribs; and shifting granulomas.When air trapping is the main finding, lung hyperinflation occurs. This may be more easily detected on expiratory films (in children unable to comply, side decubitus may also work as a \u201cforced expiratory\u201d technique).CT is the most precise technique for anatomical detection and characterisation of an obstructing lesion, and may allow distinction of a proximal obstructing lesion from adjacent mediastinal structures and lung after contrast administration as neoplastic lesions tend to not enhance as avidly as collapsed lung. [2]In a previous case report, spontaneously hyperdense non-metalic foreign bodies in the stomach were noted in a patient who had previously eaten baked beans. [3] To our knowledge, this is the first time the CT appearance of an obstructing bean in the bronchus, that was retrieved, was described. TEACHING POINTS: Non-asphyxiating foreign-body aspiration in adults can be difficult to diagnose because the symptoms are nonspecific. Special attention should be paid to findings suggesting focal hyper-inflation or resorptive atelectasis.CT allows the best anatomical depiction of lesions, likely nature, and contribution for further diagnostic or therapeutic approach.",
    "differential_diagnosis": "Endobronchial, foreign, body, (bean), Endobronchial, neoplasia, High, attenuation, mucoid, impaction, in, allergic, bronchopulmonary, aspergillosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015289/000001.png?itok=0HLi_LM1",
            "caption": "AP Chest Radiograph during admission consistent with right upper lobe atelectasis."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015289/000002.png?itok=ZdQUKi1Z",
            "caption": "Axial reformat of non-contrast chest CT showing an hyper-attenuating small lesion at the emergence of the right upper lobe."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015289/000003.png?itok=w4EnQxyU",
            "caption": "Coronal reformat of non-contrast CT showing no relation of the hyper-attenuating lesion to the interlobar bronchi, and further showing it's location in the upper lobe."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015289/000004.png?itok=VlZsC7Yw",
            "caption": "Post-contrast CT showed no visible lesion in the mediastinum, nor an existence of an hypo attenuating lesion comparing to the lung parenchyma."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Thorax"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/15289",
    "time": "07.12.2017"
  },
  "15314": {
    "case_id": 15314,
    "title": "Pneumocystis jirovecii pneumonia as an initial presentation of AIDS",
    "section": "Chest imaging",
    "age": "34",
    "gender": "male",
    "diagnosis": "Pneumocystis jirovecii pneumonia",
    "history": "A 34-year-old male patient was referred to the emergency department for a cough with expectoration, dyspnoea, fever, anorexia and weight loss (8kg) for one month. At physical examination he had white lesions in the oral cavity. He referred a personal history of unprotected sex.",
    "image_finding": "Chest X-ray showed bilateral ground-glass opacities and a right basal consolidation (Fig. 1a, 1b). A chest CT was also performed. It revealed multiple bilateral ground-glass opacities with central distribution and a consolidation in the right middle lobe (RML)(Fig. 2a-2b). There was also a smooth septal thickening in the right lower lobe (RLL) (not shown). No pleural effusion was observed.A laboratory and serological test were performed. The patient was HIV-positive. The leukocyte count was 3, 300 (CD4: 16 cells / mm3). In the bronchoalveolar lavage fluid pneumocystis jirovecii (PCJ) was identified. In the oropharyngeal exudate, candida was isolated too. Finally, the patient was diagnosed with pneumocystis jirovecii pneumonia (PJP), HIV primo-infection, and oral candidiasis.",
    "discussion": "Subacute pneumonia is a key diagnostic clue between two main aetiologies: tuberculosis and PJP. PJP is the most frequent opportunistic infection in HIV-positive patients. It usually develops when CD4< 200 cells/mm3 [1]. The characteristic findings in the chest X-Ray are nonspecific: tenuous opacities with central predominance, a reticular or nodular pattern [2]. In addition, one-third of infected patients may have a normal chest X-Ray [1]. CT is more sensitive to detect the disease. Features include ground-glass opacities predominantly involving perihilar or middle zones of the lung, reticular opacities or septal thickening and pulmonary cysts of varying shape and size. Cysts are associated with an increase of pneumothorax risk. [1, 2]. Pleural effusion and lymphadenopathies are rare.In our case, the diagnosis was suspected with the combination of chest X-Ray findings, the subacute presentation, the presence of sexual risk behaviour and the oral lesions. All of them, make us suspect the possibility of PJP as a first presentation of a HIV infection. Otherwise, the differential diagnosis of ground glass opacities of the lung is broad and highly nonspecific; thus, taht is why a clinical scenario is essential to narrow the diagnosis. In fact, hypersensitive pneumonitis is probably the most common cause in isolated ground glass opacities of the lung in normal hosts [3].Ground glass opacification disorders can be split into 4 categories: diffuse pneumonias, chronic interstitial diseases, acute alveolar diseases; and other unusual disorders like drug toxicity or pulmonary alveolar proteinosis [3]. Our case is included in the group of immunocompromised patients (HIV +, transplanted patients or patients with high-dose corticosteroid treatment). In this scenario, opportunistic infections should be considered as the first diagnostic option. PJP remains the most common opportunistic infection in this population. Other possibilities could be cytomegalovirus or herpes simplex virus pneumonias. Imaging findings of cytomegalovirus include ground glass opacities predominantly and in some cases micronodules and consolidations. This is why PCJ and CMV pneumonias often have similar imaging findings and cannot be distinguished radiologically [3].Herpes simplex virus pneumonia may appear as ground glass opacities or/and widespread consolidations. Rarely, only ground glass opacities will be present. Small pleural effusions are common [3]. Treatment of choice of PCP is trimethoprim-sulfamethoxazole [1]. The same agent may be used as prophylaxis.Prognosis of PCP in HIV patients is good with a 10% mortality rate. However, PCP has an ominous prognosis in non-HIV patients, with a 30\u201360 % mortality rate [3].",
    "differential_diagnosis": "Pneumocystis, jirovecii, pneumonia, Pneumocystis, jirovecii, pneumonia, Herpes, simplex, virus, pneumonia, Cytomegalovirus, pneumonia, Subacute, hypersensitivity, pneumonitis, Respiratory, distress, Pulmonary, alveolar, oedema",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015314/000001.jpg?itok=53fVs-E5",
            "caption": "Chest radiograph shows multifocal patchy opacities (asterisk) predominantly involving perihilar zone and a consolidation in RML (arrow). No pleural effusion."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015314/000002.jpg?itok=1tG4uGSy",
            "caption": "Chest radiograph shows multifocal patchy opacities (asterisk) predominantly involving perihilar zone and a consolidation in RML (arrow). No pleural effusion."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015314/000003.jpg?itok=IVlbOz-l",
            "caption": "Diffuse bilateral ground glass opacities with central distribution (asterisk)."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015314/000004.jpg?itok=cCPi3nxN",
            "caption": "Diffuse\u00a0bilateral\u00a0ground glass opacities (asterisk) with central distribution. There is also small\u00a0area of focal consolidation in RML (arrow)."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/15314",
    "time": "17.12.2017"
  },
  "15329": {
    "case_id": 15329,
    "title": "xtrahepatic manifestations of pulmonary hydatidosis. About a case in an endemic zone in South America, Chile",
    "section": "Chest imaging",
    "age": "14",
    "gender": "male",
    "diagnosis": "Ruptured pulmonary hydatid cyst (confirmed by biopsy)",
    "history": "A 14-year-old young male patient from a rural area with a history of trauma was consulted for pain and haemoptysis in the emergency room.",
    "image_finding": "Chest x-ray reveals presence of air-fluid level in the lower third of the left hemithorax. Computed tomography confirms the presence of a cystic lesion with air - fluid level, internal membranes \"floating\", serpinginous hyperattenuating membranes and pleural effusion. He undergoes surgery. Uncomplicated postoperative course.",
    "discussion": "Background: Hydatid disease is a parasitic zoonosis produced by the larval stage of Echinococcus tapeworm [1].\nClinical perspective: This pathology is an endemic entity in some countries of the world, mainly in agricultural and livestock areas, South America [1] being an example, especially in Chile.\nIt is important to spread the imaging findings, since there are sectors in Europe with high infection rates, which may present similar manifestations (Mediterranean region). [1]\nImaging perspective: This disease affects the liver, presenting characteristic imaging findings. However, secondary involvement due to haematogenous dissemination may occur in almost every other part of the body (lung, kidneys, spleen, brain, bone). Pulmonary involvement is the most frequent site of haematogenous dissemination in children and the second in adults. [1]\nRupture of a cyst is the most frequent complication. [2]\nThe modalities of study are radiography and computed tomography. CT is the modality of choice for diagnosis of complicated hydatid cyst. [2]\nKey findings: In X-ray the presence of an air-fluid level is a sign of a complicated cyst. In CT the presence of a cystic lesion with air-fluid level and floating membranes (water lily sign), serpinginous hyperattenuating membranes (\u201cserpent sign\u201d) and pleural effusion suggest a complicated cyst. [2]\nTeaching points: Imaging of pulmonary complicated cyst in a patient in an endemic area.",
    "differential_diagnosis": "Ruptured, pulmonary, hydatid, cyst, (confirmed, by, biopsy), Lung, abscess, Tuberculosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015329/000001.jpg?itok=z-r1xQSL",
            "caption": "It is noted an air-fluid level in the lower left lobe."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015329/000002.jpg?itok=bM9JXiMp",
            "caption": "Mediastinal window. Lower left lobe cyst with air-fluid level, \"floating\" membranes and pleural effusion."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015329/000003.jpg?itok=GP6ijnAj",
            "caption": "Lung window."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015329/000004.jpg?itok=ALY6tlW0",
            "caption": "Mediastinal window. Lower left lobe cyst with serpingenous hyperattenuating membranes."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/15329",
    "time": "26.12.2017"
  },
  "15352": {
    "case_id": 15352,
    "title": "Atypical chest pain caused by spontaneous pneumomediastinum",
    "section": "Chest imaging",
    "age": "17",
    "gender": "male",
    "diagnosis": "Primary spontaneous pneumomediastinum",
    "history": "A 17-year-old male patient with no past medical history presented with a 24-hour history chest pain radiating to the anterior aspect of the neck. Physical examination revealed normal vital signs. Swelling and crepitus involving the bilateral anterolateral aspects of the neck and the submandibular fossae were noted.",
    "image_finding": "A chest X-ray, in addition to pneumomediastinum and pneumopericardium, revealed supraclavicular, para-tracheal and infrahyoid emphysema. A computed tomography of the thorax showed pneumopericardium with air dissecting from the diaphragm crus through the posterior, middle, anterior and superior mediastinum. There was also diffuse bilateral supra-clavicular, pre-tracheal, carotid, posterior cervical, retro-pharyngeal space and bilateral axillary surgical emphysema. No parenchymal lung disease was detected. A water soluble contrast fluoroscopic examination of the oesophagus revealed no evidence of extravasation or leak of contrast.",
    "discussion": "Background:Spontaneous pneumomediastinum is the presence of air within mediastinum structures. The condition is considered rare with a reported incidence of 1/42, 000 of admissions [1]. Spontaneous pneumomediastinum has been recognised at least since 1819 but it was Hamman who initially reported a case series in 1937 and revisited the disease in 1939 [1-3]. Physiopathology is related to alveolar rupture and gas dissection through the bronchovascular fascia followed by pulmonary interstitial dissemination to the mediastinum as described by Macklin in 1939 [4].Clinical Perspective:Chest pain, the predominant presenting feature affecting 55% of patients, is typically retrosternal and may have a pleuritic character. Dyspnoea, cough and neck pain occur in 40%, 32%, and 17% of patients, respectively [5, 6]. Subcutaneous emphysema may complicate 60% of cases [7, 8]. Hamman's sign, a crunching, rasping sound, synchronous with systole may be present in 50% of patients [3, 8]. The disease can be either primary or secondary to trauma. Other triggers include coughing, balloon inflation, aviation, vomiting, and oesophageal rupture [9, 10, 11, 12]. The role of cocaine has also been described [13]. In the paediatric cohort, acute asthma exacerbation [7, 14] and lower respiratory tract infections are the predominant causes [7, 14-16]. In 21% of cases no cause is found [17].Radiological Perspective:Radiologically, a number of signs such as the Naclerio's V sign, V sign at confluence of brachiocephalic veins and ring-around-the-artery sign can be observed as lucent streaks of gas outline mediastinal structures [18]. Additional signs include tubular artery, double bronchial wall and haystack signs. Other abnormalities such as pneumothorax, pleural effusion (which may indicate oesophageal rupture), and signs of chronic lung disease may be noted. Computed tomography is usually not indicated unless in patients with underlying lung disease. Contrast oesophagography is helpful if oesophageal rupture is suspected as a cause.Outcome:The management of uncomplicated spontaneous pneumomediastinum is conservative and includes analgesia, rest, oxygen, and avoidance of manoeuvres that increase pulmonary pressure. Although evidence is limited, air travel is usually permitted two weeks after radiographic resolution. In cases with complications such as pneumothorax, management should target the specific complication. The natural history of the disease is benign. Although approximately 5% of cases may recur, the outcome is favarouble [19].Take Home Message:Spontaneous pneumomediastinum is a rare, generally benign cause of chest pain.Radiologically, streaks of air are observed outlining mediastinal structures.In one fifths of cases no trigger is identified.",
    "differential_diagnosis": "Primary, spontaneous, pneumomediastinum, Medial, pneumothorax, Pneumopericardium, Pneumoperitoneum",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015352/000001.jpg?itok=ig2ey9Wm",
            "caption": "A plain chest x-ray showing pneumomediastinum, pneumopericardium, supraclavicular, axillary and neck surgical emphysema."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015352/000002.jpg?itok=doX7Wyor",
            "caption": "Axial computed tomographic image of the neck. There is diffuse supraclavicular, axillary, pre-tracheal and carotid surgical emphysema."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015352/000003.jpg?itok=xo4V_k8e",
            "caption": "Axial computed tomographic image of the thorax showing pneumomediastinum and pneumopericardium with axillary and pretracheal surgical emphysema."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015352/000004.jpg?itok=_fEamWmL",
            "caption": "Axial computed tomographic image of the thorax showing pneumomediastinum and pneumopericardium."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015352/000005.jpg?itok=z1ZDZetq",
            "caption": "Axial computed tomographic image of the thorax showing pneumomediastinum and pneumopericardium."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015352/000006.jpg?itok=1VsFhNk_",
            "caption": "A fluoroscopic water soluble contrast swallow scan showing no evidence of extravasation of contrast indicating no oesophageal tear or rupture."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015352/000007.jpg?itok=ooBrqvcF",
            "caption": "A fluoroscopic water soluble contrast swallow scan showing no evidence of extravasation of contrast indicating no oesophageal tear or rupture."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015352/000008.jpg?itok=8Uubf48E",
            "caption": "A fluoroscopic water soluble contrast swallow scan showing no evidence of extravasation of contrast indicating no oesophageal tear or rupture."
          },
          {
            "number": "Figure 3d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015352/000009.jpg?itok=pqbf-hfP",
            "caption": "A fluoroscopic water soluble contrast swallow scan showing no evidence of extravasation of contrast indicating no oesophageal tear or rupture."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Education",
      "Cardiac",
      "Thorax",
      "Oesophagus"
    ],
    "imaging_technique": [
      "Digital radiography",
      "CT",
      "Conventional radiography",
      "Fluoroscopy"
    ],
    "link": "https://www.eurorad.org/case/15352",
    "time": "17.12.2017"
  },
  "15360": {
    "case_id": 15360,
    "title": "Tracheobronchial metastasis from rectal cance",
    "section": "Chest imaging",
    "age": "61",
    "gender": "male",
    "diagnosis": "Progressive disease with endobronchial metastasis from rectal adenocarcinoma.",
    "history": "Follow-up examination of a rectal adenocarcinoma with known lung metastases receiving chemotherapy: response evaluation.\nPrevious medical history of rectum resection (adenocarcinoma) and lobectomy of the middle lobe and segmentectomy from the right upper lobe (metastasis).",
    "image_finding": "Formation of a small endoluminal irregularity adherent to the left tracheobronchial wall (diameters 10 mm anteroposterior x 5 mm laterolateral x 8 mm craniocaudal), density 80 HU, review of a PET-CT 3 weeks prior already showed a smaller lesion.\nRecurrence of a nodular lesion in the right hilum in the basal part of the RUL.\nPlate-shaped compaction against the horizontal fissure with suture material and nodular component posteromedial: presumably atelectasis.\nUnchanged volume of the right infrahilar lymph gland. No lymphadenopathies.\nNo skeletal metastases. No intra-abdominal recurrence.\n\nCONCLUSION: Disease progression. Nodular recurrence in the RUL and formation of a endobronchial mass, both suspect for metastases until proven otherwise.\n\nBronchoscopy with biopsy was performed and pathologic examination showed well-differentiated intestinal type adenocarcinoma, appropriate for metastatic localisation of the known colorectal carcinoma.",
    "discussion": "Tracheobronchial tumours are rare (<0, 4% of all tumours, <1% of all thoracic tumours) and classified as primary or secondary. [1, 2] Ninety percent of primary tracheobronchial tumours are malignant. [1] The remaining 10% are primary benign tracheobronchial tumours which are predominantly small (<2cm), mostly from mesenchymal origin and have a smooth contour as a consequence of their submucosal location. [2]\nSecondary malignant tumours are most commonly the result of direct invasion or secondly, by haematogenous spread. Most common primary malignancies are melanoma or kidney-, breast-, colorectal-, or hepatocellular cancer. [3]\n\nOnly when 50-75% of the luminal diameter is occluded symptoms of upper airway obstruction occur (dyspnoea, wheezing, stridor), possibly obscuring pathology for months or even years. [1] Other possible symptoms are cough and haemoptysis due to mucosal irritation or dysphagia or recurrent laryngeal nerve palsy due to invasion.\n\nSquamous cell carcinoma is the most common primary tracheobronchial malignancy, presenting in the 6th & 7th decades of life. [4] Men are more affected and prior tobacco use is frequent. [1] An irregular contour is typical because it arises from the surface epithelium, mostly the posterior wall of the lower trachea. It co-occurs frequently with cancer of the oropharynx, larynx or lung in 40%. Lung- and mediastinal metastases at presentation are unfortunately frequent.\nAdenoid cystic carcinoma of salivary origin is the second most common primary tracheobronchial malignancy, has equal sex distribution and occurs in the 4th & 5th decades of life. These also have a smooth contour as a consequence of their submucosal location. [5] Their submucosal circumferential and infiltrative growth can cause a remarkable craniocaudal extent, requiring multiplanar reconstructions for correct interpretation.\nMucoepidermoid carcinoma tends to occur in younger patients and more distally (in the lobar or segmental bronchi) as an intraluminal nodule, associated with atelectasis, mucus plugging and sometimes obstructive pneumonia. [6]\nCarcinoid tumours are frequently of thoracic origin (25%) and are so-called 'iceberg' tumours (having a large extraluminal component and a smalller smooth intraluminal nodular component) with intense enhancement due to their intrinsically high vascularity. [7] Metabolic uptake on FDG-PET is comparatively lower than other thoracic malignancies. [8]\n\nSecondary malignant tumours predominantly invade directly with an apparent extramural source. [6] Haematogenous metastatic disease manifests as solitary or multiple nodules, sometimes with the \u201cfinger-in-glove\" appearance, or as eccentric wall thickening. [9-11] Most common presentation is atelectasis, with or without endoluminal lesion. Differential diagnosis with a primary bronchogenic carcinoma can be difficult. [12]",
    "differential_diagnosis": "Progressive, disease, with, endobronchial, metastasis, from, rectal, adenocarcinoma., Mucus, plug, Bronchogenic, carcinoma, (second, primary), Metastasis, Lymphadenopathy, with, endobronchial, invasion, Left, hilar, mass, with, endobronchial, invasion, Carcinoid, tumour, Squamous, cell, carcinoma, (second, primary), Adenoid, cystic, carcinoma, (second, primary)",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015360/000003.jpg?itok=xn_O7NZL",
            "caption": "Coronal reformatted contrast enhanced CT in lung window:\nSmall endoluminal irregularity adherent to the left tracheobronchial wall (diameters 10 mm anteroposterior x 5 mm laterolateral x 8 mm craniocaudal), density 80 HU with foci of 120 HU."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015360/000001.jpg?itok=E4OHB7lb",
            "caption": "Axial contrast enhanced CT in lung window:\nSmall endoluminal irregularity adherent to the left tracheobronchial wall (diameters 10 mm anteroposterior x 5 mm laterolateral x 8 mm craniocaudal), density 80 HU with foci of 120 HU."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015360/000002.jpg?itok=vGXljT9J",
            "caption": "Axial contrast enhanced CT in lung window:\n\nRecurrence of a nodular lesion measuring 26 mm in diameter in the right hilum in the basal part of the RUL."
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015360/000004.jpg?itok=3w2EYD8f",
            "caption": "Sagittal reformatted contrast enhanced CT in lung window:\nSmall endoluminal irregularity adherent to the left tracheobronchial wall (diameters 10 mm anteroposterior x 5 mm laterolateral x 8 mm craniocaudal), density 80 HU with foci of 120 HU."
          },
          {
            "number": "Figure 1e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015360/000010.jpg?itok=s41IdloA",
            "caption": "Axial contrast enhanced CT in mediastinal window:\nSmall endoluminal irregularity adherent to the left tracheobronchial wall (diameters 10 mm anteroposterior x 5 mm laterolateral x 8 mm craniocaudal), density 80 HU with foci of 120 HU."
          },
          {
            "number": "Figure 1f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015360/000011.jpg?itok=OWbRMcfz",
            "caption": "Axial contrast enhanced CT in mediastinal window:\n\nRecurrence of a nodular lesion measuring 26 mm in diameter in the right hilum in the basal part of the RUL."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015360/000005.png?itok=I7N-Ri_V",
            "caption": "Native CT images of the PET-CT (3 weeks prior), axial reformatted:\n\nRetrospective of a small lesion on the left lateral wall of the distal trachea can be seen."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015360/000006.png?itok=1c0mqmxV",
            "caption": "Native CT images of the PET-CT (3 weeks prior), coronal reformatted:\n\nRetrospective a small lesion on the left lateral wall of the distal trachea can be seen."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015360/000007.png?itok=Y8n6Y0Ik",
            "caption": "PET-CT fusion image (3 weeks prior) shows discrete metabolic activity of the smaller lesion on the left tracheal wall, but difficult to ascertain due to the size."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015360/000008.png?itok=TauNHOfG",
            "caption": "PET-CT fusion image (3 weeks prior) shows high metabolic activity of the right hilar mass."
          },
          {
            "number": "Figure 2e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015360/000009.png?itok=B03xTjVa",
            "caption": "PET-CT fusion image (3 weeks prior) shows high metabolic activity of the right hilar mass, probably discrete metabolic activity of the smaller lesion on the left tracheal wall but difficult to ascertain."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015360/000015.png?itok=6Wil8XpV",
            "caption": "Surface volume rendering at level of carina shows endoluminal mass from the left tracheobronchial angle."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015360/000014.png?itok=B1gPz2ja",
            "caption": "Surface volume rendering at level of carina shows endoluminal mass from the left tracheobronchial angle."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015360/000013.png?itok=6mbL9T-S",
            "caption": "Pulmo 3D reconstruction showing endoluminal impression originating from the left tracheal wall corresponding to tracheal mass."
          },
          {
            "number": "Figure 3d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015360/000012.png?itok=weu5113m",
            "caption": "Pulmo 3D reconstruction showing endoluminal impression from the left tracheal wall corresponding to tracheal mass."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015360/000018.png?itok=nO5d0QRC",
            "caption": "Trachea: Mucosal lesion at left tracheobronchial angle with additional bronchoscopic biopsy. Pathologic examination revealed adenocarcinoma, compatible with metastasis of known rectal adenocarcinoma."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015360/000017.png?itok=twiPhdWa",
            "caption": "Trachea: Mucosal lesion at left tracheobronchial angle with additional bronchoscopic biopsy. Pathologic examination revealed adenocarcinoma, compatible with metastasis of known rectal adenocarcinoma."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "CT-High Resolution",
      "PET-CT",
      "Image manipulation / Reconstruction"
    ],
    "link": "https://www.eurorad.org/case/15360",
    "time": "09.01.2018"
  },
  "15367": {
    "case_id": 15367,
    "title": "Lymphomatoid granulomatosis",
    "section": "Chest imaging",
    "age": "71",
    "gender": "male",
    "diagnosis": "Lymphomatoid granulomatosis",
    "history": "A 71-year-old male patient presented with a 6-month history of upper abdominal pain radiating to the back, fatigue and 10 kg weight loss.",
    "image_finding": "A thoracoabdominal CT (Fig 1) revealed bilateral heterogeneous adrenal masses, multiple bilateral pulmonary nodules and a soft-tissue lesion next to 10th dorsal vertebrae, without bony injury. The body PET-CT (Fig 2) performed for screening of primary neoplasm showed increased uptake of FDF in both adrenal masses, thoracic soft-tissue lesion and diffusely in pulmonary fields. A focal increased uptake was seen in right renal cortex.Follow up PET-CT (Fig 3) performed 3 months later showed enlargement of pulmonary nodules and right adrenal mass. The hypermetabolic focus of right renal cortex increased significantly, corresponding to a focal cortical lesion visible on CT. Several foci of increased uptake were seen in brain parenchyma.Cranial MRI (Fig 4) showed two large right occipital and left temporo-occipital lesions with large surrounding oedema without significant mass effect,  ring enhancement, intralesional peripheral haemorrhage, low ADC values and low perfusion. Left laparoscopic adrenalectomy finally revealed the diagnosis of lymphomatoid granulomatosis.",
    "discussion": "Lymphomatoid granulomatosis (LYG) is a very rare B-cell extranodal lymphoproliferativedisorder. There is an angiocentric and angiodestructive accumulation of atypical B-cell lymphocytes infected by Epstein-Barr virus (EBV) and reactive T-cell lymphocytes. Lymphoid cells directly accumulate within affected tissues in the form of infiltrative nodular lesions [1, 3]. LYG is closely related to host's underlying immune system. Although most patients do not have a preexisting diagnosis of an immunodeficiency, evidence of immune dysregulation can be found in almost all. Patients may have a history of recurrent infections, autoimmune illnesses, other lymphoproliferative disorders or be under innmunosuppressive treatment [1]. LYG generally presents in men between the third and fifth decades of life, although patients can be affected at any age [4].Constitutional symptoms such as weight loss, fever and fatigue are present in most patients.Lungs are virtually always involved in LYG,  characteristically in the form of multiple bilateral pulmonary nodules of variable size in a bronchovascular distribution, mainly in mid and lower lung fields. In 30% cavitation caused by necrosis is seen. Marked accumulations of FDG are seen on 18F-FDG-PET/CT. Since LYG is an extranodal lymphoproliferative disorder,  there is no hilar lymphadenopathy [1, 3]. CNS involvement occurs in 25-50% of cases, showing multiple focal asymptomatic lesions involving the white matter, deep gray matter or brainstem, characterised by punctate linear enhancement. Larger lesions may be solid or demonstrate ring enhancement. They have variable surrounding oedema and may be associated with leptomeningeal enhancement [1, 2].Involvement of the kidneys (40-50%),  focal nodular lesions without organ dysfunction, and skin (25%-50%),  subcutaneous-dermal nodules and purplish eruptions that can ulcerate, is also frequently seen [1].Histopathologic grading of LYG is performed depending on the number of EBV-positive atypical B-cells: grade I <5 lymphocytes in a highpower field, grade II, 6-19, grade III >20.LYG has a poor prognosis, with mortality over 60% after 5 years. Management depends principally on the histopahologic grade. Patients taking immunosuppressive treatments should stop them. In low-grade cases a brief period of observation may be justified, as some will undergo spontaneous remission. High-grade LYG requires immediate therapy, generally with combined chemotherapy [1, 4]. The rareness of LYG and its nonspecific presentation contributes to delays in diagnosis. Considering that pulmonary manifestations are characteristic and almost always present, LYG should be included in the differential diagnosis of pulmonary processes that share those manifestations, so EBV-encoded RNA in situ hybridisation (ISH) can be ordered on biopsy specimens.",
    "differential_diagnosis": "Lymphomatoid, granulomatosis, Granulomatosis, with, polyangiitis, Eosinophilic, granulomatosis, with, polyangiitis, Tuberculosis, Sarcoidosis, Non-hodgkin, lymphoma, Lung, metastases",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015367/000005.jpg?itok=QQHJksL_",
            "caption": "Bilateral heterogeneous adrenal masses, suspicious of malignancy."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015367/000036.jpg?itok=u8EgYRcV",
            "caption": "MIP reconstruction of the lung showing pulmonary nodules."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015367/000038.jpg?itok=3WUKLBfT",
            "caption": "MIP reconstruction of the lung showing pulmonary nodules."
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015367/000039.jpg?itok=16W_klKX",
            "caption": "Pulmonary nodules."
          },
          {
            "number": "Figure 1e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015367/000040.jpg?itok=sjTSmXDD",
            "caption": "Pulmonary nodules."
          },
          {
            "number": "Figure 1f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015367/000004.jpg?itok=Kr808czk",
            "caption": "Soft-tissue lesion next to 10\u00ba dorsal vertebrae."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015367/000008.jpg?itok=quIif__G",
            "caption": "Increased uptake of FDF in both adrenal masses."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015367/000007.jpg?itok=WFNOFgwF",
            "caption": "Focal increased uptake in right renal cortex."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015367/000009.jpg?itok=JWB-9DWG",
            "caption": "Increased uptake of FDF in thoracic soft-tissue lesion."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015367/000010.jpg?itok=PJvAbVvd",
            "caption": "Diffusely increased uptake of FDF in pulmonary fields."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015367/000026.jpg?itok=AnGNeH9h",
            "caption": "T1."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015367/000025.jpg?itok=Ih33A0L8",
            "caption": "T1 gadolinium."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015367/000027.jpg?itok=Bc9srURW",
            "caption": "T1 coronal."
          },
          {
            "number": "Figure 3d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015367/000024.jpg?itok=bdl92b_b",
            "caption": "T1 gadolinium coronal."
          },
          {
            "number": "Figure 3e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015367/000028.jpg?itok=5x_VPF7D",
            "caption": "FLAIR."
          },
          {
            "number": "Figure 3f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015367/000029.jpg?itok=fMk6SDo6",
            "caption": "FLAIR coronal."
          },
          {
            "number": "Figure 3g",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015367/000016.jpg?itok=--bKrWvs",
            "caption": "Perfusion."
          },
          {
            "number": "Figure 3h",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015367/000030.jpg?itok=96OzJyqN",
            "caption": "SWI."
          },
          {
            "number": "Figure 3i",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015367/000031.jpg?itok=n1-FwDHJ",
            "caption": "SWI."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015367/000041.jpg?itok=m3Ya5VCf",
            "caption": "Right renal cortex lesion."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015367/000042.jpg?itok=pUKSbEcB",
            "caption": "Right adrenal mass."
          },
          {
            "number": "Figure 4c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015367/000022.jpg?itok=Dyk8FPde",
            "caption": "Soft-tissue lesion."
          },
          {
            "number": "Figure 4d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015367/000019.jpg?itok=QmRmjj7N",
            "caption": "Cerebral foci of FDG increased uptake."
          },
          {
            "number": "Figure 4e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015367/000043.jpg?itok=KBLflgmo",
            "caption": "Pulmonary nodules."
          },
          {
            "number": "Figure 4f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015367/000044.jpg?itok=W_kk2eNW",
            "caption": "Pulmonary nodules."
          },
          {
            "number": "Figure 4g",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015367/000045.jpg?itok=sRyp1SwP",
            "caption": "Pulmonary nodules."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Adrenals",
      "Lung",
      "Thoracic wall",
      "Kidney",
      "Thorax",
      "Neuroradiology brain"
    ],
    "imaging_technique": [
      "CT",
      "PET-CT",
      "MR",
      "MR-Diffusion/Perfusion"
    ],
    "link": "https://www.eurorad.org/case/15367",
    "time": "20.02.2018"
  },
  "15422": {
    "case_id": 15422,
    "title": "Pulmonary Langerhans cell histiocytosis in an early stage",
    "section": "Chest imaging",
    "age": "50",
    "gender": "female",
    "diagnosis": "Pulmonary Langerhans cell histiocytosis (early/nodular stage)",
    "history": "A 50-year-old female patient with a recently diagnosed left breast cancer, underwent chest CT for cancer staging. She was a smoker, diagnosed with mild chronic obstructive pulmonary disease (COPD) 4 years before. Occasional dyspnoea on exertion. No chest pain. Afebrile. No evidence of cyanosis, lymphadenopathy or clubbing.",
    "image_finding": "Chest CT (Fig. 1-3) shows innumerable nodules, with ill-defined margins and measuring less than 10 mm, with centrilobular location. They are predominantly distributed in the upper lobes. A few cavitated nodules can be seen posteriorly in the left lower lobe (Fig. 1d).A chest CT performed 5 months later showed complete resolution of the aforementioned nodules (Fig. 4).",
    "discussion": "Langerhans Cell Histiocytosis (LCH) is a disorder characterised by the accumulation of LCs in different organs and tissues [1]. LCH may affect an isolated organ (an entity previously known as eosinophilic granuloma) or may present as a multisystemic disease [2]. Pulmonary involvement of Langerhans Cell Histiocytosis (PLCH) is rare, occurring almost exclusively in smokers and affecting mainly young adults between the ages of 20 and 40 [3].There is no gender preference. Pathologically PLCH consists of an accumulation of Langerhans cells (and other inflammatory cells) in small airways, which results in the formation of nodular inflammatory lesions. This may be accompanied by variable lung vascular and interstitial involvement [2]. Whilst cellular inflammation is prominent in early disease, cystic lung destruction, cicatricial scarring of the small airways and vascular remodelling are the hallmark of more advanced stages [2]. Patients with PLCH commonly present with unspecific symptoms such as non-productive cough or dyspnoea [3]. They may, however, be entirely asymptomatic. Chest radiographs are usually abnormal, showing reticulonodular infiltrates in early disease and cystic lesions in advances stages [4]. High resolution computed tomography (HRCT) should be obtained in every patient. Nodules (with or without cavitation) measuring 1 to 10mm with a centrilobular location are often seen in early stages [5], as in our case. Pulmonary cysts, although seen in any stage of disease, are more commonly found in more advanced disease [6]. Their wall may be thin or thick (up to 20 mm). This pattern of nodular and cystic changes is usually distributed in the upper and middle lobes (with relative sparing of lung bases) [5], although our patient presented with cysts in the left lower lobe.Typical chest CT features may be sufficient for establishing a presumptive diagnosis. However, when findings are non-diagnostic (predominant lower lobe involvement, cystic changes without nodules or nodular changes without cysts), either transbronchoscopic or surgical lung biopsy may be required [2]. Due to the patient's oncologic history, she was submitted to surgical lung biopsy of the nodules at another institution, which confirmed PLCH. Prognosis is variable and unpredictable.Smoking cessation is fundamental and may lead to disease regression [7]. Immunosuppressive agents should be considered for all adults with severe disease [2]. Our patient showed complete spontaneous resolution without immunosuppressive agents or smoking cessation.",
    "differential_diagnosis": "Pulmonary, Langerhans, cell, histiocytosis, (early/nodular, stage), Miliary, tuberculosis, Wegener, granulomatosis, Metastases, Sarcoidosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015422/000001.png?itok=rgzG4QBk",
            "caption": "Upper segments"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015422/000002.png?itok=PERGJOLf",
            "caption": "Middle segments"
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015422/000003.png?itok=06Lgozbw",
            "caption": "Lower segments"
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015422/000004.png?itok=bZH_8YNV",
            "caption": "Cavitated nodules in the left lower lobe"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015422/000005.png?itok=kJH-1AxT",
            "caption": "Anterior segments"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015422/000006.png?itok=ruUxHDR7",
            "caption": "Middle segments"
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015422/000007.png?itok=fIFMKDSx",
            "caption": "Posterior segments"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015422/000008.png?itok=d6yTxW1u",
            "caption": "Left lung"
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015422/000009.png?itok=TgMKZiJL",
            "caption": "Right lung - medial"
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015422/000010.png?itok=xI-qzZcH",
            "caption": "Right lung - lateral"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015422/000011.png?itok=V8nxBeLg",
            "caption": "Upper segments"
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015422/000012.png?itok=p6vKqWqX",
            "caption": "Middle segments"
          },
          {
            "number": "Figure 4c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015422/000013.png?itok=d-S5oovf",
            "caption": "Lower segments"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/15422",
    "time": "28.02.2018"
  },
  "15425": {
    "case_id": 15425,
    "title": "Pulmonary sclerosing pneumocytoma: beyond the solitary nodule in childh",
    "section": "Chest imaging",
    "age": "5",
    "gender": "male",
    "diagnosis": "Pulmonary sclerosing haemangioma or pneumocytoma",
    "history": "A 5-year-old boy presented to the emergency department with dysphagia to solid food after choking. He had no history of dyspnoea or cyanosis. Physical examination and blood tests were normal. Chest radiography was performed where a pulmonary nodule was found incidentally. A thorax CT was requested to complete the study of this patient.",
    "image_finding": "Posteroanterior chest radiography: Incidental, well-defined pulmonary nodule located in the right upper lobe (arrow in Fig. 1).Thorax CT with intravenous contrast confirmed the existence of a well-defined pulmonary nodule located in the upper right lobe (Fig. 2 and 3). It showed high density in enhanced CT (Fig. 3) and an area of air-trapping in the adjacent pulmonary parenchyma (arrow in Fig. 2). Despite the age, the clinical situation (normal physical examination and normal blood test) suggests the diagnosis of a tumour and not an infectious disease. In childhood the radiological characteristics of solitary pulmonary nodules are not enough to decide if they are benign or malignant, so a biopsy of this nodule was performed. Pathological anatomy results revealed a pulmonary sclerosing haemangioma (pneumocytoma) (Fig. 4). It is a benign tumour, more frequent in adults.",
    "discussion": "The radiological and tomographic findings of lung tumours are not specific in most cases. For these reasons, they constitute a great diagnostic challenge. [1]Pulmonary masses are less frequent than mediastinal masses in children. Most of them are non-neoplastic congenital or inflammatory lesions. Furthermore, neoplastic lesions are more frequently malignant. [2]In our case, the clinical situation (normal physical examination and normal blood test) exclude an inflammatory-infectious disease. Although radiological findings of pulmonary nodules are not specific, in this patient the existence of a well-defined nodule with homogeneous enhancement suggests a benign neoplasm.The spectrum of benign lesions includes inflammatory myofibroblastic tumours, hamartomas and sclerosing haemangiomas (pneumocytomas), as well as nodular lymphoid hyperplasia and lymphoproliferative syndromes [3].Pulmonary sclerosing haemangioma or pneumocytoma is a rare benign neoplasm which is more frequent in adults and women. Usually, patients who have this kind of tumour are asymptomatic. The diagnosis is confirmed by histology. Nevertheless, radiological features are very helpful to approach the diagnosis of this entity. In chest radiographs and thorax CT, it presents as a well-defined, solitary nodule with homogeneous enhancement after administration of intravenous contrast [4]. Sometimes, it can be associated with an air-trapping area in the periphery of the nodule (\u201cair meniscus sign\u201d) (Fig. 2). This sign is better seen in thorax CT. Despite being rare, it is very useful to differentiate this neoplasm from others like inflammatory myofibroblastic tumour. [4] On MR, pneumocytoma is hyperintense on T1-weighted and T2-weighted sequences. Sometimes, it can present cysts o haemorrhage areas. In childhood, MR is the technique of choice to complete the characterisation of a solitary pulmonary nodule because of the absence of radiation. However, in our case, a CT was performed because the diagnosis was made during the emergency shift.Surgical excision is the treatment of choice, which was also performed in the case presented.",
    "differential_diagnosis": "Pulmonary, sclerosing, haemangioma, or, pneumocytoma, Inflammatory, myofibroblastic, tumour, Hamartorma, Nodular, lymphoid, hyperplasia",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015425/000001.jpg?itok=InB5UBMf",
            "caption": "Posteroanterior chest radiography which shows a well-defined nodule located in upper right lobe (black arrow)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015425/000003.jpg?itok=xiuhVDyr",
            "caption": "Pathological anatomy results of the biopsied nodule: H-E staining shows polygonal cells with round-oval, regular and vesicular nucleus. These cells were positive in TTF-1 staining (top left). These findings are compatible with pulmonary sclerosing haemangioma."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015425/000004.jpg?itok=HmVdpoK2",
            "caption": "Coronal scan which confirmed the existence of a well-defined pulmonary nodule, located in the upper right lobe. It was associated with an air-trapping area in the adjacent pulmonary parenchyma (arrow)."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015425/000005.jpg?itok=4Nerxbpm",
            "caption": "Axial scan confirming the existence of a well-defined pulmonary nodule, located in the upper right lobe. This nodule showed a homogeneous enhancement and was associated with an air-trapping area in the adjacent pulmonary parenchyma (arrow)."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015425/000006.jpg?itok=D2z9cioS",
            "caption": "Sagittal scan which confirmed the existence of a well-defined pulmonary nodule, located in the upper right lobe. It was associated with an air-trapping area in the adjacent pulmonary parenchyma (arrow)."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015425/000007.jpg?itok=Z91AimXg",
            "caption": "Axial scan thorax CT with soft tissue window which shows that the nodule had high density in enhanced CT."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT",
      "Digital radiography",
      "Experimental"
    ],
    "link": "https://www.eurorad.org/case/15425",
    "time": "05.02.2018"
  },
  "15436": {
    "case_id": 15436,
    "title": "Mediastinal non-Hodgkin lymphoma with cardiac involvement and cardiac chamber compression",
    "section": "Chest imaging",
    "age": "88",
    "gender": "female",
    "diagnosis": "Mediastinal non-Hodgkin lymphoma with cardiac involvement and chamber compression",
    "history": "An 85-year-old male patient presented to our institution with a 1 to 2 month history of vague chest discomfort and bilateral upper limb swelling. As part of his admission work up, he was initially evaluated with a chest radiograph followed by a contrast CT scan which showed the following findings.",
    "image_finding": "Initial chest radiographs (Fig. 1a-b) show abnormal cardiomediastinal contours, with increased soft tissue density outlining both left hilar and right paraspinal regions.Subsequent contrast-enhanced CT images (Fig. 2a-f, 3a-b and 4) show a rather homogeneous large mass-like conglomeration infiltrating through the anterior mediastinum with invasion into the right atrial walls and its cardiac chamber with resultant marked narrowing of the right atrial chamber and lower part of the superior vena cava. Only a filiform contrast tract is seen communicating with the right ventricle. There is partial encasement of great vessels especially in the region of the aortic arch. Further work up with CT-PET (Fig. 5) to assess wider disease status within the rest of the body showed avid FDG enhancement throughout the anterior mediastinal mass-like conglomeration but no areas of distant uptake. The patient then underwent a CT-guided mediastinal biopsy (Fig. 6) giving a diagnosis of non-Hodgkin lymphoma.",
    "discussion": "Diffuse large B-cell lymphoma is an aggressive form of non-Hodgkin lymphoma (NHL) and is also the most common type of lymphoma. NHL accounts for more than 80% of all cases of lymphoma with approximately half of affected patients having intra-thoracic disease. In comparison with Hodgkin lymphoma (HL), NHL is three times less likely to occur in the mediastinum. Mediastinal lymphoma can often be responsible for superior vena cava (SVC) syndrome. Primary cardiac lymphoma is exceedingly rare with occurrence in around 1% of extranodal lymphoma cases [1]. Secondary involvement of the myocardium to some degree has been demonstrated in up to 30% of patients in patients with systemic lymphoma with disseminated disease at autopsy [2].Clinical presentation of cardiac metastases is dependent on various factors including tumour location, size, growth rate, degree of invasion, and friability of the tumour. In cases of malignant lymphoma, a cardiac or cardiovascular manifestation as an initial sign of the disease is extremely rare, and symptoms can often be sub-clinical or non-specific [3-7]. Common presentations of cardiac lymphoma include dyspnoea, congestive heart failure, pericardial effusion, and haemopericardium. Cardiac arrhythmias and other non-specific electrocardiographic abnormalities can also be common, notably with ranging degrees of atrioventricular block [8].Computed tomography with contrast can adequately demonstrate morphology, location, and extent of cardiac neoplasms with a larger field view. However, magnetic resonance imaging with contrast enhancement results in superior images identifying anatomy, blood flow, and cardiac function [9, 10]. Fluorodeoxyglucose (18F) positron emission tomography imaging has been reported to be a useful tool in revealing previously unsuspected cardiac involvement [11, 12].Cardiac lymphoma has the tendency to extend along the epicardial surfaces of the heart, encasing adjacent structures including coronary arteries and the aortic root. Infiltration beyond the myocardium may occur, and if affecting the right atrium, may result in venous extension leading to superior or inferior vena caval thrombosis. Right-sided cardiac chamber involvement (as with our case) is commoner while left atrial and ventricular infiltration tends to be far less common [13-18].Overall prognosis for primary and secondary cardiac lymphoma is generally poor.The literature on management contains several treatment combinations including chemotherapy, chemotherapy plus radiation therapy and varying combinations of these options [19]. The most frequently used chemotherapy regime is cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP). With the tissue necrosis that occurs with the administration of chemotherapy, cardiac rupture and embolic phenomena [20, 21] are important complications to consider.",
    "differential_diagnosis": "Mediastinal, non-Hodgkin, lymphoma, with, cardiac, involvement, and, chamber, compression, Thymic, carcinoma, with, cardiac, invasion, Mediastinal, sarcoma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015436/000001.jpg?itok=2OESzQBX",
            "caption": "Frontal projection showing abnormal mediastinal contours, with increased soft tissue density abutting the left hilum and right para-tracheal region (as demarcated by green curvilinear lines)."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015436/000002.jpg?itok=osUFAMH9",
            "caption": "Lateral projection outlining added increased soft tissue density overlying the anterior mediastinal space (as demarcated by a green curvilinear line)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015436/000003.jpg?itok=1YnzSCnN",
            "caption": "Axial contrast-enhanced CT image showing the cranial aspect of the anterior mediastinal mass (as demarcated by green curvilinear line)."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015436/000004.jpg?itok=gbLv3jC5",
            "caption": "Axial contrast-enhanced CT image showing the anterior mediastinal mass (as demarcated by green curvilinear lines)."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015436/000005.jpg?itok=VJkhrSrJ",
            "caption": "Axial contrast-enhanced CT image showing the lobulated anterior mediastinal mass, encasing the great vessels (as demarcated by green curvilinear lines)."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015436/000006.jpg?itok=8V0NnAK-",
            "caption": "Axial contrast-enhanced CT image shows the lobulated anterior mediastinal mass (as demarcated by green curvilinear line)."
          },
          {
            "number": "Figure 2e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015436/000007.jpg?itok=khRsWJy9",
            "caption": "Axial contrast-enhanced CT image shows the lobulated anterior mediastinal mass invading the right atrium and with significant compression of the cavo-atrial junction (green arrow)."
          },
          {
            "number": "Figure 2f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015436/000008.jpg?itok=n1UAG-DE",
            "caption": "Axial contrast-enhanced CT image shows the lobulated anterior mediastinal mass invading the right atrium (as demarcated by green curvilinear lines)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015436/000009.jpg?itok=w6GeJ1Fe",
            "caption": "Selected coronal contrast-enhanced CT image shows a large mostly homogenously attenuating lobulated mass-like conglomeration occupying the anterior mediastinal region with invasion of the right atrium."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015436/000010.jpg?itok=WXEqod_H",
            "caption": "Selected coronal contrast enhanced CT image showing the degree of right atrial invasion as well as flattening at the cavo-atrial junction (green arrow). Only a filiform contrast tract is seen towards its inferior portion."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015436/000011.jpg?itok=d8Q647KM",
            "caption": "Selected contrast-enhanced CT image showing a large lobulated anterior mediastinal mass-like conglomeration (demarcated by a green arrow) associatyed with encasement of great vessels."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015436/000012.jpg?itok=veN2YSq5",
            "caption": "Selected single FDG CT-PET image shows intense avidity corresponding to the large anterior mediastinal mass. No other abnormal uptake is seen with physiological uptake noted in the urinary bladder."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015436/000013.jpg?itok=_7kgV8ep",
            "caption": "Image taken during biopsy:  proving large B-cell non-Hodgkin lymphoma."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Cardiac",
      "Cardiovascular system"
    ],
    "imaging_technique": [
      "PET-CT",
      "CT",
      "Conventional radiography"
    ],
    "link": "https://www.eurorad.org/case/15436",
    "time": "29.01.2018"
  },
  "15464": {
    "case_id": 15464,
    "title": "Fatal complication of intrapleural fibrinolysis: massive air embolism",
    "section": "Chest imaging",
    "age": "72",
    "gender": "male",
    "diagnosis": "Massive air embolism",
    "history": "Patient with left pleuric mesothelioma complicated with empyema, not suitable for surgery, underwent positioning of thoracic drainage. Through drainage, he underwent pleural fibrinolytic therapy. After 10 minutes from administration of therapy, he developed loss of consciousness and after a while appeared cyanotic, with bradycardia and hypotension.",
    "image_finding": "Brain CT was performed for suspicion of haemorrhage, but didn't demonstrate any bleeding or signs of acute ischaemic stroke; most prominent finding was a discrete amount of air in the peripheral cerebral vessels (Fig. 1).Thoracic CT angiography (for suspicion of pulmonary embolism) didn't show signs of thrombi. Mesothelioma was well-recognisable and also the pleural cavity with thoracic drainage in it. The main finding was a large amount of air inside the left heart, ascending aorta and all coronary arteries (Fig. 2-4), compatible with massive air embolism. No fistulas were identified with CT. The patient was immediately brought into a hyperbaric chamber but died towards the end of treatment. Autopsy was performed, which demonstrated important cardiac infarct as cause of death. Nevertheless it still wasn't able to confirm a fistula. Pathologist concluded that the drainage probably created a decubitus fistula with a pulmonary vein and when intrapleural fibrinolysis was performed it \u201copened\u201d the fistula allowing air to enter a blood vessel.",
    "discussion": "Air embolism is a rare but potentially fatal occurrence, in fact the nonspecific nature of the signs and symptoms, as well as the difficulty in documenting the diagnosis does not allow the true incidence of it to be known; it can occur in either the venous or arterial system depending on where the air enters the systemic circulation. Venous air embolism occurs when air enters the systemic venous system and reaches the lungs via the pulmonary arteries leading to trapping of air bubbles in the pulmonary capillary bed, while systemic arterial embolism, as in our case, is due to the entry of air into pulmonary veins or directly into the arteries of the systemic circulation. The severity of symptoms varies according to the amount of air instilled and the end location of the air bubble; patients may be asymptomatic or, as in our case, may have a cardiovascular collapse. Lethal volumes of air in an acute bolus for humans has been hypothesized to be around 3-5 ml/kg and it is estimated that 300-500 ml of gas introduced at a rate of 100 ml/sec is a fatal dose for humans [1]. Air embolism may result from a number of medical-surgical procedures, as reported in literature, such as placement of an IV-access or an IV infusion [2], CT- guided transthoracic needle biopsy of pulmonary nodules [4] or following diagnostic bronchoscopy [3].Intrapleural fibrinolysis is an established modality in the management of complicated parapneumonic effusions, empyema and multiloculated malignant effusions, providing symptom relief and palliation [4]. A possible complication described in literature is pleural bleeding [5]; whereas there is none regarding air embolism as a complication of this type of procedure. Contrast-enhanced CT imaging is the modality of choice in cases of suspected air embolism, as it can perfectly demonstrate air in the cavities of the heart, in the main vessels and filling defects in the coronary arteries. This setting was very evident in our case as our images demonstrate.The primary therapeutic intervention is now considered to be hyperbaric oxygen treatment, which results in overall reduction in the air bubble size by \u201ccrushing\u201d the bubbles in the body. It has also been shown to minimise endothelial damage and end-vessel occlusion and reduce oedema in hypoxic tissues [6]. Nevertheless, treatment may prove futile if the air bolus is larger than 50 ml [1].",
    "differential_diagnosis": "Massive, air, embolism, Pulmonary, embolism, Brain, haemorrhage",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015464/000001.jpg?itok=dP6uqExl",
            "caption": "Axial MinIP reconstruction well demonstrates discrete presence of air in peripheral cerebral vessels"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015464/000002.jpg?itok=k7fkUCC3",
            "caption": "Coronal MinIP reconstruction well demonstrates discrete presence of air in peripheral cerebral vessels"
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015464/000003.jpg?itok=_HvC0oaU",
            "caption": "Sagittal MinIP reconstruction well demonstrates discrete presence of air in peripheral cerebral vessels"
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015464/000004.jpg?itok=4i2UGJVm",
            "caption": "3D reconstruction (where air appears blue) well demonstrates discrete presence of air in peripheral cerebral vessels"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015464/000005.jpg?itok=cutojqcq",
            "caption": "Axial MinIP reconstruction demonstrates coronary arteries full of air"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015464/000006.jpg?itok=o9NRYHU0",
            "caption": "Coronal MinIP reconstruction demonstrates coronary arteries full of air"
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015464/000007.jpg?itok=q4YA2m9v",
            "caption": "Sagittal MinIP reconstruction demonstrates coronary arteries full of air"
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015464/000008.jpg?itok=-eghSR1g",
            "caption": "3D reconstruction (where air appears blue) demonstrates coronary arteries full of air"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015464/000009.jpg?itok=YH3n-9SK",
            "caption": "Axial CT shows air at the origin of the ascending aorta (*). It also shows the pleural cavity with pleuric mesothelioma"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015464/000010.jpg?itok=tq4yczxP",
            "caption": "Coronal CT better demonstrates the presence of air in the ascending aorta (*) and in the left ventricle (C)"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Head and neck",
      "Thorax",
      "Cardiac"
    ],
    "imaging_technique": [
      "CT-Angiography"
    ],
    "link": "https://www.eurorad.org/case/15464",
    "time": "13.03.2018"
  },
  "15498": {
    "case_id": 15498,
    "title": "ndobronchial lipoma, a rare cause of endobronchial lesion",
    "section": "Chest imaging",
    "age": "63",
    "gender": "male",
    "diagnosis": "Endobronchial lipoma",
    "history": "63-year-old male patient on the lung transplant list due to interstitial disease. A programmed CT was performed before the surgery.",
    "image_finding": "The thoracic CT showed a low-density lesion ( -72HU) of 8 mm within the lingual lobe bronchus. The expiratory sections showed selective air trapping in the lingual lobe.A bronchoscopy was performed confirming the obstruction of the lingual lobe bronchus which was caused by a round yellow lesion. The suspected diagnosis was endobronchial lipoma.",
    "discussion": "A - BACKGROUND [1, 2, 3]Endothoracic lipoma is a rare benign tumour. According to the localisation, five classifications are made: Cardiac, parenchymal, pleural, mediastinal and endobronchial.Endobronchial lipomas are very rare, the incidence is 0.1-0.5% of the total lung tumours. A man with 50 to 60 years of age is the prototype patient. Obesity, heavy smoking and male sex are related factors, but no clear risk factors exist.B - CLINICAL PRESPECTIVE [4]The clinical presentation will be different based on the localisation of the lipoma, the level of obstruction and the size. If symptoms are presented, cough is the most common. Recurrent pneumonias, wheeze and dyspnoea are also common. Those symptoms can lead to a misdiagnosis of asthma/COPD or malignancy.C - IMAGING PRESPECTIVE [1, 2, 3, 4, 5]- X-ray: Unspecific, non-diagnostic- Chest CT: Fat tissue density without contrast enhancement- Chest MRI: Normal fat density tissue- Bronchoscopy: Soft, round, yellow lesion with few or no vessels on surface and smooth borders.Although chest CT is diagnostic, bronchoscopy remains indispensable for the diagnosis and treatment of endobronchial lipoma.  A sequence of chest CT and bronchoscopy should be performed as soon as possible due to the complications of long-term obstruction.D - OUTCOMEOnce the diagnosis is made with CT, two treatments are possible: Endoscopic resection (bronchoscopy) and thoracotomy. Endoscopic treatment is preferred as the lung parenchyma is preserved. However, if extraluminal extension, uncertain tumour aetiology or parenchymal destruction is detected, thoracotomy should be performed.In this case, after the CT, a bronchoscopy was performed. After the pathological analysis the suspected diagnosis of endobronchial lipoma was confirmed.E - TAKE HOME MESSAGE- Endobronchial lipomas are rare, benign tumours of the lung.- The symptomatology can lead to a misdiagnosis of asthma / COPD or malignancy tumours.- Early diagnosis and bronchoscopy are indispensable to prevent the destruction of the parenchyma due to the long-term obstruction.",
    "differential_diagnosis": "Endobronchial, lipoma, Endobronchial, hamartoma, Bronchogenic, adenocarcinoma, Small, cell, carcinoma, Pulmonary, pleomorphic, adenoma, Endobronchial, metastases",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015498/000001.png?itok=6aNrYHU3",
            "caption": "An endobronchial lesion is seen within the lingula lobe bronchus. An area of different attenuation ratio is seen peripherally of the endobronchial lesion."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015498/000002.png?itok=cftCy2HN",
            "caption": "An endobronchial lesion is seen within the lingula lobe bronchus (yellow arrow). An area of different attenuation ratio is seen peripherally of the endobronchial lesion (blue area)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015498/000003.png?itok=hbQ0Z0g6",
            "caption": "Abdominal window showing a -72HU endobronchial lesion."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015498/000004.png?itok=sstMwzdb",
            "caption": "Expiratory study shows a circumscribed area of air trapping on lingula lobe due to the bronchial obstruction (blue area)."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015498/000005.png?itok=0z0Z54cz",
            "caption": "Expiratory study shows a circumscribed area of air trapping on lingula lobe due to the bronchial obstruction (blue area)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015498/000006.png?itok=vRAWA5hw",
            "caption": "Bronchoscopy image showing a round, yellow  lesion with few small vessels on surface obstructing the lingula lobe."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015498/000007.png?itok=KH4QItN5",
            "caption": "Pathological image showing mature fat cells and bronchial epithelium."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/15498",
    "time": "24.04.2018"
  },
  "15511": {
    "case_id": 15511,
    "title": "Multimodality imaging in a case of paediatric SVC syndrome",
    "section": "Chest imaging",
    "age": "8",
    "gender": "male",
    "diagnosis": "Superior vena cava syndrome due to lymphoma",
    "history": "8-year-old boy presented with history of facial puffiness and gradually progressive breathlessness for two weeks. On examination, the child was tachypnoeic and distended superficial veins were seen over the temple and neck region. On percussion, a dull note was obtained on the right side.",
    "image_finding": "Massive right-sided pleural effusion with tracheomediastinal shift to the left was seen on chest radiograph. Ultrasound revealed a heterogeneous predominantly iso to mildly hyperechoic lesion with minimal internal vascularity in close proximity to cardia and the great vessels. On computed tomography, a fairly-defined, relatively hypodense mass lesion was seen in the anterior and superior mediastinum extending from T1 to T7 vertebra causing compression of left subclavian, common carotid, right innominate arteries, superior vena cava and oesophagus, trachea, right and left main bronchus with no bony erosion. The lesion showed relatively homogeneous enhancement on contrast administration with non-enhancing necrotic areas within.Screening MRI of the thorax showed that the lesion was T1 iso-hypo, iso to hyperintense on HASTE sequences.",
    "discussion": "The superior vena cava is the major venous drainage system for blood returning from upper extremities, head and neck. Superior vena cava syndrome (SVCS) is a condition which occurs when there is predominant major vessel compression in the superior mediastinum. It is also called superior mediastinal syndrome when there is compressive involvement of trachea, oesophagus and other associated structures. [1]In adults, malignant tumours such as lung cancer, lymphoma and metastatic tumours are responsible for the majority of SVCS cases. In the paediatric age group, SVCS is rare but serious. Malignant lymphoma is one of the most common causes of SVCS. Germ cell tumours can also cause SVCS in the paediatric age group. [2] Thrombosis due to central venous catheters, aortic aneurysms, heart surgery are the other causes of SVCS in children. Dyspnoea, coughing and swelling of the face, neck, upper body and arms are commonly encountered symptoms in SVCS. Hoarseness, chest pain, dysphagia and haemoptysis may also occur. Prominent neck or chest veins, rapid breathing, cyanosis, Horner\u2019s syndrome and a paralysed vocal cord may also be present. [3]Chest radiography may pick up associated indirect findings like pleural effusion, but is not adequate to identify the cause.Ultrasound helps in identifying thrombosis in accessible veins and less frequently in visualising the lesion.MDCT with contrast is useful in localising the site of the lesion, extent and characterising the lesion. It is fast, less expensive and bony changes can be studied well. On CT, lymphomas generally appear hypodense on plain films, showing homogeneous enhancement on contrast administration. Both Hodgkin and non-Hodgkin lymphomas can cause SVCS. [4]MRI has the ability to image in several planes of view with excellent soft tissue characterisation and can directly visualise blood flow using contrast agents with better safety profile. However, increased scanning time, respiratory artefacts and cost are the disadvantages. MRI picks up chest wall invasion and neurovascular involvement more accurately in malignant mediastinal tumours.Head end elevation, oxygen inhalation and diuretics are helpful supportive measures in patients of SVCS. Steroids provide symptomatic relief by decreasing oedema and tumour burden in malignant causes. Paediatric patients with malignancy as a source of SVCS, radiation and chemotherapy may be the initial course of treatment. Surgery may be necessary when medical or interventional treatments fail.A definitive histological diagnosis is preferable before going for treatment. In the present case, image guided biopsy revealed tumour of small blue round cell origin consistent with non-Hodgkin lymphoma. The patient improved symptomatically after administration of intravenous dexamethasone and later underwent chemoradiation.",
    "differential_diagnosis": "Superior, vena, cava, syndrome, due, to, lymphoma, Superior, vena, cava, syndrome, due, to, lymphoma, Superior, vena, cava, syndrome, due, to, germ, cell, tumour",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015511/000001.png?itok=aMZmtsg9",
            "caption": "Homogeneous opacity in the right hemithorax silhouetting right hemidiaphragm, right heart border and obscuring right costophrenic angle causing tracheomediastinal shift to left  \u2013 massive right pleural effusion."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015511/000005.png?itok=K2SMLaLG",
            "caption": "Iso to mildly hyperechoic mass lesion with no significant internal vascularity in close proximity to great vessels."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015511/000006.png?itok=Ub1YIcfG",
            "caption": "Lesion in close proximity to heart."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015511/000012.png?itok=UgFBOmGA",
            "caption": "Fairly defined anterior mediastinal mass lesion with right pleural effusion."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015511/000009.png?itok=drttPxxq",
            "caption": "Minimal relatively homogeneous enhancement on post-contrast image with non-enhancing necrotic areas within encasing the SVC."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015511/000010.png?itok=pZBD3lAZ",
            "caption": "Lesion appears iso- hypointense on T1 image"
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015511/000011.png?itok=JAOFuk4W",
            "caption": "Lesion appears iso-intense on HASTE image"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "Ultrasound",
      "CT",
      "MR"
    ],
    "link": "https://www.eurorad.org/case/15511",
    "time": "03.05.2018"
  },
  "15520": {
    "case_id": 15520,
    "title": "Unusual complication of Ivor Lewis oesophagectomy",
    "section": "Chest imaging",
    "age": "47",
    "gender": "female",
    "diagnosis": "Right lung torsion following Ivor Lewis oesophagectomy.",
    "history": "A 47-year-old previously healthy female patient underwent Ivor Lewis oesophagectomy for benign achalasia requiring a right thoracotomy incision. 48 hours after the operation she had an unsuccessful extubation attempt as she developed absence of air entry into the right lung, type-2 respiratory failure and required urgent re-intubation.",
    "image_finding": "Initial AP semi-erect chest radiograph showed extensive opacification of the right lung with superior displacement of the horizontal fissure (Fig. 1).Subsequent contrast enhanced CT chest revealed an abrupt tapering of the right main pulmonary artery and right main bronchus, best highlighted on the axial view (Fig. 2-3).The abnormal positions of the right interlobar fissures are appreciable on all views (Fig. 3-6). The sagittal reconstruction best demonstrates the extent of the abnormal rotation of the interlobar fissures, with the highlighted curved arrow indicating the direction of torsion (Fig. 6).Furthermore, there is extensive ground glass opacification in combination with interlobar smooth septal thickening forming a crazy-paving pattern, with patches of consolidation within the ground glass opacities. An important note is the absence of enhancement within the consolidation in the right lung when compared to the contralateral lung, in keeping with inadequate perfusion of the right lung secondary to torsion (Fig. 2\u20136).",
    "discussion": "Lung torsion (LT) is defined as the rotation of pulmonary lobe(s) around the hilar pedicle resulting in bronchovascular compromise [1, 2, 3]. The torsion does not have to be complete.In the literature, LT is described following three contexts- thoracic surgery, blunt trauma or spontaneously. Mortality rate is 12%-16% when complicated [4, 5]. Predisposing factors include pneumothorax, neoplasm, pleural effusion and complete lung fissures leading to freedom of movement of the lung [6]. Reported incidence is 0.09-0.4%, making it a rare event [1, 2, 3]. However, it may be more common than is realised following thoracic surgery, with up to 30% of UK thoracic surgeons encountering at least one case [6]. LT is more frequent following pulmonary resection, especially torsion of the middle lobe after upper or lower lobectomy. Clinical features include rapid cessation of air entry to the affected lung and respiratory failure. If unrecognised, it can progress to haemorrhagic infarction and fatal lung gangrene. Early recognition and prompt intervention are essential in preventing potentially fatal complications.Radiological imaging plays a crucial role in diagnosis. It is fast, non-invasive and guides the clinician to the correct management.Chest radiograph is the first line radiological investigation. It may reveal a combination of hilar displacement, bronchial distortion or cut-off, collapsed or consolidated lobe/lung [2]. A further suggestive feature is progressive lobar consolidation on repeat radiographs, as highlighted in Fig. 1. CT can better demonstrate the relations of the twisted structures. The hallmark features are luminal obstruction of the proximal pulmonary vasculature and bronchus at the level of the torsion, along with lobar malposition. Furthermore, features of a congested lung including septal thickening, ground-glass opacification and bronchial wall thickening are well demonstrated on CT. All of which are due to the impedance of venous return. Contrast-enhanced scans demonstrate absence of intrapulmonary vessels [7].Usually CT is sufficient to confirm the diagnosis. This is made easier with post-processing techniques such as MIP, minIP and Virtual Bronchoscopy; demonstrating vasculature and bronchoscopic views, aiding the radiologist in making the diagnosis and supporting patient care [8]. Once diagnosed, LT is a surgical emergency. Therapeutic options include explorative thoracotomy to confirm and assess viability of the twisted lung allowing for one of two options; detorsion or pneumonectomy [2, 8]. Teaching points:1.Whole LT is rare, however there should be a high index of suspicion in acutely unwell patients following surgery involving a thoracotomy. 2.Imaging plays an essential role in identifying the hallmark features of lung torsion.",
    "differential_diagnosis": "Right, lung, torsion, following, Ivor, Lewis, oesophagectomy., Pneumonia, Acute, respiratory, distress, syndrome, Pulmonary, oedema, Pulmonary, haemorrhage, Pulmonary, infarction",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015520/000001.png?itok=gwbqgD-N",
            "caption": "Extensive opacification of the right lung with abnormal displacement of the fissure"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015520/000002.png?itok=uGFFBRsd",
            "caption": "1. Abrupt tapering of right main pulmonary artery. \n2. Abnormal positions of fissures.\n3. Lack of enhancement within the consolidation in the right lung when compared to contralateral lung."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015520/000003.png?itok=2VbkkjlA",
            "caption": "1. Occlusion of the right main bronchus. \n2. Abnormal position of interlobar fissures. \n3. Extensive ground glass opacification combined with septal lines (crazy-paving pattern) and patches of consolidation within ground glass opacities."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015520/000004.png?itok=UVRZFeKU",
            "caption": "Abnormal position of interlobar fissure."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015520/000005.png?itok=m84RcbML",
            "caption": "1. Occlusion of the right upper lobar bronchus and right intermediate bronchus at the level of secondary carina.\n2. Abnormal positions of interlobar fissures. \n3. Presence of septal lines."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015520/000006.png?itok=d_XX6I7S",
            "caption": "Abnormal rotation of interlobar fissures suggestive of right lung torsion. Curved arrow highlighting the probable direction of torsion."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Pulmonary vessels"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/15520",
    "time": "11.03.2018"
  },
  "15525": {
    "case_id": 15525,
    "title": "Aortic dissection in patient with alpha 1 antitrypsin deficiency",
    "section": "Chest imaging",
    "age": "53",
    "gender": "female",
    "diagnosis": "Aortic dissection in a patient with alpha 1 antitrypsin deficiency",
    "history": "53-year-old female patient presenting with acute pleuritic chest pain.She had a past medical history of chronic obstructive pulmonary disease and alpha 1 antitrypsin deficiency and had been admitted 2 years ago with a similar presentation when she had a computed tomographic pulmonary angiography (CTPA); pulmonary embolism had been ruled out, while the pulmonary arteries were dilated (Fig.1).",
    "image_finding": "Echocardiography ruled out pulmonary hypertension and showed dilation of the ascending and the abdominal aorta.\n\nCT aortography showed aortic dissection confined to the lower thoracic aorta (Fig. 2a), further dissection commencing at the level of the coeliac axis and extending throughout the abdominal aorta (Fig. 2b) into the left common iliac artery (CIA), ending at the CIA bifurcation (Fig. 2c). The ascending aorta and the aortic arch were dilated but there was no type A dissection (Fig. 2e).\n\nFlow was identified both in the true and false lumen in the thoracic and abdominal components of the dissection. The aorta was aneurysmal at the level of the aortic hiatus of the diaphragm (Fig. 2d, f).\n\nOnly after this new study, an even earlier CTPA examination performed 3 years ago became available (Fig. 3a, b). Although performed during the pulmonary arterial phase, its review showed aortic dissection, a diagnosis missed prospectively. This review also clarified that this was chronic dissection.",
    "discussion": "Background:\nAlpha 1 antitrypsin (A1AT) is a protease inhibitor, which protects the tissue from proteolytic enzymes (e.g. neutrophil elastase [1]). The locus for the A1AT protein is on chromosome 14q32.1. The M allele is associated with normal levels of A1AT in the serum, whereas S and Z alleles are associated with reduced levels of plasma A1AT respectively [2]. A genetic deficiency in A1AT manifests systemically, causing pulmonary emphysema, hepatic cirrhosis and vascular diseases [2]. Vascular pathologies associated with A1AT deficiency manifest in the aorta, the visceral and intracranial arteries [3]. Unopposed proteolytic activity in severe deficiency of A1AT leads to vascular damage, causing the vascular manifestations of A1AT deficiency, above all dissection [4].\n\nClinical Perspective:\nThe main clinical presentation of aortic dissection is chest and/or back pain, mainly depending on the involved site of the aorta [5]. Syncope, hypotension, shock and hypertension are other common presenting features [6].\nA1AT deficiency is found to be associated with extracranial arterial dissection and aortic dissection [7]. In these cases, the overall prognosis is poor [8, 9]; early recognition and diagnosis in the suspected patients with A1AT deficiency are imperative.\n\nRadiologist Perspective:\nAortic dissection can be demonstrated using multiple imaging modalities, including magnetic resonance angiography (MRA), computed tomographic aortography (CTA), and transoesophageal echocardiography (TEE) [10].\nCTA is the most commonly used initial modality, due to its widespread availability, particularly in the emergency setting [5]. More than one study is often required to get the information necessary to fully guide the treatment. Patients found to have both aortic dissection and massive, predominantly basal bullous lung disease/emphysema need to be investigated for a possible common aetiology, and A1AT deficiency is one amongst those.\n\nOutcome:\nThe patient was referred to the vascular team and treated conservatively, because of the comorbidities, mainly the poor lung function.\n\nTake Home Message:\n1) Aortic dissection must be ruled out in patients with chest pain and other suspicious clinical signs.\n2) Consider aortic involvement in patients presenting with chest pain who are known to have A1AT deficiency.\n3) Always evaluate all vascular territories imaged in angiographic studies performed for one specific vascular area, even when the chosen phase is suboptimal.\n\nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Aortic, dissection, in, a, patient, with, alpha, 1, antitrypsin, deficiency, Conditions, clinically, presenting, with, chest, pain, Other, causes, of, aortic, dissection, Myocarditis, Pericarditis, Pulmonary, embolism, Aortic, trauma, (rupture/dissection)",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015525/000034.png?itok=_Pg1Zg0R",
            "caption": "CTPA 1 year ago. Axial slice showing no evidence of pulmonary embolism during the pulmonary arterial phase."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015525/000035.png?itok=NslT5PP2",
            "caption": "Axial non-contrast chest CT section at lung window showing emphysema."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015525/000036.png?itok=q5rXYT9O",
            "caption": "Axial CTA: dissection is identified in the lower thoracic aorta in a retrocardiac location."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015525/000037.png?itok=6C5lpriU",
            "caption": "Axial CTA at the level of the origin of the left renal artery showing the dissection flap."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015525/000038.png?itok=h0ur4BQF",
            "caption": "Axial CTA at upper pelvic level: dissection extends from the abdominal aorta into the left common iliac artery."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015525/000039.png?itok=lKqKjRYZ",
            "caption": "Coronal CTA reformation: the aorta is measuring approximately 40 mm in maximum short axis diameter at the level of the aortic hiatus of the diaphragm."
          },
          {
            "number": "Figure 2e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015525/000040.png?itok=zMCTWn6K",
            "caption": "Axial CTA showing a dilated ascending aorta but no evidence of type A aortic dissection."
          },
          {
            "number": "Figure 2f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015525/000041.png?itok=GFHwy0tn",
            "caption": "Sagittal CTA reformation showing both the dilated ascending aorta and the dissected abdominal aorta."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015525/000042.png?itok=SCUc5nPz",
            "caption": "Axial slice of CTPA showing a dilated main pulmonary artery. Although the phase is too early for aortography, early filling of the true lumen of aortic dissection can be detected, a finding missed prospectively."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015525/000043.png?itok=2klkl-Hp",
            "caption": "Axial slice of CTPA at the level of the right diaphragm: the right ventricle is large, and again, dissection of the descending aorta is a faint but obvious finding."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Thorax",
      "Arteries / Aorta"
    ],
    "imaging_technique": [
      "CT",
      "CT-Angiography"
    ],
    "link": "https://www.eurorad.org/case/15525",
    "time": "06.07.2018"
  },
  "15526": {
    "case_id": 15526,
    "title": "Langerhans cell histiocytosis - early stage",
    "section": "Chest imaging",
    "age": "41",
    "gender": "male",
    "diagnosis": "Langerhans Cell Histiocytosis",
    "history": "A 41-year-old man, with type 1 diabetes and a history of heavy smoking underwent a routine chest X-ray examination.",
    "image_finding": "PA and lateral films were performed, revealing a nodular pattern projected over both lung fields, predominantly in the middle and upper zones, in a patient without respiratory symptoms.Later, a contrast-enhanced CT scan was performed, confirming multiple small lung nodules bilaterally (<1cm). Some nodules appear solid while others show cavitation, dispersed in lung parenchyma but sparing most inferior segments. Additionally, mild hepatomegaly was visualised, with some hypodense nodules dispersed in the liver and spleen, measuring up to 13mm.The patient underwent bronchofibroscopy and upper/lower GI endoscopy, which were all inconclusive.The histological diagnosis was made by percutaneous transthoracic lung biopsy.",
    "discussion": "Langerhans cell histiocytosis (LCH), formerly known as histiocytosis X, is a disease of unknown etiology [4], in which Langerhans cell accumulations involve one or more body systems (bone, lung, reticuloendothelial system, lymph nodes, skin, central nervous system, etc.). [2]LCH is commonly seen in early childhood and middle-aged adults (20-40y). Its occurrence in adults is rare. [3]Lung involvement in LCH is common, seen in 40% of patients. In adults, pulmonary LCH occurs primarily in smokers, with peak age at presentation between 30 to 40 years. Symptoms vary widely, from being asymptomatic to having severe dyspnoea. Up to 20% of patients present with pneumothorax. [1]Abnormalities are usually bilateral, predominantly involving the upper and middle lung zones, sparing costophrenic angles. [2]In the early stage, pulmonary LCH is characterised by small scattered lung nodules, mainly peribronchiolar, not exceeding 1cm, representing granulomas containing a large number of Langerhans cells and eosinophils. Over time, the lesions may regress spontaneously or progress with destruction of lung tissue, resulting in cavitation, and later be replaced by fibrosis and lung cysts. These cysts tend to be irregular, thick-walled, sometimes with bizarre shapes. Late disease may present with cysts that nearly replace normal lung, eventually becoming thin-walled. [1]In adults, liver involvement in LHC is relatively frequent but often overlooked, with two distinct forms: early involvement with hepatomegaly and liver nodules (solid or cystic), usually responsive to treatment, and a second form with chronic fibrosis centred on bile ducts, progressing to sclerosing cholangitis. Prognosis is worst in LCH if the liver is involved. The spleen is involved less frequently in LCH than the liver, and it\u2019s also considered a risk organ. This may manifest with splenomegaly or spleen nodules, similar to liver involvement. [3]Take-home message: Adult LCH is a rare disease but should be considered in the differential diagnosis of a middle-aged smoker with bilateral small cavitating lung nodules (relative sparing of lung bases) and liver/spleen involvement, in addition to other aetiologies like septic emboli, metastasis, granulomatosis with polyangiitis (Wegener), rheumatoid arthritis, and infection.",
    "differential_diagnosis": "Langerhans, Cell, Histiocytosis, Septic, emboli, Metastasis, Granulomatosis, with, polyangiitis, (Wegener), Rheumatoid, arthritis, Infection",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015526/000001.png?itok=8uwXycmP",
            "caption": "Nodular pattern \npredominantly in the middle and upper zones, in a patient without respiratory symptoms"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015526/000002.png?itok=m5eFmSgs",
            "caption": "Lateral View"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015526/000003.png?itok=d7lwSMiS",
            "caption": "Multiple small lung nodules, mixed solid and cavitating, bilaterally dispersed but  costophrenic angles."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015526/000004.png?itok=M1_yCFnw",
            "caption": "Multiple small lung nodules, mixed solid and cavitating, bilaterally dispersed but \nsparing costophrenic angles."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015526/000007.png?itok=viQ_YMd5",
            "caption": "Multiple small lung nodules, mixed solid and cavitating, bilaterally dispersed but \nsparing costophrenic angles."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015526/000008.png?itok=9xalnYr5",
            "caption": "Multiple small lung nodules, mixed solid and cavitating, bilaterally dispersed but \nsparing costophrenic angles."
          },
          {
            "number": "Figure 2e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015526/000009.png?itok=7xm4lIo5",
            "caption": "Multiple small lung nodules, mixed solid and cavitating, bilaterally dispersed but \nsparing costophrenic angles."
          },
          {
            "number": "Figure 2f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015526/000010.png?itok=Nc0Rq96A",
            "caption": "Small hypodense nodules dispersed in the liver and spleen."
          },
          {
            "number": "Figure 2g",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015526/000011.png?itok=NPE7irwG",
            "caption": "Small hypodense nodules dispersed in the liver and spleen."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015526/000012.png?itok=_L2zosb3",
            "caption": "A right lower lobe lung nodule measuring 13mm, with spiculated borders, accessible for percutaneous transthoracic lung biopsy"
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015526/000015.png?itok=3eC7goj5",
            "caption": "CT-guided percutaneous needle biopsy"
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015526/000016.png?itok=nKGBR4IE",
            "caption": "Alveolar haemorrhage along the needle tract (red arrow) and minimal pneumothorax (green arrows), after percutaneous needle biopsy"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax",
      "Abdomen"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT-High Resolution",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/15526",
    "time": "09.03.2018"
  },
  "15539": {
    "case_id": 15539,
    "title": "Pulmonary epithelioid haemangioendothelioma: a rare clinical entity",
    "section": "Chest imaging",
    "age": "52",
    "gender": "female",
    "diagnosis": "Pulmonary epitheliod haemangioendothelioma",
    "history": "A 52-year-old female patient, non-smoker, presented to our chest unit with exertional dyspnoea, weight loss and troublesome dry cough for the previous three months. She had no professional exposure, no clinical signs of connective tissue diseases. Her past medical history and physical examination were unremarkable.",
    "image_finding": "Chest X-ray, performed at a private hospital and not shown by the patient, and chest CT scan, requested by our pulmonologists without intravenous contrast medium, showed multiple, random and bilateral nodules of various size from 3 mm to 14 mm in diameter and predominantly lower lobe thickening of both bronchovascular bundles and interlobular septa with small amount of right-sided pleural effusion. Abdominal ultrasound was unremarkable. Routine laboratory findings, tumour markers and autoantibodies were within normal limits. BAL on bronchoscopy revealed mild lymphocytosis (52%) with CD4/CD8 ratio of 2.2%. A wedge resection by video-thoracoscopic surgery was required and immunostaining of the tissue was positive for CD31 and ERG, but negative for CAMTA1 and a diagnosis was established. After adequate therapy, we observed complete resolution of the nodules on the last CT scan of the chest, abdomen and pelvis with iodine intravenous contrast medium of 2 months before.",
    "discussion": "Pulmonary epithelioid haemangioendothelioma (PEH) is a rare, vascular tumour of low-to intermediate grade malignancy, described as an intravascular bronchioloalveolar tumour by Dail and Liebow in 1975. Most affected patients are women, ranging in age from 19 to 70 years; many of them are asymptomatic but others show pleuritic pain, cough, dyspnoea or haemoptysis. This tumour may arise simultaneously or sequentially from many organs (lungs, liver, bone and soft tissues); it is difficult to determine if the tumour is multicentric or a primary lesion with metastases to other tissues. Lung involvement is relatively rare with 19% of all cases of epithelioid haemangioendothelioma (EHE). On chest X-ray there are multiple, well or ill-defined small nodules measuring up to 2 cm in both lungs but in less than 10% of the cases reported in the literature a solitary pulmonary nodule was found. There is no hilar or mediastinal lymph node enlargement, but sometimes diffuse infiltrative pleural thickening. Chest CT scan shows multiple nodules with irregular margins, rarely with calcifications, in a perivascular distribution. 20% of PHE patients may have hepatic nodules with peripheral contrast enhancement and some calcifications. [1-4]PHE can also be associated with congenital anomalies of the musculoskeletal system such as hemihypertrophy and scoliosis. [5]Histologically, the tumour shows oval or round nodules with a central hypocellular zone and a cellular peripheral one; immunostaining of the tissue is positive for endothelial markers, particularly CD31 and CD34 in about 90% of the cases. The independent risk factors of poor prognoses are weight loss, anaemia, pulmonary symptoms and pleural haemorrhagic effusion. The treatment for PHE can vary from observation in asymptomatic patients, sometimes with spontaneous regression, to surgery in patients with unilateral lung nodule and drugs in patients with disseminated disease using carboplatin, etoposide, interferon 2a, bevacizumab, azathioprine and corticosteroids. Most patients die from respiratory failure due to increasing size and number of tumour nodules, but death can occur from sepsis, myocardial infarction or other malignancy. The 5-year survival is around 60%. [1, 3, 4, 6]According to some authors the FDG uptake on FDG-PET scan is useful because it reflects the activation of tumour cells, resulting in progression of the disease, but in some patients it was observed that PET findings were negative, probably related to a low proliferation rate of the tumour cells. So it is difficult for any clinicians to manage PHE because of its variable course and the therapeutic options. [1, 6, 7]",
    "differential_diagnosis": "Pulmonary, epitheliod, haemangioendothelioma, Sarcoidosis, Non-small, cell, lung, cancer, Metastases, Vasculitis, Organising, pneumonia, Infectious, diseases, particularly, tuberculosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015539/000011.jpg?itok=pgzuI_VM",
            "caption": "Chest CT scan with mediastinal window setting, requested without intravenous iodine contrast medium, shows a small amount of right-sided pleural effusion."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015539/000012.jpg?itok=To3dHLQ2",
            "caption": "Chest CT scan with mediastinal window setting, requested without intravenous iodine contrast medium, shows a small amount of right-sided pleural effusion."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015539/000013.jpg?itok=G2u7vuH0",
            "caption": "Chest CT scan \u2013 with lung window setting - shows complete resolution of the pulmonary nodules after adequate therapy."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015539/000014.jpg?itok=pORCAqVv",
            "caption": "Chest CT scan \u2013 with lung window setting - shows complete resolution of the pulmonary nodules after adequate therapy."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015539/000015.jpg?itok=Yvwofw9N",
            "caption": "Chest CT scan \u2013 with lung window setting - shows complete resolution of the pulmonary nodules after adequate therapy."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015539/000016.jpg?itok=OEfIULm5",
            "caption": "Chest CT scan \u2013 with lung window setting - shows complete resolution of the pulmonary nodules after adequate therapy."
          },
          {
            "number": "Figure 2e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015539/000017.jpg?itok=vRZObNoO",
            "caption": "Chest CT scan \u2013 with lung window setting - shows complete resolution of the pulmonary nodules after adequate therapy."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015539/000018.jpg?itok=X-9xHEPI",
            "caption": "Chest CT scan \u2013 with mediastinal window setting - shows post-surgical wedge resection on the right lung and bilateral pleural effusion. There are no mediastinal or hilar lymphadenopathies. Abdominal findings are unremarkable."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015539/000019.jpg?itok=-3BqYe5I",
            "caption": "Chest CT scan \u2013 with mediastinal window setting - shows post-surgical wedge resection on the right lung and bilateral pleural effusion. There are no mediastinal or hilar lymphadenopathies. Abdominal findings are unremarkable."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015539/000020.jpg?itok=OG570OLX",
            "caption": "Chest CT scan \u2013 with mediastinal window setting - shows post-surgical wedge resection on the right lung and bilateral pleural effusion. There are no mediastinal or hilar lymphadenopathies. Abdominal findings are unremarkable."
          },
          {
            "number": "Figure 3d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015539/000021.jpg?itok=mEqzLvSp",
            "caption": "Chest CT scan \u2013 with mediastinal window setting - shows post-surgical wedge resection on the right lung and bilateral pleural effusion. There are no mediastinal or hilar lymphadenopathies. Abdominal findings are unremarkable."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015539/000022.png?itok=LIio9YJU",
            "caption": "Chest CT scan with lung window setting, requested without intravenous iodine contrast medium, shows multiple, random nodules of various size, lower lobe thickening of both bronchovascular bundles and interlobular septa."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015539/000023.png?itok=F_dh_qWj",
            "caption": "Chest CT scan with lung window setting, requested without intravenous iodine contrast medium, shows multiple, random nodules of various size, lower lobe thickening of both bronchovascular bundles and interlobular septa."
          },
          {
            "number": "Figure 4c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015539/000024.png?itok=mrTcTLTk",
            "caption": "Chest CT scan with lung window setting, requested without intravenous iodine contrast medium, shows multiple, random nodules of various size, lower lobe thickening of both bronchovascular bundles and interlobular septa."
          },
          {
            "number": "Figure 4d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015539/000025.png?itok=NVfvShH3",
            "caption": "Chest CT scan with lung window setting, requested without intravenous iodine contrast medium, shows multiple, random nodules of various size, lower lobe thickening of both bronchovascular bundles and interlobular septa."
          },
          {
            "number": "Figure 4e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015539/000026.png?itok=mVv_X6H2",
            "caption": "Chest CT scan with lung window setting, requested without intravenous iodine contrast medium, shows multiple, random nodules of various size, lower lobe thickening of both bronchovascular bundles and interlobular septa."
          },
          {
            "number": "Figure 4f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015539/000027.png?itok=C9f_Aq-g",
            "caption": "Chest CT scan with lung window setting, requested without intravenous iodine contrast medium, shows multiple, random nodules of various size, lower lobe thickening of both bronchovascular bundles and interlobular septa."
          },
          {
            "number": "Figure 4g",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015539/000028.png?itok=BxNTQini",
            "caption": "Chest CT scan with lung window setting, requested without intravenous iodine contrast medium, shows multiple, random nodules of various size, lower lobe thickening of both bronchovascular bundles and interlobular septa."
          },
          {
            "number": "Figure 4h",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015539/000029.png?itok=f7viakKA",
            "caption": "Chest CT scan with lung window setting, requested without intravenous iodine contrast medium, shows multiple, random nodules of various size, lower lobe thickening of both bronchovascular bundles and interlobular septa."
          },
          {
            "number": "Figure 4i",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015539/000030.png?itok=trVrggYK",
            "caption": "Chest CT scan with lung window setting, requested without intravenous iodine contrast medium, shows multiple, random nodules of various size, lower lobe thickening of both bronchovascular bundles and interlobular septa."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax",
      "Lung",
      "Mediastinum"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/15539",
    "time": "26.03.2018"
  },
  "15581": {
    "case_id": 15581,
    "title": "Overlooked foreign body aspiration mimicking chronic disease",
    "section": "Chest imaging",
    "age": "72",
    "gender": "male",
    "diagnosis": "Foreign body aspiration, plastic cap",
    "history": "A 72-years-old man without previous history of smoking was referred to the hospital with prolonged cough and repetitive pneumonia during the past 8 years. There were also episodes of haemoptysis until the past few years. The patient also had left-sided hemiparesis due to previous intracranial haemorrhage 8-9 years before.",
    "image_finding": "Initially chest radiographs were performed which revealed no infiltrates or heart failure (Fig. 1). The patient underwent a series of examinations and was given sypmtomatic treatment over time and was considered to have a restrictive type of lung problem.\n\nMany years after the onset of symptoms a high resolution computed tomography (HRCT) was obtained and it was interpreted as blockage and atelectasis of right inferior lobe caused by mucous plug with calcification. No intersititial changes were seen (Fig. 2).\n\nAfter the first chest CT numerous chest radiographs were obtained showing progression of atelectasis (Fig. 3)\n\nIn second chest CT one year after the first one, enlarged lymph nodes in mediastinum and further progression in atelectasis in right lower lobe was observed, and it was considered to be caused by a foreign body, probably a tooth (Fig. 4).\n\nEventually a flexible bronchoscopy procedure was performed and a plastic cap was removed from the right intermediate bronchus (Fig. 5).",
    "discussion": "BACKGROUND\nAlthough foreign body (FB) aspiration is more common in children, there is an increase in prevalence of FB aspiration in patients > 60 years of age [1]. In elderly patients such problems as unclear history of FB, unspecific symptoms, false negative radiological results can lead to late diagnosis and extraction with bronchoscopy [1, 2]. Morover, any condition as head trauma, intracranial haemorrhage, Alzheimer disease, swallowing disorder etc. that impairs the neurological status may predispose to FB aspiration [3, 4].\nCLINICAL PERSPECTIVE\nAccording to many case series in the literature, cough is the most common symptom, when it comes to FB aspiration. Other symptoms can be sputum, dyspnoea, chest pain, wheezing, haemoptysis and recurrent pneumonia depending on the size and location of the FB [1, 2, 3, 4]. A minority of patients, especially geriatric patients, with FB may be asymptomatic and mistaken for another diagnoses [1, 3].\nIMAGING PERSPECTIVE\nRadiological features of FB aspiration rely on type and location of aspired material. Only a low percentage of foreign bodies are radiopaque and can be identified on plain films. Although chest X-rays have limited use, they can demonstrate indirect findings such as atelectasis, hyperinflation, bronchiectasis, lobar consolidation, focal hyperinflation [2, 4]. In a minority of patients chest X-ray may be normal or with irrelevant findings as in our case (Fig. 1). Chest CT is more sensitive and specific for identification of FB aspiration, and demonstration of the aspirated FB [2]. Moreover, indirect findings and complications of FB such as atelectasis, bronchiectasis, pneumonic patch, lobar consolidation, tree-in-bud infiltrates, ipsilateral pleural effusion, ipsilateral hilar adenopathy and thickened bronchial wall can also be detected by CT imaging [1, 2].\nTEACHING POINTS\nForeign body aspiration is seen more often in geriatric patients than in other adult patients, especially when they are known with predisposing factors such as neurological problems. In this patient group careful and detailed history taking is of greater importance, however, it is not always possible to hear the critical informations giving rise to suspicion of possible FB aspiration as seen in our case. At this point it must be remembered that a prolonged cough anamnesis may be consequence of an occult FB in the airways.\nFrom the radiological perspective, this case points out the importance and value of knowing detailed clinical information such as disposing factors, the patient's symptoms etc. for a faster diagnosis and treatment.\nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Foreign, body, aspiration,, plastic, cap, Asthma, Lung, cancer",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015581/000002.png?itok=V2VFhbaF",
            "caption": "The first chest CT was interpreted as having mucous plug with calcification blocking the right inferior lobe."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015581/000003.png?itok=F6jSMYwQ",
            "caption": "On this sagittal plane, atelectasis is seen clearly."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015581/000004.png?itok=JdD-8UEt",
            "caption": "During flexible bronchoscopy procedure, a blue foreign body and polypoid granulation tissue were seen in the right intermediate bronchus."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015581/000005.png?itok=WvuyJ5R1",
            "caption": "During flexible bronchoscopy procedure, a blue-coloured plastic cap was removed."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015581/000008.png?itok=UFZ1b29i",
            "caption": "Progression in atelectasis in right lower lobe which was considered to be caused by foreign body."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015581/000009.png?itok=HBVeOmtw",
            "caption": "Progression in atelectasis in right lower lobe which was considered to be caused by foreign body."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015581/000010.png?itok=DCjSzwyU",
            "caption": "Progression in atelectasis in right lower lobe which was considered to be caused by foreign body."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015581/000011.png?itok=bO6zWgkI",
            "caption": "An early chest radiography shows no infiltrates or cordial incompensation."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015581/000012.png?itok=NGgamsBs",
            "caption": "An example of AP chest radiographs after the first chest CT showing further atelectasis on the right side."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Abdomen"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT-High Resolution",
      "CT",
      "Experimental"
    ],
    "link": "https://www.eurorad.org/case/15581",
    "time": "14.07.2018"
  },
  "15582": {
    "case_id": 15582,
    "title": "A large mediastinal teratoma presenting with acute abdomen",
    "section": "Chest imaging",
    "age": "22",
    "gender": "male",
    "diagnosis": "Mature teratoma with assumed origin from thymus",
    "history": "The patient presented with acute onset right-sided pleuritic chest pain with mild shortness of breath and abdominal pain. On examination the patient had decreased breath sounds on the right side and signs of peritoneal irritation. He is smoker and his medical history is clear. There has not been any loss of appetite or weight.",
    "image_finding": "Initially a workup of coronary syndrome was applied without significant results.\nSubsequently owing to the patient's history an initial chest radiograph was obtained showing loss of silhouette sign that gave impression of a possible radiopaque mass on the right side.\nFor investigating a possible extra-cardiac pathology a computed tomography (CT) scan of the chest was obtained. CT scan showed a large well-differentiated process measuring 14 x 11 x 11 cm in the right hemithorax along the mediastinum with compression and displacement of the heart to the left side. The process is inhomogeneous and contains liquid, fatty and solid areas including small calcification (Fig. 2). The patient's abdominal pain and the present CT appearance raise suspicion of Morgagni hernia with complications, and a diagnostic laparoscopy was applied revealing no abdominal pathology. Eventually the mass was removed by lateral thoracotomy. Discovery of tallow and discreet exudate in pleura during surgery led to suspicion of teratoma rupture as a likely cause of acute chest pain.",
    "discussion": "BACKGROUND\nAbout 15% of primary mediastinal masses originate from germinal tissue. Mature teratomas are slow-growing benign congenital tumours that should be kept in mind when evaluating an anterior mediastinal mass [1, 2].\nCLINICAL PERSPECTIVE\nMature mediastinal teratomas are usually diagnosed in adolescence or early adulthood at the average age of 27 [3]. They grow slowly and are asymptomatic in most cases, until the tumour compresses nearby structures. Individuals may present with chest pain, dyspnea, cough, back or shoulder pain as well as atrial fibrillation or symptoms of pulmonary stenosis [3, 4, 5].\nIMAGING PERSPECTIVE\nThe routine chest radiograph is valuable to diagnose mature teratomas. These tumours may appear as either well-circumscribed or more lobulated depending if they are cystic or solid [2]. A large mediastinal teratoma adjacent to diaphragm can resemble Morgagni hernia at first sight, but a defect in the diaphragmatic wall must be shown with an accurate imaging modality [6]. Calcifications, bone or teeth-like structures or soft tissue may be seen in CT imaging [1, 2]. Magnetic resonance imaging (MRI) can be beneficial in case of unclear diagnosis or need for more details about the relations of the mass to other mediastinal structures [1, 5]. Some mediastinal teratomas close to the heart may also be detected by a cardiologist via echocardiography [5]. A bronchoscopic examination may be performed for obtaining a tissue sample. If the teratoma is ruptured or invades the bronchial tree, hair-like material may be visualised in this examination [7].\nOUTCOME\nCT is accepted to be the radiographic modality of choice to evaluate a mature mediastinal teratoma. It can visualise the three-dimensional anatomy of the tumour and its relation to the adjacent mediastinal organs. In this way it will also provide valuable information during the planning process of surgical resection [1, 2]. The recommended treatment for mature teratomas is a complete surgical resection for both diagnosis and prevention of complications in the future [1, 7].\nTEACHING POINTS\nMature teratomas are rarely seen, yet should be taken into account as a differential diagnosis when evaluating a mediastinal mass.\nAlthough the routine chest radiograph is an important diagnostic tool, it may show nonspecific findings as in our case.\nWhen a mediastinal mass is initially evaluated by a clinician, its inhomogeneous appearance can be confused with a Morgagni hernia. In this point determination of existence or absence of an intact diaphragm by CT scan may be helpful to confirm the diagnosis.\nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Mature, teratoma, with, assumed, origin, from, thymus, Thymoma, Lymphoma, Neurogenic, tumour, Carcinoma, Parathroid, adenoma, Lymphangioma, Aortic, aneurysm, Intrathoracic, goitre, Morgagni, hernia, (for, our, case)",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015582/000001.png?itok=p171O2V9",
            "caption": "There is a filling appearance at the right heart, which can also raise suspicion of enlarged heart. Loss of silhouette sign gives the impression of a possible radiopaque mass on the right side of the heart."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015582/000002.png?itok=Cjpnsz85",
            "caption": "A chest plain film was also obtained on suspicion of pneumothorax because of the patient's age and symptoms. However, no pneumothorax was seen."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015582/000003.png?itok=K5FW1Qj3",
            "caption": "The process is inhomogeneous and contains large amounts of liquid fatty areas and solid areas including small calcifications."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015582/000004.png?itok=yHQPVTNe",
            "caption": "Computed tomography (CT) of the chest showed a large well-differentiated process with compression and displacement of the heart to the left side."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015582/000005.png?itok=4gBV6FZw",
            "caption": "A large well-differentiated process measuring 14x11x11 cm in the right hemithorax along the mediastinum with compression and displacement of the heart to the left side."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015582/000006.png?itok=LdwIKzLa",
            "caption": "There was also discreet pleural effusion and a little lower lob compression atelectasis posteriorly on the right side."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Gastrointestinal tract",
      "Lung",
      "Adrenals",
      "Abdomen"
    ],
    "imaging_technique": [
      "CT",
      "Mammography",
      "Conventional radiography"
    ],
    "link": "https://www.eurorad.org/case/15582",
    "time": "18.09.2018"
  },
  "15651": {
    "case_id": 15651,
    "title": "Unusual presentation of multiple endocrine neoplasia type 1: Primary thymic neuroendocrine tum",
    "section": "Chest imaging",
    "age": "60",
    "gender": "male",
    "diagnosis": "Thymic neuroendocrine tumour in multiple endocrine neoplasia type 1",
    "history": "60-year-old male patient with MEN-1 syndrome presented for evaluation of anterior mediastinal mass. Patient has had neuroendocrine tumour metastatic to the liver, status post modified Whipple procedure and exploratory laparotomy for partial hepatectomy. Patient also has history of parathyroidectomy x 2 and thyroidectomy x 2.",
    "image_finding": "Computed tomography (CT) scan of the thorax confirmed a heterogeneous soft tissue mass with an unclear margin (dotted arrow) that is infiltrating the adjacent structures (white arrows) in the anterior mediastinum (Fig. 1 a and b). Magnetic resonance imaging (MRI) post contrast T1 imaging shows mildly heterogeneously enhancing anterio-mediastinal mass with irregular borders (Fig. 2). Radio-labelled fused Octreotide scan for MEN 1 evaluation showed a right anterior mediastinal mass that has increased radio-uptake (Fig. 3). Gross image of surgically removed mass shows greatest dimension 5.5 cm with additional dimensions 5.2 x 3.6 cm (Fig. 4 a). The tumour cells were arranged in wide trabeculae with irregular nests separated by thin fibrovascular stroma, and scattered abortive rosette-like structures. (Fig. 4 b). Tumour cells were diffusely positive for Synaptophysin (Fig. 4 c).",
    "discussion": "A. Background:Multiple endocrine neoplasia type 1 (MEN1) is an autosomal dominant syndrome that is associated with a large group of malignancies that are derived from embryonic neural crest tissue found in various organs such as parathyroid (90-97%), enterohepatic pancreatic tumours (30-80%), and anterior pituitary tumours (15-30%). [1] B. Clinical Perspective:Primary hyperparathyroidism and anterior pituitary tumours are surgically removed with good clinical outcomes. To date, enteropancreatic neuroendocrine tumours (NETs) are now the primary life-threatening manifestation of MEN1. [7] NETs are more aggressive, metastasise more often and have a poorer prognosis than other MEN 1 tumours. [4] Thymic NETs are the least common among the MEN 1 endocrine tumours with a prevalence of 2-8% in MEN 1 patients. [2] Additionally 25% of all thymic NETs occur in MEN 1 patients. Thymic NETs are also rare in the general population, accounting for 2-5% of all thymic tumours. [3] In a study of 80 cases of thymic NET, overall 5- and 10-year survival rates were 28 and 10 percent, respectively. [5] The poor prognosis may partially be due to late detection. C. Imaging Perspective:In all guidelines for MEN1 patients, NET localisation is an essential step in all aspects of their management. 111In-DTPA-octreotide (octreoscan) has been used for evaluation of pancreatic NETs. Recommended screening guidelines include chest X-ray and chest computed tomography (CT) every 3 years in male patient with MEN1 over the age of 25, but the benefits are still uncertain. [3] While CT imaging remains the recommended choice for initial cross-sectional imaging evaluation of mediastinal lesions, thoracic MRI provides definitive evaluation of mediastinal masses because of its superior tissue characterisation. [8] MR is the preferred modality for follow-up in patients with MEN 1 where repeated imaging may be required for prolonged surveillance due to the frequent recurrence of the disease. [8] D. Outcome:Surgical resection is the only curative technique in NETs. [8] Patient had video-assisted right thoracoscopic surgery for mediastinal mass resection with partial pericardial resection. Pathology report found this to be consistent with well-differentiated primary thymic NETs with invasion to neighbouring structures.E. Teaching point:Thymic NETs contribute to significant mortality in patients with MEN 1. Prophylactic thymectomy is considered in MEN1 male patients, but the benefits are uncertain as there are cases of recurrent thymic NET in patients after prophylactic thymectomy. [6] Thus, further studies of thymic NET cases are important to assess clinical management strategies.",
    "differential_diagnosis": "Thymic, neuroendocrine, tumour, in, multiple, endocrine, neoplasia, type, 1, Thymoma, Thymic, neoplasm, Ectopic, thyroid, Lymphoma, Teratoma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015651/000001.png?itok=27oxB8ac",
            "caption": "(A) Coronal view shows heterogeneous anterior mediastinal soft tissue mass with irregular border line (dotted arrow) that is invading adjacent structures (white arrows)."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015651/000002.png?itok=N9zyq0Bv",
            "caption": "(B) Sagittal view shows anterior mediastinal mass with invasion of nearby structures (white arrows)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015651/000003.png?itok=u7Y489cY",
            "caption": "T1 axial post-contrast showing a heterogeneously enhancing anterior mediastinal mass with irregularly speculated borders (white arrow)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015651/000004.jpg?itok=NQtwm5o2",
            "caption": "Fused Octreotide scan showing increased radioactive uptake in the anterior mediastinal mass (white dotted arrow)."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015651/000005.jpg?itok=WLGULwPb",
            "caption": "(A) Gross pathology image shows tumour size, greatest dimension 5.5 cm with additional dimensions of 5.2 x 3.6 cm."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015651/000006.png?itok=ZHST09oS",
            "caption": "(B) H&E stained (40X magnification) shows organoid pattern with islands, ribbons, festoons, trabeculae, rosettes of small round cells with minimal cytoplasm, salt and pepper chromatin."
          },
          {
            "number": "Figure 4c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015651/000007.png?itok=IUV51dVA",
            "caption": "(C) Tumour cells are diffusely positive for Synaptophysin (\u00d7400)"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Mediastinum"
    ],
    "imaging_technique": [
      "MR",
      "Nuclear medicine conventional",
      "Percutaneous",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/15651",
    "time": "09.04.2018"
  },
  "15694": {
    "case_id": 15694,
    "title": "Dysphagia lusoria \u2013 A rare clinical entity in the adult",
    "section": "Chest imaging",
    "age": "40",
    "gender": "female",
    "diagnosis": "Dysphagia lusoria",
    "history": "A 40-year-old otherwise healthy woman presented with a long-standing history of mild dysphagia to solids. Fiberoptic endoscopic evaluation and upper gastrointestinal endoscopy were unremarkable.",
    "image_finding": "A barium swallow was performed revealing an oblique indentation of the upper oesophagus with a left-to-right trajectory, consistent with an aberrant right subclavian artery (Fig. 1 a, b). CT angiography confirmed the presence of an aberrant right subclavian artery arising distally from the aortic arch with a retro-oesophageal course, slightly compressing the oesophagus (Figure 2 a, b and c).",
    "discussion": "Aberrant origin of the right subclavian artery is the most frequent developmental anomaly of the aortic arch [1]; however, it does not usually cause oesophageal impairment [1]. In these cases, such an entity is termed dysphagia lusoria. Adult onset is extremely rare [2]. Surgery is reserved for patients with prominent symptoms or aneurysmal dilation. Re-establishment of flow by reimplantation or bypass is currently the method of choice [3]. Because the dysphagia was only mild, no surgical correction was performed.",
    "differential_diagnosis": "Dysphagia, lusoria, Tumour, Gastro-oesophageal, reflux, disease",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015694/000001.jpg?itok=-ZvVpYWD",
            "caption": "AP (left) and lateral (right) view of a barium swallow examination showing an oblique indentation in the upper oesophagus."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015694/000002.jpg?itok=XmleeuI3",
            "caption": "AP (left) and lateral (right) view of a barium swallow examination showing an oblique indentation in the upper oesophagus (red markers)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015694/000003.png?itok=VW2X5xFn",
            "caption": "CT (axial view) showing an aberrant right subclavian artery arising distally from the aortic arch (arrow)."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015694/000004.png?itok=oZXZHw-t",
            "caption": "CT (coronal view) showing an aberrant right subclavian artery arising distally from the aortic arch (arrow)."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015694/000005.png?itok=MfXUI1yk",
            "caption": "CT (sagittal view) showing an aberrant right subclavian artery arising distally from the aortic arch (arrow)."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Arteries / Aorta"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/15694",
    "time": "20.04.2018"
  },
  "15697": {
    "case_id": 15697,
    "title": "A rare case of multiple pulmonary arteriovenous malformations (PAVMs)",
    "section": "Chest imaging",
    "age": "56",
    "gender": "male",
    "diagnosis": "Pulmonary arteriovenous malformations",
    "history": "A 56-year-old female patient with past history of hypertension presented to emergency following a minor trauma with right-sided chest pain at the midclavicular line. On physical examination she was afebrile, eupnoic (12 breaths/minute) with bilateral vesicular murmur and saturation rate of 97%.",
    "image_finding": "She underwent chest X-ray that showed no traumatic bone lesions; however, a single rounded nodule at the apex of the upper right lobe was seen. CT was then performed. Two additional nodules were seen: one in the right middle lobe and one in the left lingular paracardiac region (maximum diameter 36x25 mm). After contrast injection there was rapid opacification and wash out of all three lesions, simultaneously with the main pulmonary artery and right ventricle. All had irregular shape and sharp edges and each of them was fed by one artery and drained by one vein.",
    "discussion": "Pulmonary arteriovenous malformations (PAVMs), also known as arteriovenous fistulae, are abnormal connections between the pulmonary arterial and venous circulation.\n\nTheir prevalence is 38/100000 individuals with a predilection for females. Up to 70% of cases of PAVMs are associated with Rendu-Osler-Weber disease (hereditary haemorragic telangiectasia-HHT), but in some patients they are incidental findings; they can be multiple in 35% and bilateral in 10% of cases [1, 2].\n\nSymptoms relate to PAVM\u2019s size: lesions with diameter > 2 cm are more likely symptomatic. The most common symptoms are cyanosis, dyspnoea and haemoptysis, and the major complications are rupture and paradoxical embolisation. Dyspnoea and cyanosis are the expression of a right to left shunt between pulmonary veins and arteries that causes left-heart overload. Pregnant women with PAVMs are at increased risk of haemorrhage [3].\nPAVMs can be simple, with just one feeding artery and one draining vein, or complex (less common), which have more than one feeding artery.\n\nDiagnosis is performed by contrast-enhanced CT, and treatment is based on embolisation [4].\n\nOur patient had no cardiac symptoms and didn\u2019t show any clinical signs of Rendu-Osler-Weber disease (according to Curacao criteria: recurrent epistaxis; teleangiectasias at typical sites: oral cavity, nose, fingers; visceral lesions: GI, CNS and lung; and family history of a HHT-affected first-degree relative. Diagnosis is based on presence of at least 3 of these 4 criteria) [5].\nIn order to evaluate the risk of future complications, the patient was addressed to the Pulmonology department and she is currently followed-up.",
    "differential_diagnosis": "Pulmonary, arteriovenous, malformations, Sporadic, PAVMs, PAVMs, associated, with, Rendu, Osler, Weber, syndrome, Hypervascular, parenchymal, mass",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015697/000001.jpg?itok=D-b_-75A",
            "caption": "Chest X-ray in PA projection shows a rounded nodular lesion in the apex of the right upper lobe."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015697/000002.jpg?itok=CltA9aDy",
            "caption": "Chest X-ray in LL projection."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015697/000003.jpg?itok=sHN0KqL6",
            "caption": "Chest CT scans show\u00a0irregularly-shaped masses in the the left lingular paracardiac region characterised by fast c.e. simultaneously with the main pulmonary artery and right ventricle, thus suggesting PAVMs.-Lung window-"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015697/000004.jpg?itok=Tr8WPetN",
            "caption": "Chest CT scans show\u00a0irregularly-shaped masses in the right upper lobe.\r\n-Lung window-"
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015697/000005.jpg?itok=FXEld389",
            "caption": "Chest CT scans show\u00a0irregularly-shaped masses in the right middle lobe and in the left lingular paracardiac region.\r\n-Lung window-"
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015697/000007.jpg?itok=JIJneD97",
            "caption": "Chest CT scans show\u00a0irregularly-shaped masses in the the left lingular paracardiac region and right middle lobe. -Tissue window-"
          },
          {
            "number": "Figure 2e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015697/000008.jpg?itok=cwFezEGF",
            "caption": "Chest CT scans show\u00a0irregularly-shaped masses in the right upper lobe.\r\n-Tissue window-"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015697/000006.jpg?itok=9ZXwovw4",
            "caption": "Three-dimensional reconstruction of CT scans has been performed in order to give the surgeons clear data about morphology, position, afferent and efferent vessels."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT",
      "Conventional radiography"
    ],
    "link": "https://www.eurorad.org/case/15697",
    "time": "19.05.2018"
  },
  "15702": {
    "case_id": 15702,
    "title": "Tracheobronchial amyloidosis",
    "section": "Chest imaging",
    "age": "38",
    "gender": "male",
    "diagnosis": "Tracheobronchial amyloidosis",
    "history": "A 38-year old male patient with prior history of pulmonary embolism and factor V Leiden thrombophilia visited our emergency department, because of respiratory dependent chest pain. The patient complained about sputum production and haemoptysis for at least one week. Laboratory tests showed a D-dimer of 920 \u00b5g/L.",
    "image_finding": "Because of high suspicion of pulmonary embolism CT angiography was performed which revealed no contrast filling defects, thrombi or other signs of pulmonary embolism. However, there was a continuous irregular circumferential mucosal wall thickening of the distal trachea, the entire left main bronchus and the proximal left segmental bronchi, with significant narrowing of the left bronchial lumen (Fig. 1). Within the mucosal thickening some small calcifications were identified (Fig. 2). Some deposits were present in a few left lower lobe (sub)segmental bronchi. Small consolidations were seen in the right lower lobe and in the lingula. The patient was referred to a pulmonologist and a bronchoscopy-guided biopsy was performed. The biopsy specimens contained both normal and metaplastic squamous cell epithelium. Deposition of homogenous eosinophilic amorphic material was seen in the underlying stroma. Congo red stain was positive, confirming the patient suffering from primary tracheobronchial amyloidosis (TBA).",
    "discussion": "Pulmonary amyloidosis is a rare disease, which is characterised by extracellular deposition of fibrillary proteins in the lungs. In amyloidosis, respiratory involvement occurs in 50 % of patients [1]. Fraser et al. were the first to develop a radiological classification system for pulmonary amyloidosis in which they described tracheobronchial, nodular parenchymal and diffuse interstitial forms of amyloidosis [2]. Lymphatic, laryngeal, and pleural impairment have also been described [3, 4]. Patients with tracheobronchial amyloidosis may not always present with symptoms, depending on the extent of mucosal wall thickening. Symptoms commonly seen in patients with TBA are cough, wheezing, dyspnoea, haemoptysis, stridor and recurrent pneumonia [5, 6]. In radiological examination, tracheal and bronchial submucosal wall thickening with irregular calcifications and luminal narrowing can be seen on thoracic CT imaging. The differential diagnosis includes diffuse tracheal diseases such as tracheobronchopathia osteochondroplastica (TBO), relapsing polychondritis, Wegener granulomatosis, sarcoidosis, inflammatory bowel tracheobronchitis, tracheobronchial paracoccidioidomycosis, tuberculosis, as well as malignancy such as lymphoma and bronchial carcinoma [1]. High resolution CT is able to discriminate between some of these entities. In TBA small calcifications involving tracheal or bronchial segments are sometimes present, but these are not specific for diagnosis. In patients with tracheal mucosal wall thickening, the tracheal posterior membrane should classically be involved. The distribution of mucosal wall thickening can either be focal or diffuse. Primary tracheobronchial amyloidosis should be considered when no other abnormalities can be identified. Tissue biopsy is essential for a definitive diagnosis. Amyloidosis is a benign lesion, but can be fatal due to airway obstruction or respiratory failure [6]. Resection of obstructive masses using laser techniques and bronchoscopic dilatation or stent implantation are treatment options for TBA. Since the airway lesions in our patient also extended throughout the segmental bronchi, endobronchial treatment was not expected to be sufficient. Radiotherapy is an alternative treatment for patients with extensive disease. Recently, new forms of treatment like colchicine have suggested by some authors [7].",
    "differential_diagnosis": "Tracheobronchial, amyloidosis, Tracheobronchopathia, osteochondroplastica, (TBO), Wegener, granulomatosis, Sarcoidosis, In\ufb02ammatory, bowel, tracheobronchitis, Tracheobronchial, paracoccidioidomycosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015702/000001.png?itok=JkXdq6-6",
            "caption": "Axial view of the thorax at the level slightly below the carina. There is circumferential mucosal wall thickening of the left main bronchus with significant narrowing of the lumen."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015702/000002.png?itok=h6pN4dMF",
            "caption": "Coronal view of the thorax showing small calcifications within the mucosal wall thickening of the left main bronchus and proximal segmental branches (white arrow)."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "CT-Angiography"
    ],
    "link": "https://www.eurorad.org/case/15702",
    "time": "06.06.2018"
  },
  "15717": {
    "case_id": 15717,
    "title": "Bronchiectasis in primary ciliary dyskinesia: Radiological keys for its diagnosis",
    "section": "Chest imaging",
    "age": "36",
    "gender": "female",
    "diagnosis": "Bronchiectasis due to primary ciliary dyskinesia",
    "history": "A 36-year-old woman consulted for greenish bronchorrhea and moderate effort dyspnea. The patient suffered from pneumonia when she was a child and she had suffered from repetitive respiratory infections since then. She had family members diagnosed with bronchiectasis, so a chest X-ray and a chest Multidetector Computed Tomography (CT) were performed.",
    "image_finding": "The posteroanterior and lateral chest X-ray revealed parallel and ringlike opacities consistent with multiple bronchiectasis with bilateral and diffuse distribution (black arrows in Fig. 1). Chest CT showed bronchiectasis with universal distribution, they were predominantly cylindrical (blue arrows in Fig. 2a) and varicose (white arrowheads in Fig. 2b) in the upper lobes, cystic in the middle lobe (anterior red arrow in fig. 2c), and varicose and cystic in lower lobes where they were more numerous (red arrows in Fig. 2c, 2d and 3). Some of the bronchiectasis were occupied. In addition, there was a bilateral mosaic attenuation with patchy areas of lower density suggestive of air trapping areas (yellow asterisks in Fig. 2a, 2b and 3), due to the coexisting constrictive bronchiolitis in patients with bronchiectasis.",
    "discussion": "Primary ciliary dyskinesia is a genetic disease with autosomal recessive inheritance, in which there is an abnormality of the dynein arms of epithelial cilia that leads to an alteration in mucociliary clearance predisposing to pulmonary infections, airway damage, bronchiectasis, sinusitis and otitis media [1, 2]. It is a disease that is diagnosed relatively late because of its nonspecific symptoms in children [2].\n\nAlthough in the chest X-ray we can see signs of bronchiectasis such as \"tram-track\" appearance of parallel and ringlike opacities, the thoracic CT is the reference standard because it shows the bronchiectasis distribution and additional findings that help us make an aetiological diagnosis [1, 3]. The typical imaging findings of primary ciliary dyskinesia in thoracic CT are bilateral and diffuse bronchiectasis with variable severity, which predominate above all in the lower lobes, as well as in the middle lobe and lingula. Other frequent findings are tree-in-bud nodules related to acute infection, mucous plugging due to alteration in mucous clearance, and the mosaic attenuation secondary to areas of air trapping because of the coexisting constrictive bronchiolitis [1, 2].\n\nIn the differential diagnosis, we must take into account those entities that present with bronchiectasis predominantly in the lower lung fields: chronic aspiration of gastric contents in the context of patients with gastroesophageal reflux disease or alterations in oesophageal motility; immunodeficiencies (especially hypogammaglobulinaemia) that are usually diagnosed in childhood and usually present other associated symptoms such as intestinal infections; and the alpha-1-Antitrypsin deficiency that typically causes panlobular emphysema and sometimes has bronchiectasis but rarely they appear before emphysema [1, 2]. Other diseases to consider in this case are: cystic fibrosis, in which upper lobes predominance of bronchiectasis is seen in many but not in all cases, being also a diffuse distribution a common finding; and allergic bronchopulmonary aspergillosis, which usually manifests with cystic or varicoid bronchiectasis with central or proximal upper lobe predominance [1].\n\nThe definitive diagnosis of primary ciliary dyskinesia can be made by measuring mucociliary clearance through different studies such as the saccharin test or a test with radioisotopic tracers, exhaled nitric oxide can be measured, or a biopsy can be done to study ciliary structure under an electron microscope. In our case, the patient underwent a dynamic scintigraphic study, with instillation of the radioisotopic tracer in the nasal meatus, demonstrating that there was no movement of the tracer, which was compatible with mucociliary akinesia [4, 5].",
    "differential_diagnosis": "Bronchiectasis, due, to, primary, ciliary, dyskinesia, Primary, ciliary, dyskinesia, Chronic, aspiration, of, gastric, contents, Immunodeficiencies, (hypogammaglobulinaemia), Alpha-1-Antitrypsin, deficiency, Cystic, fibrosis, Allergic, bronchopulmonary, aspergillosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015717/000004.jpg?itok=lETZJPL7",
            "caption": "Cylindrical (blue arrows in Fig. 2a) bronchiectasis in the upper lobes. Bilateral mosaic attenuation with patchy areas of air trapping areas (yellow asterisks in 2a and 2b)."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015717/000005.jpg?itok=MjTziQVM",
            "caption": "Varicose bronchiectasis (white arrowheads in Fig. 2b) in the upper lobes. Bilateral mosaic attenuation with patchy areas of air trapping areas (yellow asterisks in 2a and 2b)."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015717/000006.jpg?itok=82D_P-2n",
            "caption": "Cystic bronchiectasis in the middle lobe (anterior red arrow in Fig. 2c), and varicose and cystic in lower lobes where they were more numerous (red arrows in Fig. 2c and 2d)"
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015717/000007.jpg?itok=OcctjpqX",
            "caption": "Varicose and cystic bronchiectasis in lower lobes where they were more numerous (red arrows in Fig. 2c and 2d)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015717/000008.jpg?itok=8Q1-2V3K",
            "caption": "Bronchiectasis predominates in the lower lung fields (red arrows) and there is a bilateral mosaic pattern secondary to areas of air trapping (yellow asterisks)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015717/000009.jpg?itok=q7HjSFhM",
            "caption": "Parallel and ringlike opacities (black arrows) consistent with multiple bronchiectasis with bilateral and diffuse distribution."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015717/000010.jpg?itok=RIdzBLuF",
            "caption": "Parallel and ringlike opacities (black arrows) consistent with multiple bronchiectasis with bilateral and diffuse distribution."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT",
      "Conventional radiography"
    ],
    "link": "https://www.eurorad.org/case/15717",
    "time": "19.05.2018"
  },
  "15721": {
    "case_id": 15721,
    "title": "Chronic thromboembolic pulmonary hypertension: a review of imaging findings on ECG gated pulmonary circulation MDCTA",
    "section": "Chest imaging",
    "age": "63",
    "gender": "female",
    "diagnosis": "Chronic thromboembolic pulmonary hypertension.",
    "history": "A 63-year-old female patient presented recurrent and progressive dyspnoea. Clinical examination revealed lower legs swelling. History included prior pulmonary embolism. Echocardiography, combined ventilation perfusion scintigraphy, right cardiac catheterisation and CT angiography were performed.",
    "image_finding": "Radiological evaluation by means of chest CT angiography revealed a filling defect in the right pulmonary artery (Fig. 1), smaller partial mural adherent defects in the branches for the left lower lobe and smaller webs in others (Fig. 2). Also, shunt circulation in the posterior basal segments of right lower lobe (Fig. 4) and bronchial shunt circulation in mediastinum were noted (Fig. 6). CT scan showed also enlarged pulmonary artery trunk and central branches. High resolution CT of lung parenchyma revealed the characteristic mosaic perfusion pattern (Fig. 5). Venous triplex examination showed no findings of deep venous thrombosis. Right cardiac catheterisation revealed high pressures in the pulmonary artery and echocardiography findings were right ventricle enlargement, hypertrophy, and moderate systolic dysfunction suggesting the diagnosis of severe pulmonary hypertension. Combined ventilation perfusion scintigraphy showed a mismatch between normal ventilation and non-perfused areas.",
    "discussion": "Chronic thromboembolic pulmonary hypertension (CTEPH) is a treatable form of pulmonary hypertension which requires multimodality imaging for accurate diagnosis. Pulmonary hypertension is defined as elevation of pressure in pulmonary circulation higher than 25mmHg at rest and above 30mmHg during physical activity [1]. Catheterisation of the right side of the heart is the gold standard for the diagnosis. It confirms pulmonary hypertension by direct measurement of pulmonary pressures, resistance and cardiac output. [2] Echocardiography estimates peak velocity of tricuspid valve regurgitation, and detects right atrial and right ventricular dilatation, right ventricular systolic dysfunction and Doppler flow abnormalities in the right ventricular outflow tract. ECG-gated pulmonary circulation CT angiography is of great value for the diagnosis of CTEPH. The trunk of pulmonary artery has a diameter larger than 29mm and ratio pulmonary trunk: ascending aorta > 1:1. CTA reveals also the mural defects (thrombus) being attached to the vessel wall with eccentric position and obtuse angle, in contrast to the centrally located and with acute angle defects seen in acute pulmonary embolism patients [3]. Bronchial shunt circulation is of great importance and a highlight of CTEPH. Also imaging with intravenous contrast media, is mandatory for findings such as the webs due to prior pulmonary embolism [4]. A characteristic finding in lung parenchyma is the mosaic perfusion pattern caused by irregular lung perfusion. Parenchymal fibrosis, cavities, irregular peripheral linear densities and wedge-shaped areas \u2014pulmonary infarction\u2014 in the periphery of the lung field are seen [5].",
    "differential_diagnosis": "Chronic, thromboembolic, pulmonary, hypertension., CTEPH, COPD, Pulmonary, artery, sarcoma, Interstitial, lung, disease, induced, pulmonary, hypertension",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015721/000001.jpg?itok=_VEiiAd2",
            "caption": "This shows enlarged right pulmonary artery and a mural attached filling defect at its bifurcation branch (eccentric thrombus \u2014arrowhead)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015721/000002.jpg?itok=jTlyzfLw",
            "caption": "This shows the partial intraluminal and attached to the vessel wall defects (arrowhead: webs, arrow: eccentric thrombus). Enlarged pulmonary artery trunk and abrupt angular narrowing of pulmonary artery branch is noted"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015721/000003.jpg?itok=lECMMPeK",
            "caption": "This shows the enlarged left pulmonary artery and branches. There are also small filling defects attached to the vessel wall."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015721/000004.jpg?itok=l69A8r3j",
            "caption": "Collateral arterial shunt in posterior basal segments of right lower lobe is shown (arrowhead)"
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015721/000005.jpg?itok=Rc23Lajq",
            "caption": "Mosaic pattern due to irregular perfusion. Hypo- and hyperperfused areas."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015721/000006.jpg?itok=v9PhuZWk",
            "caption": "Enlarged bronchial arteries arising from thoracic aorta and coursing behind the carina."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT-Angiography"
    ],
    "link": "https://www.eurorad.org/case/15721",
    "time": "09.05.2018"
  },
  "15811": {
    "case_id": 15811,
    "title": "Iatrogenic haemothorax following thoracentesis",
    "section": "Chest imaging",
    "age": "57",
    "gender": "female",
    "diagnosis": "Iatrogenic actively bleeding haemothorax following thoracentesis",
    "history": "A 57-year-old female patient with history of radical cystectomy and external urinary diversion with ureteral stents (18 months earlier), hospitalised in the intensive care unit (ICU) because of persistent urinary sepsis, anasarca, and impaired renal function requiring haemodialysis. After thoracentesis, she suddenly developed worsening of respiratory function and haemoglobin levels dropped.",
    "image_finding": "Initial CT (Fig.1) showed presence of significant pericardial effusion, bilateral fluid-attenuation pleural effusions and atelectatic consolidations of both inferior lung lobes. A few hours after left-sided thoracentesis, emergency CT (Fig.2) showed development of near-complete left lung atelectasis, appearance of some intrapleural air, marked increase of ipsilateral pleural effusion containing hyperattenuating components consistent with haemothorax, which caused contralateral dislocation of mediastinum and downwards dislocation of the hemidiaphragm. Additionally, a sizeable focus of contrast medium extravasation indicating active bleeding originating from the visceral pleura was visible within the haemothorax.The patient underwent immediate tracheal intubation and pleural tube drainage. Repeated CT a day later (Fig.3), which showed partial re-expansion of left lung, moderately decreased haemothorax and minimal residual focal bleeding at visceral pleura. Despite clinical and laboratory stabilisation, she ultimately required thoracotomic surgery to evacuate the haemothorax and achieve haemostasis.",
    "discussion": "Pleural effusion is a common condition which may develop secondary to a variety of causes and contributes to dyspnoea and patients\u2019 sufferings. Nowadays, thoracentesis is routinely performed as a bedside procedure to remove fluid from the pleural space via percutaneous introduction of a needle: in the USA, among 1.5 million people with an effusion, an estimated 178.000 procedures are performed each year. Thoracentesis allows both symptomatic relief and evaluation of pleural fluid features which aid in recognizing the underlying aetiology [1]. Albeit regarded as safe and generally well tolerated, thoracentesis is not without risks, particularly pneumothorax from puncture of the visceral pleura (at least 3% of cases, depending on definition). Other complications include haemorrhage (0.1%) and re-expansion pulmonary oedema (0.01%) [1-5]. Albeit uncommon, iatrogenic bleeding may be increasingly encountered since recent evidence suggested that patients with contraindications such as prolonged International Normalized Ratio (INR), low platelet count, anticoagulation or clopidogrel may undergo thoracentesis without correcting bleeding risk or withholding medications [6-9].Iatrogenic bleeding is potentially fatal, generally occurs shortly (within 24 hours) after thoracentesis, may develop in either pleural space or thoracic wall, and manifests with worsening respiratory distress, chest pain and hypotension. As in this patient, this complication is more common (0.6% of procedures) in the intensive care unit (ICU) and may also develop following thoracostomy for chest tube insertion or central venous catheterisation. Notably, overall short-term mortality after thoracentesis is high (>20%, >35% in ICU patients) particularly in bilateral, malignant, and multiple-aetiology effusions [5, 10]. As exemplified by the hereby presented case, the role of CT includes detection of haemothorax and of active bleeding. Borrowing from experience with polytraumatised patients, haemothorax appears as hyperattenuating (35-70 Hounsfield units) effusion with dependent layering of dense clots [11]. Most haemorrhages result from laceration during needle access of the intercostal artery [12-14], which is often tortuous and does not always lie along the inferior rib edge. Awareness of the higher \u201csafe space\u201d laterally than medially and use of colour Doppler US for guidance of thoracentesis significantly reduces risk of bleeding [9, 15, 16].Management depends on haemodynamic conditions and blood volume evacuated via tube drainage. Surgical exploration (either video-assisted or thoracotomy) is warranted in massive (>1.5 l) haemothorax and ongoing blood loss [13, 17].",
    "differential_diagnosis": "Iatrogenic, actively, bleeding, haemothorax, following, thoracentesis, Chest, wall, haematoma, Pneumothorax, Re-expansion, pulmonary, oedema",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015811/000001.jpg?itok=6Q9AXwHt",
            "caption": "Before thoracentesis, unenhanced CT showed bilateral fluid-attenuation (5-8 Hounsfield units) pleural effusions (*) and atelectatic consolidations of lower lung lobes. Additionally, significant pericardial effusion (+) was present."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015811/000002.jpg?itok=yKmHWNax",
            "caption": "Before thoracentesis, unenhanced CT showed bilateral fluid-attenuation (5-8 Hounsfield units) pleural effusions (*) and atelectatic consolidations of lower lung lobes. \nNote small-sized kidneys with urinary stents (thick arrows) in place."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015811/000003.jpg?itok=0yNHXy0_",
            "caption": "Compared to Fig.1, repeated CT after thoracentesis showed near-complete atelectasis of left lung, appearance of some intrapleural air (o) and contralateral dislocation of mediastinal structures."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015811/000004.jpg?itok=VLq3WVyZ",
            "caption": "On pre-contrast images (b,c), the left-sided pleural effusion (large *) was markedly increased with appearance of hyperattenuating (mean 35-40 HU) components consistent with haemothorax. \nNote stable findings at right lung base (*) and pericardial effusion (+)."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015811/000005.jpg?itok=nZ1dIz7D",
            "caption": "On pre-contrast images (b,c), the left-sided pleural effusion (large *) was markedly increased with appearaance of hyperattenuating (mean 35-40 HU) components consistent with haemothorax."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015811/000006.jpg?itok=baMB6bfN",
            "caption": "Coronal post-contrast viewing effectively showed markedly increased, inhomogeneous left pleural effusion (large *) causing near-complete lung atelectasis, contralateral mediastinal displacement and downwards dislocation of hemidiaphragm. Note pericardial effusion (+)."
          },
          {
            "number": "Figure 2e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015811/000007.jpg?itok=vwIPAyz0",
            "caption": "Additionally, a sizeable focus of contrast medium extravasation (arrowheads) indicating active bleeding was visible within haemothorax (large *), originating from the visceral pleura."
          },
          {
            "number": "Figure 2f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015811/000008.jpg?itok=s4R_hLml",
            "caption": "Additionally, a sizeable focus of contrast medium extravasation (arrowheads) indicating active bleeding was visible within haemothorax (large *), originating from the visceral pleura. Note downwards displacement of left hemidiaphragm."
          },
          {
            "number": "Figure 2g",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015811/000009.jpg?itok=ryk4dS2G",
            "caption": "Additionally, a sizeable focus of contrast medium extravasation (arrowheads) indicating active bleeding was visible within haemothorax (large *), originating from the visceral pleura. Note downwards displacement of left hemidiaphragm."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015811/000010.jpg?itok=ouv45gj3",
            "caption": "24 hours after Fig.2, CT showed tracheal intubation, positioning of left pleural drainage tube (thick arrows), partial re-expansion of left lung and decreased mediastinal displacement."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015811/000011.jpg?itok=IqAVSjRH",
            "caption": "24 hours after Fig.2, CT showed tracheal intubation, positioning of left pleural drainage tube (thick arrows), partial re-expansion of left lung and decreased mediastinal displacement. Note moderately decreased haemothorax (large *), persistent pericardial effusion (+)."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015811/000012.jpg?itok=7Onm3Skg",
            "caption": "On pre-contrast images, the moderately decreased haemothorax (large *) still contained hyperattenuation bloody components."
          },
          {
            "number": "Figure 3d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015811/000013.jpg?itok=L0nVnoYc",
            "caption": "After iv contrast, the focal contrast extravasation at visceral pleura (arrowheads) within haemothorax (large *) was markedly decreased in size compared to Fig.2. \nNote pleural drainage (thick arrows), pericardial effusion (+), right pleural effusion (*) and atelectasis."
          },
          {
            "number": "Figure 3e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015811/000014.jpg?itok=SI2NN57e",
            "caption": "After iv contrast, the focal contrast extravasation at visceral pleura (arrowheads) within haemothorax was markedly decreased in size compared to Fig.2."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/15811",
    "time": "01.08.2018"
  },
  "15820": {
    "case_id": 15820,
    "title": "Multiple phantom tumours: An unusual case",
    "section": "Chest imaging",
    "age": "90",
    "gender": "female",
    "diagnosis": "'Phantom' or 'vanishing' tumours",
    "history": "A 90-year-old female patient fully independent regarding the basic activities of daily living (BADL) but with past medical history of hypertension and congestive heart failure (CHF) was referred to the radiology department for high suspicion of a pulmonary mass on a routine chest X-ray.",
    "image_finding": "On the posteroanterior chest X-ray (Fig. 1a) projection two well-defined opacities are present on the right middle and lower pulmonary fields. The lateral view (Fig. 1b) reveals the pleural semiology of the greater opacity as well as its allineation with the major fissure. The second opacity is pictured on the periphery of the posterobasal segment of the right lower lobe.A contrast-enhanced CT (Fig. 2) in the arterial phase is performed and revealed two collections with tomodensitometric values of serous fluid (5 Hounsfield Units) located within the major and superior accessory fissure.",
    "discussion": "'Phantom' or 'vanishing' tumours are commonly secondary to a transudative pleural effusion within the fissures and are frequently associated with congestive heart failure (CHF). Sometimes, these findings can be misdiagnosed as malignancy leading to invasive unnecessary procedures to confirm the diagnosis.It is important to remark that these opacities correspond to pleural effusion loculating within the fissures due to the higher hydrostatic pressure present in CHF [1]. The most common location is the minor fissure [2] but, as in this case, they can appear within the major fissure as well giving place to multiple mass-like opacities.There is no specific treatment for such condition as long as effective fluid depletion with diuretics will mobilise the fluid forcing the opacities to disappear [3].This case illustrates the condition particularly well, as 'phantom' tumours can be multiple and may appear wherever there is a fissure. Our patient had two 'phantom' tumours, one of them within a superior accessory fissure of the right lower lobe, and both disappeared after fluid depletion.Written informed patient consent for publication has been obtained.",
    "differential_diagnosis": "'Phantom', or, 'vanishing', tumours, Malignant, tumour, Metastases, Atelectasis, Abscess",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015820/000001.png?itok=BQAU-Qsk",
            "caption": "Posteroanterior chest X-ray showing two well-demarcated opacities (arrows) and costophrenic angle blunting (arrowhead) in keeping with pleural effusion."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015820/000002.png?itok=JgXgw9iG",
            "caption": "Lateral projection chest X-ray showing two well-demarcated opacities (arrows) and costophrenic angle blunting (arrowhead) in keeping with pleural effusion."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015820/000003.png?itok=1sEChlyd",
            "caption": "Axial projection of chest CT. Well-defined fluid collection extending into the major and minor fissure."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015820/000004.png?itok=WmTKEk-Z",
            "caption": "Axial projection of chest CT. Fluid collection of the major and minor fissures partially included. Note a second collection appearing into an accessory superior fissure of the right lower lobe."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015820/000005.png?itok=X_-ZafYX",
            "caption": "Sagittal projection of chest CT. Greater fluid collection within the major and minor fissures with the second collection pictured into the accessory superior fissure of the right lower lobe."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015820/000006.png?itok=-hNArlkq",
            "caption": "Sagittal projection of chest CT. Note the detail of the accessory superior fissure of the right lower lobe (arrowhead) containing the small fluid collection."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/15820",
    "time": "30.07.2018"
  },
  "15841": {
    "case_id": 15841,
    "title": "Mobile thoracolithiasis",
    "section": "Chest imaging",
    "age": "53",
    "gender": "female",
    "diagnosis": "Thoracolithiasis (demonstration of mobility on serial imaging confirms diagnosis)",
    "history": "A patient with a history of a resected melanoma in the right thigh underwent a follow-up chest X-ray after six months.",
    "image_finding": "The chest X-ray showed a nodular opacity laterobasal in the left lower lung zone (Fig. 1). A previous chest CT demonstrated a subpleural calcified lesion of 0.7 cm posterior in the dependent portion in the left lower lung zone (Fig. 2). This calcification was initially thought to represent a calcified granuloma and was not seen on the chest X-ray. To exclude lung metastasis a new CT of the thorax was performed. This revealed that the subpleural calcification was in a different location in comparison with the previous CT (Fig. 3). There was no metastatic disease.",
    "discussion": "Thoracolithiasis is defined as a freely mobile nodule in the pleural cavity with or without calcification [1]. Other names include \u2018pleural stone\u2019, \u2018intrathoracic calculus\u2019 and \u2018pleurolith\u2019 [2]. Thoracolithiasis is rare (reported incidence of less than 0.1 %) [3]. There is no known age or sex predilection [2]. The stones are more frequent on the left than the right [1-3]. Stone formation is thought to originate from necrosis of the pericardial fat [3].\nThoracolithiasis is a benign entity that does not require surgical intervention [3]. Radiologic findings are important in order to differentiate from other, potentially, harmful lesions. CT plays the most central role in the diagnosis, it helps confirm calcific density when the density of the nodule is indeterminate on chest X-ray [2]. The size of the stones range from 5 to 15 mm and occur more frequently in the left pleural cavity [1]. The stones are usually ovoid and smoothly marginated [3]. Since they are mobile, location varies on serial imaging [4]. They are most often found in the dependent part of the pleural cavity on the surface of the diaphragm, on the chest wall adjacent to the lower lung, abutting the left cardiac margin, or near the para-spinal space [1]. The lesions may or may not be calcified and can demonstrate variable patterns of calcification including spotty and central, peripheral \u2018eggshell\u2019 and diffuse and homogeneous [5, 6, 7]. Since they often contain central fat, pleural stones may have central low density [2].\nIn conclusion thoracolithiasis is a rare benign pulmonary entity that should be differentiated from other lung pathology based on characteristic radiologic findings, including extrapleural location and demonstration of mobility on serial imaging.\n\nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Thoracolithiasis, (demonstration, of, mobility, on, serial, imaging, confirms, diagnosis), Calcified, granuloma, Hamartoma, Metastatic, disease",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015841/000001.jpg?itok=-pFxWN2c",
            "caption": "Chest X-ray in PA position shows an ovoid nodular opacity laterobasal in the left lower lung zone (arrow)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015841/000010.jpg?itok=Kx3r-P_1",
            "caption": "A previous chest CT scan shows a calcified lesion near the left paraspinal space. Soft tissue window."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015841/000011.jpg?itok=Nknq1c35",
            "caption": "A previous chest CT scan shows a calcified lesion near the left paraspinal space. Lung window."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015841/000012.jpg?itok=qlbaAx5Z",
            "caption": "Sagittal plane. Lung window."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015841/000013.jpg?itok=JlrN3cg3",
            "caption": "Coronal plane. Soft tissue window."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015841/000014.jpg?itok=4YLfsWbY",
            "caption": "A new chest CT scan shows the subpleural calcification on a different location, confirming mobile thoracolithiasis. Soft tissue window."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015841/000015.jpg?itok=TPuCUYKZ",
            "caption": "A new chest CT scan shows the subpleural calcification on a different location, confirming mobile thoracolithiasis. Lung window."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015841/000016.jpg?itok=J0K2LlrL",
            "caption": "Sagittal plane. Lung window."
          },
          {
            "number": "Figure 3d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015841/000017.jpg?itok=Bj1npIzV",
            "caption": "Coronal plane. Soft tissue window."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/15841",
    "time": "17.07.2018"
  },
  "15872": {
    "case_id": 15872,
    "title": "Rib metastasis of clear cell renal cell carcinoma: an isolated and unusual localisation",
    "section": "Chest imaging",
    "age": "82",
    "gender": "male",
    "diagnosis": "Rib metastasis of clear cell renal cell carcinoma",
    "history": "An 82-year-old male patient was referred to the Emergency Department for left inter-scapular pain, lasting for one week.\nHis medical history included hypertension under treatment and right occipital haemorrhage.",
    "image_finding": "Chest X-ray showed left pleural thickening and soft tissue injury on the fifth left rib (Fig. 1). Non-enhanced CT scan was performed to gain further information about the lungs. CT showed lesions involving the fifth left rib for its entire length and D3-D4 vertebras with spinal cord invasion (Fig. 2).\nCT images showed left pleural effusion but no pulmonary parenchymal abnormalities. To investigate the neoplastic origin of the lesion, the observation was also extended to the abdomen and completed with contrast agent. We observed a large mass involving the mid-lower pole of the left kidney, showing heterogeneous enhancement with peripheral hypervascular areas and thrombosis with filling defect involving the left renal vein (Fig. 3-4). An MRI was acquired to better characterise the spinal cord involvement (Fig. 5).\nUltrasound-guided biopsy of renal and rib lesion revealed the diagnosis: clear cell renal cell carcinoma.",
    "discussion": "The prevalence of the malignant costal lesions is about 3-8%, and the most commonly found are metastasis and myeloma. They are usually associated with primary neoplasm like breast cancer, prostate gland, lung and kidney cancer (RCC) [2], as in this case, and they may be osteolytic, sclerotic or mixed [3].\nRib metastases are generally multiple and small: isolated ones are rare (0.7-2.5 %) [1], mainly in RCC, and they are hardly bigger than 5 cm. They can be considered an atypical primary cancer presentation, otherwise the classical presentation of RCC is haematuria (55%), abdominal pain (40%), and palpable abdominal mass (35%).\nConventional chest radiograph and CT scanning represent the best method for rib lesions evaluation. At imaging, they have blurred outlines and can break the cortical bone, and occupy near soft tissue [3].\nBone scintigraphy is widely accepted as the standard test to evaluate bone metastasis. Although highly sensitive, bone scintigraphy lacks specifity, while CT improves specifity [2]. Surgical treatment represents the best approach for isolated rib metastasis, requiring wide resection including the rib below and the one under the metastatic one [1].\n\nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Rib, metastasis, of, clear, cell, renal, cell, carcinoma, Myeloma, Chondrosarcoma, Aneurysmal, bone, cyst, Lymphoma, Tubercolosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015872/000001.jpg?itok=OggPTFCN",
            "caption": "AP projection \u2013 Pleural thickening on left middle lung zone and soft tissue swelling (yellow arrows) with small effusion."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015872/000002.jpg?itok=e955JPVq",
            "caption": "Coronal view image showing the lesion of the fifth rib with an attenuation of soft tissue (37 HU) and its own calcifications."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015872/000003.jpg?itok=aN5fI0Pn",
            "caption": "Axial view of the lesion (red arrow) showing strong and heterogeneous enhancement."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015872/000013.jpg?itok=2Y2ymsJi",
            "caption": "Coronal view: left kidney lower pole mass showing peripheral contrast enhancement and well-defined central area of low density without enhancement. A filling defect (yellow arrow) involving the left renal vein, likely as thrombosis."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015872/000014.jpg?itok=MRNLpCMs",
            "caption": "Coronal view: In thorax field, the contrast-enhanced injury of the fifth rib like renal mass."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015872/000006.jpg?itok=CVG9sXel",
            "caption": "Lateral view: 3D reconstruction better shows the complete alteration of the fifth rib, involving its entire length."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015872/000007.jpg?itok=w1NyJput",
            "caption": "3D reconstruction. Oblique view."
          },
          {
            "number": "Figure 4c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015872/000008.jpg?itok=Yt0AKqga",
            "caption": "3D reconstruction. Superior view."
          },
          {
            "number": "Figure 4d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_video/2018-08/0000015872/000012F.png?itok=Q5OXFtq9",
            "caption": "VRT rotation"
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015872/000009.jpg?itok=JTorgncA",
            "caption": "D3-vertebra lesion's heterogeneous hyperintensity on FSE T2-weighted axial image: it spreads to vertebra's pedicle, transverse process and left lamina; the mass invades the spinal cord and it leaves an imprint on the latter."
          },
          {
            "number": "Figure 5b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015872/000010.jpg?itok=2AzbuErR",
            "caption": "MRI sagittal FSE T1-weighted image shows the same lesion with hypointensity."
          },
          {
            "number": "Figure 5c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015872/000011.jpg?itok=XDHuafyX",
            "caption": "Coronal FSE T2w image: heterogeneous hyperintensity D3-vertebra mass localisation (yellow arrow) similar to the rib lesion (red arrow)."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax",
      "Thoracic wall",
      "Spine",
      "Abdomen"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "Image manipulation / Reconstruction",
      "CT",
      "MR"
    ],
    "link": "https://www.eurorad.org/case/15872",
    "time": "14.07.2018"
  },
  "15889": {
    "case_id": 15889,
    "title": "Dilated thoracic duct mimicking a left supraclavicular mass",
    "section": "Chest imaging",
    "age": "54",
    "gender": "male",
    "diagnosis": "Dilated thoracic duct",
    "history": "A 54-year-old man with alcoholic liver cirrhosis, gastroesophageal varices and portal hypertensive gastropathy was admitted with decompensated cirrhosis.",
    "image_finding": "As part of the study protocol to be included in the liver transplant list, the patient underwent a contrast-enhanced chest computed tomography (CT) examination. The CT study showed a very tortuous tubular structure, next to the thoracic aorta, representing a dilated thoracic duct, very likely due to decompensated cirrhosis and portal hypertension. Mild pericardial effusion and moderate perihepatic and perisplenic ascites were also found together with evident signs of chronic liver disease and portal hypertension.",
    "discussion": "The thoracic duct is the largest collecting lymphatic vessel. Lymphatics from the lower part of the body converge in the lumbar region to form the cisterna chyli, which, at the 12th thoracic vertebra, narrows and becomes the thoracic duct. It enters the thoracic cavity through the aortic hiatus, ascends to the right of the midline in the posterior mediastinum, crosses to the left of midline at the thoracic plane (T4-T6), continues superiorly through the thoracic inlet, and drains as a single trunk into the left subclavian vein [1-3].\nThe thoracic duct can be associated with various pathological conditions related either with impaired transportation or excessive production of lymph. In patients with liver cirrhosis and portal hypertension (as our patient), hepatic hilar lymphatics become distended due to the disturbance in the drainage from the sinusoid to the terminal veins. In decompensated cirrhosis, any rise in pressure in the portal system entails an increase in liver and splanchnic lymph production, responsible for thoracic duct dilatation. Other conditions, such as pancreatic obstruction or right-sided cardiac decompensation may also lead to an increase in the amount of thoracic duct lymph [2].\nAlthough most radiological techniques may be limited to assess the morphology and course of the thoracic duct due to its hidden course or small diameter, CT can reliably depict its various appearances. In fact, multidetector-row CT has been shown to achieve almost 100% visualisation of thoracic duct, particularly after contrast administration, which helps differentiate the distal thoracic duct in the left supraclavicular area from adjacent structures [4].\nAlthough the diameter of the thoracic duct can increase slightly during the lifetime, it is unlikely to be clinically or radiographically appreciable. However, patients with decompensated cirrhosis show a remarkable dilatation of the left distal thoracic duct (\u2265 5mm). This fact seems to be significantly associated with disease severity. Little is known, however, about the prognostic significance of visibility of this anatomical structure on CT or if this radiological sign could be used to monitor disease progression [1].\nIn conclusion, the dilated thoracic duct can be incidentally detected on contrast-enhanced chest CT performed for the evaluation of cirrhosis-related intrathoracic disease. It usually appears as a tortuous and dilated tubular structure ascending in the thoracic cavity between the aorta and azygos vein to the right of the midline in the posterior mediastinum. A dilated thoracic duct (\u2265 5mm) may be associated with the status of decompensated cirrhosis.\nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Dilated, thoracic, duct, Enlarged, cervical, lymph, node, like, a, Virchow's, lymph, node, Lymphadenopathies, Mediastinal, or, duplicate, cysts",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015889/000004.jpg?itok=R-YzFJSE",
            "caption": "The study showed a dilated distal thoracic duct (15 mm) mimicking a left supraclavicular mass (arrow)."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015889/000003.jpg?itok=GU12AiHv",
            "caption": "The thoracic duct (arrow) ascends to the right of the midline in the posterior mediastinum between the aorta (Ao) and azygos vein (Az), posterior to the oesophagus (e)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015889/000005.jpg?itok=YMSlbxPf",
            "caption": "The coronal reformation shows a tortuous and dilated thoracic duct (arrows) ascending to the right of the aorta (Ao) in the posterior mediastinum."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015889/000006.jpg?itok=ADl1Y-qJ",
            "caption": "The sagittal reformation shows a tortuous and dilated thoracic duct (arrows) ascending anterior to the azygos vein (Az) in the posterior mediastinum."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015889/000007.jpg?itok=SrMJSz-g",
            "caption": "Cinematic rendering reformation shows a tortuous and dilated thoracic duct (arrows) entering the thoracic cavity and ascending between the aorta (Ao) and azygos vein (Az) to the right of the midline in the posterior mediastinum."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lymphatic"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/15889",
    "time": "17.09.2018"
  },
  "15913": {
    "case_id": 15913,
    "title": "Rib articulation between the sixth and seventh rib in an adult patient mimicking a lung nodule",
    "section": "Chest imaging",
    "age": "37",
    "gender": "male",
    "diagnosis": "Pseudo rib articulation, a normal variant mimicking a lung nodule.",
    "history": "A 37-year-old patient had a chest radiograph performed for dyspnoea.",
    "image_finding": "Chest radiograph showed a nodule overlying the mid thoracic spine. A CT examination of the chest confirmed this to be a rib articulation between the left sixth and seventh ribs. This is a normal congenital anatomical variant.",
    "discussion": "A.     BackgroundRibs articulation or pseudo rib articulation is a normal anatomical variant that is often detected on CT of the chest. Sometimes rib articulation may mimic other anomalies and is difficult to define on chest radiographs [1]. A review of the chest anomalies found congenital rib anomalies in 544 men (1.4%), while other studies have found a higher percentage of up to 8% [2]B.\tClinical PerspectiveChest CT was performed to investigate the suspected nodule in the chest radiograph. The pseudo rib articulation between the left posterior sixth and seventh ribs was identified on the CT examination instead of a lung nodule. C.\tImaging PerspectiveA nodule was suspected in the chest radiograph on the lateral view. A chest CT was recommended. CT of the chest showed a pseudo rib articulation between the left sixth and seventh ribs posteriorly, that is mimicking a pseudo lung nodule [3].D.\tTake HomePseduo rib articulation is a normal congenital variant. No further follow-up is needed. It will mimic a lung nodule on the chest radiograph.Written informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Pseudo, rib, articulation,, a, normal, variant, mimicking, a, lung, nodule., Pseudo, lung, nodule, Pseudo, rib, articulation, Lung, nodule",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015913/000001.jpg?itok=Sg9SHU9v",
            "caption": "Axial CT chest in lung window showing the rib articulation."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015913/000006.jpg?itok=Vj_GbxhO",
            "caption": "Axial CT chest in bone window showing the rib articulation."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015913/000003.jpg?itok=UGEoZiQ-",
            "caption": "Lung Coronal CT in bone window showing the left 6th- 7th rib articulation, pseudo joint formation."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015913/000005.jpg?itok=hfjDQG4N",
            "caption": "Sagittal CT showing the rib articulation between the left sixth and seventh rib."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015913/000014.jpg?itok=rgmzXQiR",
            "caption": "Volume rendering is showing a pseudo rib articulation between the posterior left sixth and seventh ribs."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015913/000016.png?itok=KIGGaeJ4",
            "caption": "Chest PA X-Ray showing a nodule in the left side measuring approximately 0.9 cm by 1.0 cm"
          },
          {
            "number": "Figure 5b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000015913/000017.png?itok=yVJxn4_O",
            "caption": "Lateral radiograph showing a nodule overlying the spine."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Mediastinum",
      "Bones"
    ],
    "imaging_technique": [
      "CT",
      "Conventional radiography"
    ],
    "link": "https://www.eurorad.org/case/15913",
    "time": "03.09.2018"
  },
  "16011": {
    "case_id": 16011,
    "title": "Pulmonary Langerhans cell histiocytosis in the end stage",
    "section": "Chest imaging",
    "age": "61",
    "gender": "female",
    "diagnosis": "Pulmonary Langerhans cell histiocytosis in the end stage",
    "history": "A 61-year-old female patient with chronic dyspnoea without fever, malaise or weight loss. Personal history: ex-smoker of 2-3 cigarettes per day up to 40 years, pulmonary hypertension, diabetes mellitus, and bone injury which was treated with radiotherapy 20 years ago.",
    "image_finding": "First, a chest X-ray was performed which revealed bilateral interstitial alteration without loss of volume and increased caliber of pulmonary arteries (Figure 1).\nLater, it was completed with a chest high resolution computed tomography (HRCT). It showed a diffuse and symmetric parenchymal involvement with cysts in lower lung lobes and fibrosis in upper lung lobes (Figure 2, 3 and 4).\nFinally, a video-assisted thoracoscopy was performed to obtain the definitive diagnosis. The histology shows a granuloma constituted by Langerhans cells, and inmunohistochemical staining for CD1a was positive (Figure 5).",
    "discussion": "Pulmonary Langerhans cell histiocytosis (PLCH) refers to a group of diseases of unknown aetiology, in which an accumulation of Langerhans cells occurs in different organs of the body. [1, 2]. Bone injury is the most common radiographic manifestation (occurs in 80% of patients), and has a predilection for flat bones (skull). Lung involvement is observed in 10% of patients. About 90% are smokers. PLCH affects young people (average age of 32 years) without differences in sex and race [2, 3, 4]. The most frequent symptoms (50%) are dry cough, dyspnoea or chest pain accompanied or not by constitutional syndrome. Also, they may be asymptomatic or characteristically debut with spontaneous pneumothorax (15- 20%) [1, 2, 3].\n\nIn the chest X-ray it is usually presented as a reticular pattern (corresponding to the wall of the cysts) or reticulonodular and the lung volume is usually preserved or increased [4, 5].\nHRCT usually shows cysts less than one centimetre, with thin (<2mm) or thick (>2mm) walls and rounded or irregular shape. In some patients, small (most frequently) or large nodules may be seen, these may cavitate and form cysts. Therefore the pulmonary nodules are more numerous at the beginning, but after a while the number of cysts increases and exceeds the number of nodules. A feature to differentiate it from the rest of diffuse cystic lung diseases on HRCT are early centrilobular nodules, sparing of costophrenic angle.\nThe lesions are distributed mainly in the middle and upper lobes [4, 5, 6]. In highly evolved phases we can find fibrotic changes and signs of pulmonary hypertension [6].\nThe HRCT has a high diagnostic yield and a good relationship with the histology, but the definitive diagnosis is anatomopathological (as in this case) [2, 3]. The biopsy methods can be transbronchial (lower performance), guided by thoracoscopy and open.\n\nThe first therapeutic measure is to quit tobacco. In severe and symptomatic patients, the treatment consists of corticosteroids with or without immunosuppressants. In advanced stages of the disease, treatment is bilateral lung transplantation (as in this case) [4.]\n50% of patients will experience clinical and radiological stabilisation and the 25% will resolve spontaneously. Others (25%) progress to respiratory failure with or without pulmonary hypertension (the main causes of death) [3, 4, 5].\n\nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Pulmonary, Langerhans, cell, histiocytosis, in, the, end, stage, Lymphangioleiomyomatosis, Pulmonary, emphysema, Sarcoidosis, (stage, IV), Allergic, allergic, extrinsic, (chronic, phase), Tracheobronchial, papillomatosis, Pneumoconiosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000016011/000005.jpg?itok=Ps4sK4iK",
            "caption": "Bilateral interstitial alteration without loss of volume. Increased caliber of pulmonary arteries (yellow arrows)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000016011/000006.jpg?itok=Lhxzf1A8",
            "caption": "Diffuse, symmetric parenchymal involvement, with cystic changes in lower lung lobes and fibrosis in upper lung lobes."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000016011/000007.jpg?itok=LlU9X1W8",
            "caption": "Shows cysts (most of 5mm) and peribronchial fibrotic changes."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000016011/000008.jpg?itok=8XuzXXk-",
            "caption": "Notice the irregular cysts, with a size less than one centimeter and confluent."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000016011/000009.jpg?itok=2O56rOYe",
            "caption": "Granuloma constituted by Langerhans cells. These cells have a slightly eosinophilic clear cytoplasm and a nucleus with a central cleft.\n(HE stain)."
          },
          {
            "number": "Figure 5b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000016011/000010.jpg?itok=8Add9lqR",
            "caption": "Immunohistochemical staining for CD1a is positive, characteristics of the PLCH."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Respiratory system"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT-High Resolution",
      "Percutaneous"
    ],
    "link": "https://www.eurorad.org/case/16011",
    "time": "13.09.2018"
  },
  "16024": {
    "case_id": 16024,
    "title": "mbryonal rhabdomyosarcoma of ple",
    "section": "Chest imaging",
    "age": "16",
    "gender": "female",
    "diagnosis": "Embryonal rhabdomyosarcoma of right pleura.",
    "history": "A 16-year-old previously healthy female patient presents with c/o right-sided chest pain on exertion, breathlessness and weight loss with low-grade fever and generalised weakness. She then was investigated further, including her blood, urine, sputum culture, liver and renal function tests, which were normal.",
    "image_finding": "Chest X-ray shows obliterated right cardio-phrenic angle, right entire lung field suggestive of severe right pleural effusion with passive collapse of underlying lung. Ultrasonography guided right pleural fluid tapping was done and sent for - histopathological examination and other tests. MRI examination and PET CT examination was performed after pleural fluid tapping. MRI of chest shows nodular enhancing thickening of entire right pleura. It is metabolically active in PET CT examination. Diaphragmatic pleura shows heterogeneously enhancing nodular mass lesion, causing that scalloping of right lobe of liver (Segment VIII) is seen in MRI and PET-CT examinations. No pericardial effusion, thickening, or calcification are seen. Enlarged and metabolically active lymph nodes are seen in internal mammary and subcarinal region. Moderate right pleural effusion and passive collapse of right lower lobe of lung are seen in MRI and PET-CT examination. Metabolically active focal osseous lesion is seen in right sacrum.",
    "discussion": "Rhabdomyosarcoma (RMS) is an malignant tumour of childhood from striated muscle origin commonly located in the head and neck region followed by extremities. Thoracic RMS is rare, and pleural RMS is extremely rare with a reported incidence of 3.8%. [1, 3] Chest wall or pleural tumours usually present with pain and swelling at local site. [3] Tumours may occasionally remain asymptomatic till they reach a large size. Pleural effusion resulting in dyspnoea may lead to earlier diagnosis. [2] Fever and weight loss is almost always present, which depends on the extent and aggressiveness of the tumour. Blood in sputum can also be seen sometimes. CT examination is the initial imaging modality to see local extent and size of the tumour, but pleural fluid cytology may be used in the absence of detectable mass lesion. [5] Whole body PET-CT examination, MRI Thoracic imaging are key investigations for a tumour staging purpose. [3] However, histopathological examination of mass lesion is essential for definitive diagnosis. Typical imaging features of pleural RMS are abnormally enhancing solid nodular or polypoidal pleural thickening (predominantly involving coastal, diaphragmatic, and mediastinal pleura) with or without adjacent ribs involvement or extrathoracic/mediastinal invasion; variable amount of ipsilateral pleural effusion on X-Ray, U.S.G, and other cross sectional imaging; restricted diffusion within pleural thickening or mass on MRI; increased metabolic activity within it in PET-CT imaging; increased uptake in bone scan if ribs involvement; metastatic solid lesions (if present) can be seen in visceral organs; mesentery or bones evident on Whole Body CT, MRI, or PET-CT imaging modalities. Thoracic/pleural rhabdomyosarcoma has the worst prognosis due to its larger size, advanced stage at presentation, unresectability and aggressiveness. Unresectability of the lesion and presence of multiple distant bony as well as visceral organ metastases were poor prognostic factors in almost all patients. CT, MRI, and PET-CT imaging studies are most commonly used for detecting therapeutic response of tumour to chemotherapy and also to detect residual/recurrent disease. Incomplete response to chemotherapy may be combined with appropriate post-operative radiotherapy. [3, 4]Written informed consent for publication has been obtained.",
    "differential_diagnosis": "Embryonal, rhabdomyosarcoma, of, right, pleura., Sarcomatoid, mesothelioma, Metastatic, pleural, carcinoma, Lymphoma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000016024/000001.png?itok=JOnybQ8U",
            "caption": "Chest X-ray - PA view."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000016024/000002.jpg?itok=U_wvJ431",
            "caption": "Axial T2W - Right nodular pleural thickening."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000016024/000003.jpg?itok=0KbFD_Bk",
            "caption": "Axial scan"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000016024/000004.jpg?itok=Llluf57H",
            "caption": "Axial CT - Enhancing nodular pleural thickening."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000016024/000005.png?itok=e462tQHR",
            "caption": "Coronal CT image"
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000016024/000006.jpg?itok=3h71xJPm",
            "caption": "Axial PET-CT - right pleural thickening shows metabolic activity and FDG update."
          }
        ]
      },
      {
        "number": "Figure 7",
        "subfigures": [
          {
            "number": "Figure 7",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000016024/000007.jpg?itok=R9DgX6k3",
            "caption": "PET-CT - FDG uptake in right half of sacrum."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thoracic wall"
    ],
    "imaging_technique": [
      "MR",
      "CT",
      "PET",
      "PET-CT"
    ],
    "link": "https://www.eurorad.org/case/16024",
    "time": "11.09.2018"
  },
  "16037": {
    "case_id": 16037,
    "title": "Fibrous tumour of the ple",
    "section": "Chest imaging",
    "age": "29",
    "gender": "female",
    "diagnosis": "Fibrous tumour of the pleura.",
    "history": "A 29-year-old female patient goes to the emergency room due to tremor in lower limbs since 72 hours. She suffers from habitual migraine headaches as the only precedent of interest.",
    "image_finding": "A chest X-ray was performed and it was completed with a enhanced chest computed tomography. Subsequently a MRI was performed for the best characterisation of the lesion. An initial posteroanterior and lateral chest X-ray, showed in the left lower lobe a well-defined lesion of obtuse edges with the thoracic wall, suggestive of pleural or extrapleural origin. Enhanced chest CT confirms the presence of an extrapulmonary well-defined and hypervascular lesion. It loses the obtuse angle with the pleural surface and erodes the adjacent costal arch.Dorsal column MRI showed a polylobulated and well-defined lesion, hyperintense on T2 weighted sequences and hypointense on T1-weighted sequences, showing ample contact with the pleural surface.",
    "discussion": "Solitary fibrous tumours of the pleura (SFTP) are rare neoplasms originating from submesothelial primitive mesenchymal cells. Although usually benign, approximately 10%\u201320% are malignant or locally aggressive [2, 5]. There is no known aetiologic agent and no link to tobacco or asbestos [1-5]. Most cases are identified in middle-aged adults (especially in the 6-7 decade) with no sex preponderante. However in some series there is predilection for the female sex. [2, 3, 4] Patients are usually asymptomatic and are diagnosed frequently as an incidental finding. Symptomatic cases usually start with cough, dyspnoea, haemoptysis or chest pain. Paraneoplastic syndromes are uncommon (hypoglycaemia, acropachy and osteoarthropathy). [3, 4]. Most of the tumours present as pleural-based masses, but have also been reported in other locations: mediastinum, lung, and extrathoracic sites. Most originate in the visceral pleura (80%) and have predilection towards the mid-to-lower zones of the chest [3, 4, 6].On chest X-ray, it presents as a pleural based mass, circumscribed and sometimes lobulated. It often forms an in obtuse angle with the chest wall. Tumours may grow to a large size. Pedunculated lesions can change position - appearance with respiration or with a change in position. Calcification, rib destruction, and pleural effusions are uncommon [2, 6].The chest CT is the key image test, shows the size and location of the tumour and allows a correct surgical planning. On contrast-enhanced scans shows relatively homogenous intense background enhancement (from rich vascularisation). Non-enhancing areas may be present (necrosis, myxoid degeneration, or haemorrhage) [5, 6]. On T1-weighted sequence shows a low-intermediate signal. On T2-weighted sequence presents low signal and may be having hyperintense foci (corresponds to the hypodense areas of CT), as is this case. Usually presents an intense enhancement with gadolinium administration [2, 3, 4].The usual radiographic appearance and clinical presentation gives the surgeon thepreoperative clinical suspicion that an SFTP is present. In experienced hands, prompt surgical treatment can be carried out safely without a preoperative diagnosis [1]. However, the final diagnosis is anatomopathological. Immunohistochemically expresses CD34, vimentin, bcl-2 and CD99 [5].The treatment of choice is complete resection. Approximately 80% of the forms are benign and cured. Malignant variety has a high rate of recurrence and mortality. Thus, aggressive surgery and close follow-up are needed in the postoperative period. Recurrence can occur 20 years after its presentation and is more common in the same hemithorax [1, 5].Written informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Fibrous, tumour, of, the, pleura., Pleural, sarcoma, Pleural, metastasis, Mesothelioma, Bone, metastasis, Bone, myeloma, /, plasmocytoma, Primary, bone, tumour, (for, example:, Sarcoma, of, Ewing), Askin\u00b4s, tumour, Neurogenic, tumours",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000016037/000006.jpg?itok=JKosXVCu",
            "caption": "A well-circumscribed lesion in the lower left lung lobe."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000016037/000007.jpg?itok=N2W3L8js",
            "caption": "This view\nconfirms that the posterior location and obtuse edges favour a pleural or chest wall based lesion."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000016037/000008.jpg?itok=3Ry9i4Az",
            "caption": "Notice a vascular pleurally-based lesion causing adjacent rib destruction."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000016037/000009.jpg?itok=kuumoRQA",
            "caption": "Axial view. A polylobulated and well-defined lesion. On this sequence (T1-weighted) is hypointense."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000016037/000010.jpg?itok=jEgCb01Q",
            "caption": "Coronal view.\nOn T2-weighted sequence, the lesion is heterogeneous and predominantly hyperintense."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Respiratory system"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT-High Resolution",
      "MR"
    ],
    "link": "https://www.eurorad.org/case/16037",
    "time": "05.09.2018"
  },
  "16102": {
    "case_id": 16102,
    "title": "Giant bullous emphysem",
    "section": "Chest imaging",
    "age": "40",
    "gender": "female",
    "diagnosis": "Giant bullous emphysema",
    "history": "A 40-year-old man, smoker (24 pack/years), with progressive shortness of breath over the previous 12 months, underwent a chest x-ray examination.",
    "image_finding": "PA and lateral films were performed, revealing diffuse hyperlucency in the right hemithorax, mostly without lung markings. Pneumothorax was a concern, but visceral pleural line wasn\u2019t clearly visible. Little mediastinal shift to the left side was noted. These findings were similar to older chest x-ray films of the patient, from the previous years, and the patient hadn\u2019t acute symptoms.Later, a CT scan was performed, showing giant pulmonary bullae in the right upper lobe, extending from the apex to the base of the right lung, with massive compression of the remaining lung parenchyma, being almost totally collapsed. A few septae were seen in the bullae, and no air was seen outlining external side of the bulla wall. In the left upper lung, there was parasseptal and centrilobular emphysema, with formation of bullae in the apex region measuring up to 5cm. There were no signs of pneumothorax.",
    "discussion": "Emphysema is a condition associated with progressive damage of alveoli leading to destruction of normal functioning lung parenchyma, and resulting in airspace enlargement. Although most frequently of small size (<1cm), in some cases emphysema is associated with bigger airspace enlargement, called pulmonary bullae (>1cm), which can grow significantly, compressing normal lung parenchyma [1,2].This entity is frequently observed in middle-age males, most of whom are smokers. It was firstly described by Burke in 1937, being nowadays called giant bullous emphysema, primary bullous disease or vanishing lung syndrome. [3]Its etiology is not fully understood, but some authors refer association with smoking, alpha-1 antitrypsin deficiency and drug abuse. [2]The main finding is the presence of one or more giant bullae, usually in the upper lobes, causing compression of the adjacent lung parenchyma. [4]CT scans have a major role in this disease, detecting emphysema, its type and extension and helping to differentiate giant bullae from pneumothorax.In terms of clinical presentation of giant bullous emphysema, commonly there\u2019s a history of chronic progressive dyspnea over several months. In the opposite, pneumothorax is associated with an acute sudden chest pain and acute shortness of breath. Pneumothorax can be diagnosed when the visceral pleural edge is clearly demarcated with no lung markings laterally to this line. Expiratory films are useful to detect small pneumothoraxes. [3]The double wall sign helps to identify a pneumothorax in patients with giant bullae, occurring when one sees air in both sides of the bulla wall, paralleling the chest wall, indicating the presence of pneumothorax. [3]If the patients are asymptomatic, the treatment is conservative, consisting of reassurance, advice to quit smoking and some activities like scuba diving. [5]Symptomatic patients with progressive dyspnea should undergo bullectomy. [6]Bullectomy reduces compression of adjacent lung parenchyma with significant respiratory and functional benefits in the early postoperative period. [5]Written informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Giant, bullous, emphysema, Pneumothorax, Pneumectomy",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000016102/000001.png?itok=fcXuWWDp",
            "caption": "Diffuse hyperlucency in the right hemithorax, mostly without lung markings."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000016102/000002.png?itok=wNfAw18O",
            "caption": "Lateral view"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000016102/000003.png?itok=KfDxh4dj",
            "caption": "Giant pulmonary bullae in the right upper lobe, extending from the apex to the base of the right lung, with massive compression of the remaining lung parenchyma, being almost totally collapsed.\n\n(Coronal view)"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000016102/000004.png?itok=dEKlM0Lp",
            "caption": "Axial view"
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000016102/000005.png?itok=s9F4ousz",
            "caption": "Axial view"
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000016102/000006.png?itok=k_jDOwMa",
            "caption": "Axial view"
          },
          {
            "number": "Figure 2e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000016102/000007.png?itok=DFqkhg-w",
            "caption": "Axial view"
          },
          {
            "number": "Figure 2f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000016102/000008.png?itok=eWpppnwe",
            "caption": "Axial view"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000016102/000009.png?itok=3KpdCR__",
            "caption": "Chest x-ray after bullectomy\n\n(PA view)"
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000016102/000010.png?itok=5gplEOWD",
            "caption": "Computer tomography after bullectomy\n\n(coronal view)"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000016102/000011.png?itok=auFfAFIW",
            "caption": "Chest x-ray and Computer Tomography showing significant improvement after right bullectomy"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT-High Resolution",
      "CT",
      "Conventional radiography"
    ],
    "link": "https://www.eurorad.org/case/16102",
    "time": "08.10.2018"
  },
  "16104": {
    "case_id": 16104,
    "title": "Aspirated tooth",
    "section": "Chest imaging",
    "age": "28",
    "gender": "male",
    "diagnosis": "Aspirated tooth",
    "history": "A 28-year-old man, unconscious, was brought to the hospital immediately after a major car accident.",
    "image_finding": "A CT-scan was performed, revealing a high-density elongated structure located in the trachea, in a dependent position, measuring 24mm x 6mm.Patient was re-evaluated a few hours later, revealing migration of the high-density foreign body structure to the right bronchial tree, positioned in the origin of the right lateral basal bronchus.Based on the context, morphology and density of the foreign body, it was assumed it was a tooth. Patient underwent rigid bronchoscopy, with removal of the foreign body and confirmation of the suspected nature - an aspirated tooth.",
    "discussion": "Foreign-body (FB) aspiration is a potential harmful situation requiring early detection and intervention. [1]Although more common in children, adults are also at risk of FB aspiration, especially after trauma with loss of consciousness and of airway protection. Other risk factors include intoxication, intubation or dental procedures. [2]Clinical features of FB aspiration most frequently include an acute onset of symptoms such as dyspnea, coughing, wheezing, stridor and cyanosis. Rarely, it can be asymptomatic, which could delay the diagnosis.Chest X-ray is usually the first imaging exam performed, although in many cases aspirated FB is radiolucent. Additionally, it can also show hyperinflation of one lung or lobe, atelectasis, mediastinal shift or pneumomediastinum. Expiratory films are useful on cooperative patients, demonstrating air-trapping on the affected side, and decubitus view could also be used, especially in children or non-cooperative patients, acquired with the suspected side down, showing lack of collapse of the air-trapped lung. [3] Computer tomography (CT) is superior to x-ray, allowing the detection of smaller or non-opaque FBs and its possible complications. Bronchoscopy has a dual role in diagnosis and treatment, allowing the removal of the FB. [4]Flexible bronchoscope is more suitable for small and distally located FBs, and rigid bronchoscope for bigger FB. If unsuccessful, open thoracotomy is an alternative, although rarely performed nowadays due to the effectiveness of endoscopic techniques. [4]Written informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Aspirated, tooth, Other, foreign, bodies, Calcified, tracheal/bronchial, lesion",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000016104/000001.png?itok=MU69sJWG",
            "caption": "CT-scan was performed, revealing a high-density elongated structure located in the trachea, in a dependent position, measuring 24mm x 6mm."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000016104/000002.png?itok=G1Ty2esG",
            "caption": "Sagital view: high-density elongated structure located in the trachea"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000016104/000003.png?itok=vopKj3fd",
            "caption": "Patient was re-evaluated a few hours later, revealing migration of the high-density foreign body structure to the right bronchial tree"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000016104/000004.png?itok=CrgpPo9d",
            "caption": "annotated"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000016104/000006.png?itok=KjQCcU3I",
            "caption": "Patient underwent rigid bronchoscopy, with removal of the foreign body and confirmation of the suspected nature - an aspirated tooth."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000016104/000007.png?itok=wx5QRCIc",
            "caption": "CT confirming a high-density foreign body structure positioned in the origin of the right lateral basal bronchus."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Emergency"
    ],
    "imaging_technique": [
      "CT",
      "Conventional radiography",
      "Image manipulation / Reconstruction",
      "CT-High Resolution"
    ],
    "link": "https://www.eurorad.org/case/16104",
    "time": "24.11.2018"
  },
  "16108": {
    "case_id": 16108,
    "title": "Pulmonary tumour thrombotic microangiopathy",
    "section": "Chest imaging",
    "age": "44",
    "gender": "female",
    "diagnosis": "Pulmonary tumour thrombotic microangiopathy",
    "history": "A 44-year-old female patient with known malignancy (stage IV cervical cancer, phase 1 clinical trial with bad prognosis) presented with slowly progressive shortness of breath. She had been recently diagnosed with proximal DVT and an IVC filter had been placed along with anticoagulant therapy.\n\nThe patient\u2019s symptoms worsened so a pulmonary CTA was performed.",
    "image_finding": "There was no evidence of pulmonary embolism in main, principal, lobar or segmental pulmonary arteries.\n\nSigns of pulmonary hypertension:\n- Enlarged pulmonary trunk.\n- Increased main pulmonary artery (pulmonary trunk) to ascending aorta ratio.\n- Straightening of the interventricular septum.\n- Dilatation of the right cardiac cavities.\n\nLung parenchyma findings:\n\n- No pulmonary infarcts were seen.\n- Subtle ground-glass opacification with a peribronchovascular distribution.\n- Bilateral ill-defined centrilobular micronodules (some in a tree-in-bud pattern).\n- Smooth thickening of fissures and interlobular septa.",
    "discussion": "Pulmonary embolism (PE) is a common cause of acute cardiovascular disorder with variable haemodynamic impact; going from silent PE to a high mortality presentation, despite advances in the diagnostic techniques and treatment available nowadays.[1]\n\nThere are many known entities that can cause PE, although it usually develops as secondary to lower limb deep vein thrombosis. Depending on the extent and duration of the occlusion, the patient\u2019s basal situation and the presence of vasospasm, a degree of pulmonary hypertension may develop. [2]\n\nPE remains one of the top indications for performing a CT angiogram in the emergency department, usually being a straightforward diagnosis by demonstrating a filling defect in one or more pulmonary arteries. However, the diagnosis can be challenging in some cases, where clear signs of pulmonary hypertension exist and no arterial filling defect is identified. In such cases, and especially in oncologic patients, we need to keep in mind the possibility of pulmonary tumour thrombotic microangiopathy (PTTM).\n\nPTTM describes tumour cell microemboli with occlusive fibrointimal remodelling in small vessels and lymphatics leading to precapillary pulmonary hypertension. [3]. Clinically patients present with an acute/subacute onset of severe progressive dyspnoea secondary to cor pulmonale. Diagnostic techniques include: CT-angio, HRCT, cardiac catheterisation, PET-CT and ultimately definitive diagnosis by pathology.\n\nPrice LC et al. also describe that up to a quarter of autopsy specimens from patients dying of carcinoma show evidence of PTTM, which means it is most likely an underdiagnosed entity. Most cases are published in Japanese series and are mainly related to gastric adenocarcinomas. [3]\n\nRadiographic features are best depicted on HRCT with findings similar to our case: ill-defined centrilobular micronodules, diffuse smooth interlobular septal thickening, and patchy peribronchovascular ground glass opacities along with signs of pulmonary hypertension and right heart chambers overload. [4]\n\nIn our case CT pulmonary angiography showed no filling defects and due the clinical context and the rest of the findings, PTTM was suspected. Pulmonary SPECT perfusion findings were consistent with perfusion defects, backing up the suspicion of PTTM. The patient passed away two days after being admitted in our center.\n\nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Pulmonary, tumour, thrombotic, microangiopathy, Pulmonary, embolism, Pulmonary, hypertension",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000016108/000001.png?itok=9ihnM_VP",
            "caption": "There\u2019s no evidence of pulmonary embolism in main, principal, lobar nor segmental pulmonary arteries."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000016108/000002.png?itok=XTLE9uZm",
            "caption": "Enlarged pulmonary trunk.\n\nIncreased main pulmonary artery (pulmonary trunk) to ascending aorta ratio."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000016108/000003.png?itok=O4o7vIeR",
            "caption": "Straightening of the interventricular septum.\r\n\r\nDilatation of the right cardiac cavities."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000016108/000004.png?itok=BHh1GQ6A",
            "caption": "Straightening of the interventricular septum.\n\nDilatation of the right cardiac cavities.\n\nEnlarged pulmonary trunk."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000016108/000005.png?itok=BsEb3RZN",
            "caption": "Smooth thickening of interlobular septa. (arrows)\r\n\r\nSubtle ground-glass opacification with a peribronchovascular distribution. (arrowhead)\r\n\r\nBilateral ill-defined centrilobular micronodules."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000016108/000006.png?itok=98WcOs0l",
            "caption": "Smooth thickening of the right major fissure. (arrow)\r\n\r\nBilateral ill-defined centrilobular micronodules (arrowhead)."
          }
        ]
      },
      {
        "number": "Figure 7",
        "subfigures": [
          {
            "number": "Figure 7",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000016108/000007.png?itok=wgj_LsEs",
            "caption": "MinIP image/lung windowing: ground-glass opacification with a peribronchovascular distribution."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Emergency",
      "Arteries / Aorta",
      "Cardiac",
      "Lung"
    ],
    "imaging_technique": [
      "CT-Angiography"
    ],
    "link": "https://www.eurorad.org/case/16108",
    "time": "26.09.2018"
  },
  "16191": {
    "case_id": 16191,
    "title": "Miliary tuberculosis in a patient with metastatic thymom",
    "section": "Chest imaging",
    "age": "64",
    "gender": "female",
    "diagnosis": "Miliary tuberculosis",
    "history": "A 64 year-old female comes to the ER with persistent fever for the last two weeks.She is being followed by oncology for a stage IV thymoma with multiple pleural metastasis and receives treatment with taxol, carboplatin and steroids.Chest X-Ray findings and CT scan were performed.",
    "image_finding": "The chest X-ray showed a miliary pattern consisting of profuse tiny, discrete, rounded pulmonary opacities of uniform size (3mm) and diffuse distribution throughout the lungs [5]. There is also evidence of pleural metastasis in the right chest. There is medistinum enlargement and lateralization to the right chest suggesting atelectasis.The admission CT scan confirmed the presence of randomly distributed micronodules, also known as miliary pattern [5] (Figure 2).The previous CT scans showed multiple thymoma metastasis following its characteristic pleural dissemination (Figure 3). With the antecedent of a oncological disease we have to perform a differential diagnosis with: hematogenous metastatic pulmonary disease and lymphangitic carcinomatosis. As a immunocompromised patient we must consider miliary infections such as tuberculosis.Microbiology findings of the bronchoalveolar lavage confirmed tuberculosis.",
    "discussion": "Miliary tuberculosis is an uncommon (1% of all patients with any form of tuberculosis) presentation of TBC that occurs when a primary tuberculosis focus infiltrates a pulmonary vein spreading the infection through all tissues. Lungs, liver and spleen are the most common targets of miliary TB metastasis [1].Miliary tuberculosis has a mild clinical and a poor prognosis. The most frequent clinic presentations are: fever, fatigue, anorexia, weight loss and hepatomegaly[1]. When a immune compromised patient presents this symptomatology we must include this entity in the differential diagnosis. Since this is a life threatening disease we should start empiric treatment.The first radiological approach can be done with chest X-Ray. The classical presentation of this diseases is a reticulonodular infiltrate with a homogeneous distribution that affects instinctively both the interstitium and the alveolar space. This finding in an immunocompromised patient with subacute symptomatology is highly suggestive of miliary tuberculosis. To determine the exact pattern and establish a differential diagnosis a CT scan must be performed [2].Classical findings of pulmonary tuberculosis such as tree-in bud condensations and centrilobular nodules in patients with compatible clinic presentation have proven to have a positive correlation with active TB diagnosis even when other means of diagnosis (sputum culture, BAL) fail to reach the diagnosis. [3]As we can see in the images, our patient had thymoma metastatic disease confirmed by a biopsy in 2011 that was staged as IV B2. As we can see on Figure 3 thymoma usually follows a unilateral metastatic pattern and can also affect pericardial cavity (as shown in CT scan images) [4]. The dimensions of metastatic implants compromised patient's cardiac function, a metastasectomy was performed in 2016.The miliary pattern allows us to discard the possibility of lymphangitic carcinomatosis since this disease has a perilymphatic micronodular pattern (Figure 4). This pattern is characterized by distribution along or adjacent to the lymphatic vessels in the lung: this is perihilar, peribronchovascular, and centrilobular interstitium, as well as in the interlobular septa and sub-pleural locations. Alveoli do not have lymphatics [5].As we have seen in this case thymoma metastatic disease usually affects pleural cavities, haematological dissemination is rare. We had no evidence of other primary hematological disseminating tumor.Since the most probable diagnosis was miliary tuberculosis a bronchoalveolar lavage was performed, the PCR results were positive for M. tuberculosis sensible to isoniazid and rifampicin.Written informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Miliary, tuberculosis, Hematogen, metastatic, pulmonary, disease, Lymphatic, carcinomatosis, Miliary, fungal, infection",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000016191/000001.png?itok=J0kDKVCW",
            "caption": "Profuse tiny, discrete, rounded \npulmonary opacities uniform in size, diffusely distributed throughout the lungs. \n\nLower right chest opacity and mediastinum enlargment and lateralitzation to the right side."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000016191/000002.png?itok=obVXdMli",
            "caption": "Chest X-Ray with miliary pattern where we can see uniformly distributed micronodules"
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000016191/000015.jpg?itok=7U1N2JXy",
            "caption": "Ct scan showing the mass seen on the Chest X-Ray that produces an atelectasis on the inferior right pulmonary lobe. There's also evidence of pericardic metastasic disease."
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000016191/000016.jpg?itok=PLZXm_IG",
            "caption": "Ct scan showing the mass seen on the Chest X-Ray that produces an atelectasis on the inferior right pulmonary lobe."
          },
          {
            "number": "Figure 1e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000016191/000017.jpg?itok=_Tzr1B1F",
            "caption": "Media coronal vision of the chast CT scan showing the correlation betwen Ct scan and Chest X-Ray"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000016191/000003.jpg?itok=MZeKu8go",
            "caption": "Widespread, randomly distributed micronodules (<3mm) in both lungs  (military pattern)"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000016191/000004.jpg?itok=S2BVTXXh",
            "caption": "Miliary pattern."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000016191/000011.jpg?itok=XQr9XtMC",
            "caption": "Miliary pattern."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000016191/000013.jpg?itok=MSESGdqH",
            "caption": "Miliary pattern."
          },
          {
            "number": "Figure 2e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000016191/000014.jpg?itok=naRaOiuK",
            "caption": "Miliary pattern."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000016191/000005.png?itok=xMcnWhkH",
            "caption": "Peri-lymphatic micronodular pattern. \nThis pattern is characterized by distribution along or adjacent to the lymphatic vessels in the lung. Alveoli do not have lymphatics."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000016191/000006.jpg?itok=jNRoJBVG",
            "caption": "Pleural and pericardic metastasis."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000016191/000007.jpg?itok=tYiluvBf",
            "caption": "Pleural metastasis"
          },
          {
            "number": "Figure 4c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000016191/000008.jpg?itok=vse-56he",
            "caption": "Pleural metastasis"
          },
          {
            "number": "Figure 4d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000016191/000009.jpg?itok=mZ4B2tTO",
            "caption": "Pleural metastasis"
          },
          {
            "number": "Figure 4e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000016191/000010.jpg?itok=StqTpOUx",
            "caption": "Pleural metastasis"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Respiratory system",
      "Lung"
    ],
    "imaging_technique": [
      "CT-High Resolution",
      "Conventional radiography"
    ],
    "link": "https://www.eurorad.org/case/16191",
    "time": "30.11.2018"
  },
  "16313": {
    "case_id": 16313,
    "title": "Complicated Double Bronchogenic Cysts",
    "section": "Chest imaging",
    "age": "1",
    "gender": "female",
    "diagnosis": "Anatomopatologic results confirmed both masses were bronchogenic cysts.",
    "history": "The patient arrived at our emergency department with cough, dyspnea, fever and rhinorrhea, showing signs of respiratory distress and decreased vesicular murmur in the left hemithorax. She had a history of repeated respiratory infections since 3 months old. We started antibiotics and requested chest X-Ray and CT.",
    "image_finding": "The X-Ray showed an opacity predominantly atelectatic on the lower third of the lung, as well as a rounded opacity by the left hilum. The trachea is pushed to the right, and there is also a possible compression of the left main bronchus.The CT demonstrated two hypo-dense nodular images without impregnation, one measuring 2,2x2,2x1,5 cm near the left main bronchus causing impression and reduction of it's caliber, and another one measuring 2,0x1,6x1,5 cm localized near the left hilum. It was suspected of bronchogenic cyst and scheduled a surgery for remotion.The anatomopathological result confirmed bronchogenic cyst from the material of the mediastinal lesion, and infected bronchogenic cyst with chronic suppurative inflammation and granular tissue from the pulmonary lesion. The patient did not present any complication from the surgery and was released from the hospital without symptoms.",
    "discussion": "Bronchogenic cysts represent 18% of all mediastinal masses. They are a result of abnormal bronchial budding of the foregut during embryological formation of the lungs, between the 20th and the 40th day of gestation [1]. The moment this phenomenon happens determines the location of the cysts, whether in the mediastinum (most common) if it happens sooner, or in the lungs if it happens later [5,10]. They are usually diagnosed during adulthood, being rarely seen in elder or infants [2,10]. Although mostly asymptomatic, patients may present complications from extrinsic compression or from infection [1].We found just six cases of double bronchogenic cysts in the literature so far [2,3,4,9,11,13], and, in only four, both cysts were in separate locations, and none had age less than 33 years old [2,3,9,13]. Our case reveal the diagnosis in an infant (1 year and 8 months) of double cysts, one infected in the left lung parenchyma and another one in the mediastinum causing compressive symptoms.\tThe main reason to request radiologic images and diagnose correctly is based on the importance of solving or preventing symptoms, given that most patients will develop some type of complication over time, such as infection, superior vena cava obstruction, pneumothorax, atrial fibrillation, hemoptysis, or even malignancy [1,2,5,6,12].\tSurgical correction must be done as soon as possible, even if the patient remains asymptomatic, and it should be completely resected in order to avoid recurrence [1,7,8]. In this case, it was decided to perform muscle sparing lateral thoracotomy, removing  the infected pulmonary mass with teleobstructive pneumonia from the anterior segment of the left upper lobe, and the cystic lesion in the pulmonary aortic window with reactional aortopulmonary lymph nodes. The patient had no complications and was discharged asymptomatic.\tThis case is remarkable given it had two concomitant bronchogenic cyst with different characteristics. Whilst one was confined in the mediastinum causing compression of the left bronchi, the second was in the lung parenchyma exhibiting signs of infection. Since there was an obstruction of the air way, the infant manifested recurrent pneumonias in the left lower lobe, which led her to consult a doctor numerous times. Therefore, it is essential to highlight the importance of remembering this potential congenital threat when analysing a radiographic double cystic lesion at a age far from standart.Written informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Anatomopatologic, results, confirmed, both, masses, were, bronchogenic, cysts., Enteric, cyst, Abscess, Neoplasms, Infected, bullas, Vascular, malformations, Hydatidosis, Fungal, disease",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000016313/000001.jpg?itok=f42rTU-V",
            "caption": "Frontal chest x-ray showing one mass near the left hilum, the tracheal displacement to the right, and the partially atelectatic and consolidated left lower lobe suggesting a concomitant mediastinal mass."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000016313/000002.jpg?itok=SAFdYxZi",
            "caption": "Lateral chest x-ray showing the partially atelectatic and consolidated left lower lobe, as well as gas inside the hilar mass."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000016313/000004.jpg?itok=2f1oXi5W",
            "caption": "Axial ct image showing two rounded sof-tissue density masses. Gas component can be seen in the lesion in the left hilum."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2018-08/0000016313/000005.jpg?itok=32P6YLyw",
            "caption": "Chest computed tomography coronal reconstruction showing two soft-tissue density masses, with important compression from the mediastinal lesion over the left main brunchus, causing left lower lobe atelectasis."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "CT-High Resolution"
    ],
    "link": "https://www.eurorad.org/case/16313",
    "time": "07.12.2018"
  },
  "16366": {
    "case_id": 16366,
    "title": "An unusual cause of breathlessness that will take your own breath away",
    "section": "Chest imaging",
    "age": "28",
    "gender": "female",
    "diagnosis": "Intrapulmonary teratoma",
    "history": "A 28-year-old female patient presented with a three month history of breathlessness, and a two week history of pleuritc chest pain, orthopnoea, cough, nausea and weight loss. She was a non-smoker with no history of fever or night sweats. No significant family or past medical history was ascertained.",
    "image_finding": "A chest radiograph performed on admission demonstrated a large area of dense opacification within the left hemithorax with associated tracheal and mediastinal shift to the contralateral side. There was a small volume left-sided pleural effusion. The right lung and pleural spaces were clear.\nA subsequent contrast-enhanced CT (Computed Tomography) study of the chest was performed which demonstrated a very large pulmonary mass which occupied the majority of the left lung, with some sparing of the left upper lobe. It was composed of soft tissue with foci of macroscopic fat, fluid-attenuation cystic areas and multiple foci of calcification. The CT confirmed the degree of mediastinal shift and the presence of a small left pleural effusion. There were no size-significant mediastinal lymph nodes, no associated osseous lesions and no extrapulmonary extension. The appearances of the findings were in keeping with a large mature intrapulmonary teratoma which was histologically confirmed.",
    "discussion": "Mature teratomata are tumours consisting of tissues that are derived from more than one germ cell line [1]. They are the most common histological type of germ cell tumours, followed by seminomas, characteristically found in the gonads [1]. The most likely extra-gonadal site is within the anterior mediastinum. Pulmonary teratomata are rare [1], first described in the literature by Mohr in 1839 [1], and not commonly seen in clinical practice [2]. Much like a teratoma of the anterior mediastinum, intrapulmonary (and endobronchial) teratomata arise from the third pharyngeal pouch [2]. Pulmonary teratomata are classified as either parenchymal or endobronchial lesions, with the majority of those seen falling into the former category, as is the case here [3]. They typically involve the upper lobe of the left lung [2], the reason for which is not certain.\u00a0 \nPatients typically present in the second to fourth decade [1], with the common presenting symptoms being chest pain, cough, haemoptysis, and trichoptysis, the latter being the most specific symptom as it signifies communication with a bronchus [4, 5]. \nCT is the ideal imaging modality for these patients given its ability to characterise the soft tissue components of a teratoma and ability to determine if it has ruptured [5]. This distinction is pivotal in surgical planning as rupture induces inflammation and adhesions to adjacent anatomical structures. [5] Surgical resection is the mainstay of treatment and is recommended due to the complications associated with growth and mass effect of the tumour: life-threatening haemoptysis due to invasion into the adjacent airways and bronchial vessels can lead to haemothorax, lung collapse and / or infection [4 - 6]. Although these are typically benign tumours, they are thought to have malignant potential in approximately a third of cases [1, 4], and can transform into sarcomas [3]. These transformations pose a diagnostic challenge as transformation may be restricted to a focal area of the teratoma, and may only affect one of the tissue components that otherwise appear benign on imaging [3]. This important clinical distinction is necessary as pulmonary teratomata with malignant transformation are resistant to chemotherapy and radiotherapy [3, 7]. \nTake Home Message:\nAn intrapulmonary teratoma, although rare, is an important diagnosis to consider in younger patients who present with breathlessness and masses on chest radiographs.\nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Endobronchial, teratoma, Intrapulmonary, teratoma, Anterior, mediastinal, teratoma, Liposarcoma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-05/figure_1_0.jpg?itok=euKEUWbU",
            "caption": "PA radiograph on initial admission showing dense consolidation within the left hemithorax, blunting of the left costophrenic angle, and rightward mediastinal shift."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-05/figure_2_0.jpg?itok=s97T_LZP",
            "caption": "Axial slices of subsequent CT (Computed Tomography) study confirming the presence of a large soft tissue mass within the left lung with contained macroscopic fat, fluid-attenuation cystic areas and multiple foci of calcification. There is a small pleural effusion and mediastinal shift."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-05/figure_3_0.jpg?itok=R9uFF75N",
            "caption": "Sagittal slices of subsequent CT (Computed Tomography) study confirming the presence of a large soft tissue mass within the left lung with contained macroscopic fat, fluid-attenuation cystic areas and multiple foci of calcification. There is a small pleural effusion and mediastinal shift."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-05/figure_4_0.jpg?itok=R-eJgUjl",
            "caption": "Coronal slices of subsequent CT (Computed Tomography) study confirming the presence of a large soft tissue mass within the left lung with contained macroscopic fat, fluid-attenuation cystic areas and multiple foci of calcification. There is a small pleural effusion and mediastinal shift."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-05/figure_5.jpg?itok=OChhwjTE",
            "caption": "Histology slides from the resected specimen which confirmed that the resected mass was consistent with a teratoma. This was proven by the presence of a range of epithelia including gut, epidermis and pigmented retinal-type epithelium amongst others lining cyst-like structures of different sizes and shapes. Abundant glia and areas of fat were also noted in the background. No other germ cell tumour components were seen and there was no evidence of somatic malignant transformation. The peripheral resection margins were clear and resection was therefore considered complete."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-05/figure_6.jpg?itok=-FtL8kd7",
            "caption": "Further histology slides confirming the presence of a teratoma as seen on the CT (Computed Tomography) scan."
          }
        ]
      },
      {
        "number": "Figure 7",
        "subfigures": [
          {
            "number": "Figure 7",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-05/figure_7.jpg?itok=GhqbB5cU",
            "caption": "Axial slices of post-operative CT (Computed Tomography) study confirming complete resection of the teratoma. There has been subsequent re-inflation of the residual left lung with no radiologically discernible residuum remaining. The degree of mediastinal shift has subsequently improved."
          }
        ]
      },
      {
        "number": "Figure 8",
        "subfigures": [
          {
            "number": "Figure 8",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-05/figure_8.jpg?itok=DoOkgczB",
            "caption": "Coronal slices of post-operative CT (Computed Tomography) study confirming complete resection of the teratoma. The left hemidiaphragm is now elevated suggesting a possible post-operative phrenic nerve palsy which resolved on subsequent chest radiographs. The patient also described a post-operative cough which soon settled. She continues to be closely followed up to ensure there is no future recurrence."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Respiratory system"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/16366",
    "time": "14.05.2019"
  },
  "16376": {
    "case_id": 16376,
    "title": "Post-intubation tracheal rupture",
    "section": "Chest imaging",
    "age": "86",
    "gender": "female",
    "diagnosis": "Post-intubation tracheal rupture",
    "history": "An 86-year-old female patient intubated in the postoperative period of maxillofacial surgery, with clinical signs of acute respiratory failure.",
    "image_finding": "Chest anteroposterior radiography (Fig. 1) and computed tomography (CT) of the thorax were performed, showing abundant emphysema in the soft tissues of the neck and thorax, right pneumothorax, pneumomediastinum (Fig. 2a) and disruption of continuity of the right posterolateral wall of the trachea (Figures 2b-d).",
    "discussion": "Post-intubation tracheal rupture (TR) is a very infrequent complication but with high morbidity and mortality [1]. The exact mechanism underlying the lesion is uncertain. There are some risk factors that contribute to tracheal rupture: emergency intubation, multiple attempts at intubations, use of introducers that protrude beyond the tip of the tube, hyperinflation of the cuff, repositioning of the tube without deflation of the cuff, movements of the patient with the inflated cuff and inexperience of the health professional. There are also other conditions that predispose to rupture including congenital tracheal abnormalities, weakness of the pars membranosa of the trachea, chronic obstructive pulmonary disease and other inflammatory lesions of the tracheobronchial tree, diseases that alter the position of the trachea, chronic use of steroids, advanced age, and female sex [1-6].\nTR is almost always located in the posterior wall (membranous), which is less resistant than the cartilaginous wall [1, 6].\nAlthough bronchoscopic evaluation is the gold standard for diagnosis [1-3], CT provides valuable information and it is very useful as an initial test. It shows nonspecific indirect signs such as pneumomediastinum, pneumothorax, emphysema of soft tissues that progressively increases, loss of the circumferential shape of the tracheal wall, deformity of its contour, abnormal communication of trachea with other mediastinal structures or paratracheal air. On some occasions, as in our case, a disruption of continuity of the tracheal wall can be located. This is the unique direct sign of rupture which is difficult to assess only in the axial plane so multiplanar reconstructions are useful. Despite the findings in CT, tracheo-bronchoscopy is mandatory to establish the final diagnosis and to identify the anatomy to choose the appropriate treatment and approach. Although surgery is the treatment of choice, conservative management could be justified in small ruptures in stable patients [1-6]. \nAfter the CT, our patient underwent a bronchoscopy that confirmed the diagnosis. Surgical treatment was not performed because of the small size of the rupture and patient stability. In the following CT controls, pneumomediastinum and emphysema decreased, but the patient died two weeks later due to an infectious complication.\nIn conclusion, TR post-intubation is infrequent and severe. The presence of indirect signs or the direct visualisation of tracheal lesion in an intubated patient should make us suspect this entity.\nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Post-intubation, tracheal, rupture, Bronchial, rupture, Spontaneous, pneumomediastinum, Tracheal, diverticulum",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-05/figure_1_1.png?itok=fxPY-NjH",
            "caption": "Chest anteroposterior radiography showing emphysema of the soft tissues (white arrows)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-05/figure_2a.png?itok=nBt9E5r6",
            "caption": "CT of the thorax in the axial plane (a and b) and coronal (c) and sagittal (d) reconstructions showing emphysema of the soft tissues (white arrow), pneumothorax (asterisk), pneumomediastinum (yellow arrow) and solution of continuity in the posterior wall of the trachea (red arrows)."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-05/figure_2b.png?itok=wQiuEuct",
            "caption": "CT of the thorax in the axial plane (a and b) and coronal (c) and sagittal (d) reconstructions showing emphysema of the soft tissues (white arrow), pneumothorax (asterisk), pneumomediastinum (yellow arrow) and solution of continuity in the posterior wall of the trachea (red arrows)."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-05/figure_2c.png?itok=d1qtifx7",
            "caption": "CT of the thorax in the axial plane (a and b) and coronal (c) and sagittal (d) reconstructions showing emphysema of the soft tissues (white arrow), pneumothorax (asterisk), pneumomediastinum (yellow arrow) and solution of continuity in the posterior wall of the trachea (red arrows)."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-05/figure_2d.png?itok=lxpGOMSn",
            "caption": "CT of the thorax in the axial plane (a and b) and coronal (c) and sagittal (d) reconstructions showing emphysema of the soft tissues (white arrow), pneumothorax (asterisk), pneumomediastinum (yellow arrow) and solution of continuity in the posterior wall of the trachea (red arrows)."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/16376",
    "time": "20.05.2019"
  },
  "16377": {
    "case_id": 16377,
    "title": "Thoracic CT findings in nonfatal drowning",
    "section": "Chest imaging",
    "age": "13",
    "gender": "female",
    "diagnosis": "Acute pulmonary oedema",
    "history": "A 13-year-old girl was found unconscious underwater, with unknown duration of submersion. The history of previous trauma was unknown. She required reviving with external cardiac massage and intubation at site. \nUpon admission she was conscious and agitated, with evidence of respiratory distress. CT scan was performed.\nThe patient was admitted to an intensive care unit, with need for mechanic ventilation. She had progressive clinical improvement and, after 2 days, no longer required oxygen therapy. The patient completed 10 days of amoxicillin and clavulanic acid. Upon medical release, she showed no deficits. \nAfter 3 months, she was reevaluated in external consultation, showed no symptoms and chest X-ray was then unremarkable.",
    "image_finding": "Cerebral CT scan was unremarkable.\nThoracic CT scan showed bilateral, diffuse ground-glass areas and airspace consolidation, mainly in the superior aspect of the inferior lobes (Fig. 1, 2).\nA chest X-ray was performed before medical release, 10 days after the initial evaluation, and revealed a few bilateral residual densifications.\nAfter 3 months, reevaluation chest X-ray was unremarkable (Fig. 3).",
    "discussion": "In 2002, the WHO defined drowning as the process of experiencing respiratory impairment from submersion/immersion in liquid. \nIt represents respiratory impairment in case of submersion or immersion. If the process of drowning is interrupted, it is termed nonfatal drowning.\nDrowning is a leading cause of death worldwide between 5 and 14 years of age, particularly in boys. [1]\nThe main consequence of prolonged submersion is adequate ventilation exchange impairment due to laryngospasm and aspiration of water or foreign material, leading to hypoxaemia and acidosis. Water and foreign material aspiration leads to endothelium and pneumocytes damage, with increased surfactant production, resulting in diffuse alveolar damage. If the situation persists, it can evolve into respiratory distress syndrome (ARDS).\nHypoxia is the central cause of diffuse organ pathology in case of drowning. [2] \nChest radiographic findings in these cases are well described in the literature. However, reports of CT features are scarce. [3] \nChest radiography is important for distinguishing patients with and without aspiration and allows evaluation of therapy response and possible complications. Initially it can be normal, even in patients with clinical evidence of pulmonary oedema. When it is abnormal, the most common finding is perihilar or generalised pulmonary oedema. Foreign material aspiration can lead to sand bronchogram, with radiodense material in the tracheobronchial tree.\nCT findings include bilateral patchy or diffuse areas of ground-glass attenuation and fine reticular opacities (\u201ccrazy-paving\u201d appearance). Ill-defined centrilobular nodules may be found, as well as air-space consolidation. A central distribution of ground-glass attenuation is more common. [3, 4]\nPulmonary oedema in near-drowning is secondary to hypoxic pulmonary damage and usually resolves within three to five days. [4] \nAlert mental status in the emergency room is predictive of survival in a near-drowning victim, whereas coma is suggestive of a poor outcome. [1]\nImaging plays an important role in the evaluation of near-drowning cases, allowing the characterisation of the lesions\u2019 extension as well as a possible identification of the cause. During follow-up, it may be helpful if the patient has recurrent or persistent symptoms, but is not formally required.\nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Acute, pulmonary, oedema, Alveolar, haemorrhage, Bilateral, bronchopneumonia",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-05/f_20180706_182858_1_fig.1.jpg?itok=J2Nkmp60",
            "caption": "Non-contrast enhanced CT image in axial view shows bilateral, diffuse ground-glass areas and airspace consolidation mainly in the superior aspect of the inferior lobes."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-05/f_20180706_182958_1_fig.2.jpg?itok=jS7ezW0L",
            "caption": "Non-enhanced CT image in coronal view shows bilateral ground glass areas."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-05/f_chest_20190427_085121_fig.3.jpg?itok=p0AsbMoc",
            "caption": "Plain X-ray image in PA incidence 3 months after the episode is unremarkable."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Paediatric"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/16377",
    "time": "20.05.2019"
  },
  "16383": {
    "case_id": 16383,
    "title": "Foreign body aspiration in the elderly",
    "section": "Chest imaging",
    "age": "74",
    "gender": "male",
    "diagnosis": "Aspiration pneumonia",
    "history": "A 74-year-old male patient with a background history of asthma presented with acute shortness of breath immediately after his lunch, dry cough and pleuritic chest pain. He was treated as an infective exacerbation of asthma but responded poorly to therapy.\u00a0 Given concerns with an underlying malignancy, further imaging was performed.",
    "image_finding": "Chest X-ray on admission was clear. \nCT thorax revealed an aspirate substance in the left lower bronchus with distal atelactasis. \nThe patient underwent flexible bronchoscopy and the foreign object was retrieved successfully. This was identified as a piece of carrot.",
    "discussion": "Aspiration pneumonia is common in older persons and can often be fatal. Risk factors include age-related impairment in swallowing reflex, altered level of consciousness due to sedative use, stroke-related dysphagia and degenerative neurological diseases such as Parkinson\u2019s disease [1]. \nThe presenting symptoms of foreign body aspiration would depend on the degree, size and location of obstruction. It can present as life threatening asphyxiation if obstructing the oropharynx or trachea. It can also present subacutely with a cough, haemoptysis, chest pain or wheeze if obstructing the lower airways. Bacterial superinfection is a common complication and the common pathogens include anaerobic bacteria which are the dominant organisms in the upper airways [2].\nThe usual objects recovered from the lower airways are peanuts, vegetable particles, inorganic materials and teeth [3-5]. Bronchoscopy remains the cornerstone of both the diagnosis and treatment of patients with suspected foreign body aspirations. In cases where the presentation is subtle, imaging may be more ideal. The majority of foreign bodies are radiolucent and not easily identified on plain film [6]. As such, further investigation with imaging (e.g. computed tomography) can be considered if there is a high index of suspicion in the setting of negative radiographs. \nOnce a diagnosis of foreign body aspiration is made, the foreign body should be removed as soon as possible to prevent development of granulation tissue. Flexible bronchoscopy is preferable but occasionally rigid bronchoscopy may be indicated for the extraction of large or complex foreign bodies [7]. Antibiotics are indicated when there is evidence of post-obstruction pneumonia. \nForeign body aspiration in adults commonly presents silently due to the distal wedging of foreign bodies in the lower lobe bronchi. A high index of suspicion is needed to provide an early diagnosis. Food particles are commonly radiolucent on plain films and hence CT or direct visualisation via bronchoscopy is required. \nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Aspiration, pneumonia, Asthma, exacerbation, Community-acquired, pneumonia, Anaphylaxis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-05/untitled.001_0.jpeg?itok=nHcNG4rV",
            "caption": "Chest X-ray on admission was clear."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-05/figure_2a_6.jpg?itok=jc6mbKld",
            "caption": "Axial CT thorax showed foreign body in left lower bronchus with distal mucus plugging."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-05/figure_2b_3.jpg?itok=g_OlY7CQ",
            "caption": "Sagittal CT thorax showed foreign body in left lower bronchus."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-05/figure_2c_1.jpg?itok=ZIHLZPml",
            "caption": "Coronal CT thorax showed foreign body in left lower bronchus with distal atelactasis."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-05/figure_2d_1.jpg?itok=NPN94cON",
            "caption": "Axial CT thorax showed post-obstructive atelactasis distal to the foreign body."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-05/figure_3_4.jpg?itok=APCVWMyP",
            "caption": "A piece of carrot retrieved by flexible bronchoscopy."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Respiratory system"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/16383",
    "time": "03.06.2019"
  },
  "16386": {
    "case_id": 16386,
    "title": "Accessory cardiac bronchus: a rare anatomic variant and its clinical importance",
    "section": "Chest imaging",
    "age": "55",
    "gender": "male",
    "diagnosis": "Accessory cardiac bronchus",
    "history": "A 55-year-old man presented with haemoptysis. He was not a smoker and denied a past history of respiratory disease.",
    "image_finding": "The computed tomography (CT) revealed short blind-ending anomalous bronchus arising from the medial wall of the bronchus intermedius compatible with accessory cardiac bronchus (Fig. 1, 2).",
    "discussion": "The accessory cardiac bronchus is a rare anatomic variant with a reported incidence of 0.09-0.5% and is the only true supernumerary anomalous bronchus [1]. In approximately 50% of cases the ACB is a short blind-ending pouch with no branches and in the remainder it may have branches. Although most of the patients with ACB are asymptomatic, symptomatic patients frequently present with a recurrent chest infection, probably pooling of secretions in the blind-ending pouch, and haemoptysis [2]. At the same time, malignant pathologies deriving from ACB have been reported in the literature [3-5]. Surgical resection may be indicated in patients with recurrent or severe symptoms [6].\nComputed tomography of the chest is a modality of choice to determine cardiac bronchus as well as bronchography and bronchoscopy, yet it is not recognisable on plain chest radiograph [2]. The dimensions of ACB are 8-9 mm in diameter and 12 mm in length [6]. The recognition of ACB is important, as it should be differentiated from other pathologies such as diverticulum and bronchial fistula. \nTeaching point:\nThe radiologists should recognise accessory cardiac bronchus to avoid unnecessary investigations and in some cases, to explain possible complications such as infection, hemoptysis, etc.\nWritten patient consent for this case was waived by the Editorial Board. Patient data may have been modified to ensure patient anonymity.",
    "differential_diagnosis": "Accessory, cardiac, bronchus, Diverticulum, Bronchial, fistula",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-05/figure_1_3.jpg?itok=gNPWbDgd",
            "caption": "A CT scan shows an extra bronchus (arrow) next to bronchus intermedius."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-05/figure_2a_4.jpg?itok=Ysvqk8vR",
            "caption": "Axial CT image show an accessory cardiac bronchus (arrow) arising from the medial aspect of the bronchus intermedius (arrowhead)."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-05/figure_2b_4.jpg?itok=Q7sqA8eY",
            "caption": "Coronal CT image show an accessory cardiac bronchus (arrow) arising from the medial aspect of the bronchus intermedius (arrowhead)."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Abdomen",
      "Anatomy",
      "Biliary Tract / Gallbladder",
      "Kidney",
      "Liver",
      "Lung"
    ],
    "imaging_technique": [
      "CT",
      "MR",
      "MR-Cholangiography",
      "Ultrasound"
    ],
    "link": "https://www.eurorad.org/case/16386",
    "time": "03.06.2019"
  },
  "16404": {
    "case_id": 16404,
    "title": "CT findings of septic pulmonary embolism in a 28-year-old male intravenous drug use",
    "section": "Chest imaging",
    "age": "28",
    "gender": "male",
    "diagnosis": "Infective right-sided endocarditis complicated by septic pulmonary embolism",
    "history": "A 28-year-old male intravenous drug user presented to the emergency department with fever, dyspnoea, chest pain and cough.\nOn auscultation fine crackles at the pulmonary bases and a right systolic parasternal murmur were detected.\nBlood tests revealed increased leukocytes, C-reactive protein and procalcitonin. Blood culture was positive to methicillin-resistant Staphylococcus aureus.",
    "image_finding": "The patient underwent supine chest X-rays, which showed bilateral poorly marginated nodules (Fig. 1). Consequently, a contrast-enhanced chest computed tomography (CT) was performed, which confirmed the presence of multiple bilateral nodular and wedge-shaped parenchymal lung consolidations, characterised by a predominant peripheral distribution and heterogeneous in dimensions (smaller than 3 cm) and appearance (solid and cavitated) (Fig. 2).\nAfter contrast injection, the wedge-shaped consolidations did not show any enhancement, while some of the nodules presented a peripheral rim enhancement and a necrotic center (Fig. 3).\nIn maximum intensity projection (MIP) reconstructions, the \u201cfeeding vessel sign\u201d was seen, hinting their haematogenous origin (Fig. 4).\nOther findings were: pericardial effusion, a small amount of bibasilar pleural effusion, disventilatory parenchymal bands and enlargement of hilar and subcarinal lymph nodes (Fig. 5).\nAn echocardiogram was performed, and tricuspid insufficiency with endocardial vegetations were found.",
    "discussion": "Septic pulmonary embolism is caused by fragments of thrombi containing pathogens, mobilised from an infectious site and transported in the pulmonary arterial circulation where they get implanted, leading to infarctions and micro-abscesses [1-2].\nThe microorganisms most often involved are bacteria (i.e. methicillin-resistant and methicillin-sensitive S.aureus, K.pneumoniae and Fusobacteria), fungi (i.e. Candida and Aspergillus in immunocompromised patients) and parasites [1-3].\nCauses of septic pulmonary embolism include right-sided endocarditis (caused by S. aureus in intravenous drug users), infected indwelling catheters and pacemaker wires, skin, dental and bone infections, septic thrombophlebitis (i.e. Lamierre\u2019s syndrome) and liver abscesses [1-3].\nCommon risk factors are intravenous drug use, alcoholism, diabetes and immunologic deficiencies [1-2].\nClinical findings are aspecific and include fever, dyspnoea, chest pain and cough [3].\nComplications of septic pulmonary embolism are: lung abscesses, broncho-pleural fistulas, pleural empyema, pneumothorax, septic shock and multiple organ failure [1-3].\nConsequently, a prompt diagnosis is essential and imaging techniques, especially chest CT, play an important role [4].\nChest X-ray can be negative or non-specific, showing bilateral, peripheral, poorly marginated lung nodules, which may present cavitation (1-3 cm) [1-4].\nCT findings consist of multiple parenchymal lung lesions (5-35 mm) involving all the lung lobes, represented by nodules, wedge-shaped consolidations (broad base against the pleura) and infiltrates [1-4]. They have a vascular, peripheral distribution, since the septic emboli have a small size and get implanted in peripheral pulmonary vessels [1-5]. The lesions progressively evolve into cavitations [1, 4, 5].\nThe simultaneous presence of solid, subsolid and cavitated lesions with different dimensions reflects repeated episodes of embolic shower [1-5]. For this reason the number of the lesions may vary on sequential chest CTs [6].\nAfter contrast administration, the lesions may not show contrast enhancement (pulmonary infarcts) or may present a strong peripheral rim-enhancement and a necrotic center [5, 6].\nIn limited cases, the \u201cfeeding vessel sign\u201d is present. It is a non-specific finding, characteristic of all nodules of haematogenous origin (septic emboli, metastases, etc.) and consists of a pulmonary vessel that penetrates into a nodule. Recent studies have shown that most frequently the \u201cfeeding vessel sign\" is due to a venous branch [7].\nThe treatment includes the eradication of the infection through antimicrobial drugs.\nIn tricuspid valve endocarditis, cardiac surgery may be necessary in selected cases (i.e. right heart failure, resistant microorganisms, and long-lasting bacteraemia) (Fig. 6) [8].\nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Infective, right-sided, endocarditis, complicated, by, septic, pulmonary, embolism, Tuberculosis, Non-tuberculous, mycobacterial, pulmonary, infections, Aspergillosis, Cryptococcosis, Wegener\u2019s, granulomatosis, Rheumatoid, nodules, Metastases, Pulmonary, lymphoma, Kaposi, sarcoma, Histiocytosis, x, Lymphangioleiomyomatosis, Lymphocyte, interstitial, pneumonia",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-07/figure_1_modified.jpg?itok=wbJG-O-K",
            "caption": "Supine chest X-ray shows multiple bilateral poorly-defined nodules within the pulmonary parenchyma (some of which are indicated by the red arrows). Additional findings were: enlargement of the cardiac silhouette, disventilatory parenchymal bands at the left pulmonary base (indicated by the black arrow), presence of the accessory azygos lobe."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-07/figure_2a_modified.jpg?itok=ZznAfPOm",
            "caption": "Chest CT, lung window images show multiple nodules and wedge-shaped consolidations localised in the pulmonary parenchyma of both lungs (indicated by the red arrows). The lesions have different dimensions (< 3 cm) and appearance (either solid or cavitated), reflecting their different stages. Disventilatory parenchymal bands are seen in both the pulmonary bases in Figure 2e."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-07/figure_2b_modified.jpg?itok=RPF-EHng",
            "caption": "Chest CT, lung window images show multiple nodules and wedge-shaped consolidations localised in the pulmonary parenchyma of both lungs (indicated by the red arrows). The lesions have different dimensions (< 3 cm) and appearance (either solid or cavitated), reflecting their different stages. Disventilatory parenchymal bands are seen in both the pulmonary bases in Figure 2e."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-07/figure_2c_modified.jpg?itok=5jytfeEl",
            "caption": "Chest CT, lung window images show multiple nodules and wedge-shaped consolidations localised in the pulmonary parenchyma of both lungs (indicated by the red arrows). The lesions have different dimensions (< 3 cm) and appearance (either solid or cavitated), reflecting their different stages. Disventilatory parenchymal bands are seen in both the pulmonary bases in Figure 2e."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-07/figure_2d_modified.jpg?itok=6jFjjnpV",
            "caption": "Chest CT, lung window images show multiple nodules and wedge-shaped consolidations localised in the pulmonary parenchyma of both lungs (indicated by the red arrows). The lesions have different dimensions (< 3 cm) and appearance (either solid or cavitated), reflecting their different stages. Disventilatory parenchymal bands are seen in both the pulmonary bases in Figure 2e."
          },
          {
            "number": "Figure 2e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-07/figure_2e_modified.jpg?itok=iDh425hX",
            "caption": "Chest CT, lung window images show multiple nodules and wedge-shaped consolidations localised in the pulmonary parenchyma of both lungs (indicated by the red arrows). The lesions have different dimensions (< 3 cm) and appearance (either solid or cavitated), reflecting their different stages. Disventilatory parenchymal bands are seen in both the pulmonary bases in Figure 2e."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-07/figure_3a.jpg?itok=0PlLavBG",
            "caption": "Chest CT, mediastinal window images show the appearance of the consolidations before the administration of iodinate contrast medium (Figures 3 a-c) and after the administration of iodinate contrast medium (Fig. 3 b-d). In the post contrastographic portal phase, the wedge-shaped peripheral consolidations do not show any enhancement (white arrow in Fig. 3b), while some of the nodules present a peripheral rim enhancement and a necrotic centre (red arrow in Fig. 3d)"
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-07/figure_3b.jpg?itok=DKO_rne0",
            "caption": "Chest CT, mediastinal window images show the appearance of the consolidations before the administration of iodinate contrast medium (Figures 3 a-c) and after the administration of iodinate contrast medium (Fig. 3 b-d). In the post contrastographic portal phase, the wedge-shaped peripheral consolidations do not show any enhancement (white arrow in Fig. 3b), while some of the nodules present a peripheral rim enhancement and a necrotic centre (red arrow in Fig. 3d)."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-07/figure_3c.jpg?itok=MTmpaJCa",
            "caption": "Chest CT, mediastinal window images show the appearance of the consolidations before the administration of iodinate contrast medium (Figures 3 a-c) and after the administration of iodinate contrast medium (Fig. 3 b-d). In the post contrastographic portal phase, the wedge-shaped peripheral consolidations do not show any enhancement (white arrow in Fig. 3b), while some of the nodules present a peripheral rim enhancement and a necrotic centre (red arrow in Fig. 3d)."
          },
          {
            "number": "Figure 3d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-07/figure_3d.jpg?itok=E3OE5B6Z",
            "caption": "Chest CT, mediastinal window images show the appearance of the consolidations before the administration of iodinate contrast medium (Figures 3 a-c) and after the administration of iodinate contrast medium (Fig. 3 b-d). In the post contrastographic portal phase, the wedge-shaped peripheral consolidations do not show any enhancement (white arrow in Fig. 3b), while some of the nodules present a peripheral rim enhancement and a necrotic centre (red arrow in Fig. 3d)."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-07/figure_4.jpg?itok=1TXQUiYH",
            "caption": "CT image, MIP reconstruction shows two sub-segmental pulmonary vessels penetrating into two nodular lesions (red arrows). These findings represent the \u201cfeeding vessel sign\u201d, which indicates the vascular origin of the lesions."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-07/figure_5a_modified.jpg?itok=pgJBeZ9o",
            "caption": "CT images show bibasilar pleural effusion (red arrows in Fig. 5a), pericardial effusion (black arrow in Fig. 5b), disventilatory bands in both the pulmonary bases (red arrows in Fig. 5b) and enlarged right hilar lymph node and subcarinal lymph node (red arrows in Fig. 5c)."
          },
          {
            "number": "Figure 5b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-07/figure_5b_modified.jpg?itok=I5RwRFxQ",
            "caption": "CT images show bibasilar pleural effusion (red arrows in Fig. 5a), pericardial effusion (black arrow in Fig. 5b), disventilatory bands in both the pulmonary bases (red arrows in Fig. 5b) and enlarged right hilar lymph node and subcarinal lymph node (red arrows in Fig. 5c)."
          },
          {
            "number": "Figure 5c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-07/figure_5c.jpg?itok=5D934ylQ",
            "caption": "CT images show bibasilar pleural effusion (red arrows in Fig. 5a), pericardial effusion (black arrow in Fig. 5b), disventilatory bands in both the pulmonary bases (red arrows in Fig. 5b) and enlarged right hilar lymph node and subcarinal lymph node (red arrows in Fig. 5c)."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-07/figure_6.jpg?itok=UYvKt8UB",
            "caption": "Chest X-ray (at 3 months follow up) after medical treatment (antibiotics) and cardiac surgery (tricuspid valve replacement). The pulmonary nodular lesions and the disventilatory parenchymal bands are no longer visible. The new tricuspid valve can be appreciated (red arrow). The cardiac silhouette is within normal limits."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Cardiovascular system",
      "Pulmonary vessels",
      "Thorax"
    ],
    "imaging_technique": [
      "CT",
      "CT-Angiography"
    ],
    "link": "https://www.eurorad.org/case/16404",
    "time": "22.07.2019"
  },
  "16405": {
    "case_id": 16405,
    "title": "Primary pleuropulmonary synovial sarcom",
    "section": "Chest imaging",
    "age": "34",
    "gender": "male",
    "diagnosis": "Primary pleuropulmonary synovial sarcoma",
    "history": "A 34-year-old-male smoker with unremarkable past medical history presented with 5 weeks history of shortness of breath, chest pain and nonproductive cough.",
    "image_finding": "Posterior and lateral chest X-ray demonstrated a left-sided opacity in the anterior mediastinum associated with contralateral tracheal deviation.\nAxial contrast-enhanced chest computed tomography showed a pleural-based large and well-defined mass with heterogeneous enhancement, nodular soft tissue components mixed with areas of low attenuation surrounded by atelectatic lung tissue in the left hemithorax associated with contralateral shifting of the mediastinum.\nT2-weighted MRI images better delineated the internal heterogeneity of the mass with nodular soft tissue and multilocular fluid-filled internal components.\nNo lymph node involvement or distant metastatic disease was noted.",
    "discussion": "Synovial sarcoma is a rare mesenchymal tumour (2.5%~10% of all soft-tissue sarcomas) characteristically seen in adolescents and young adults. [1]\nMore than 90% of synovial sarcomas affect the extremities, arising especially near large joints and particularly near the knee, but other locations have been described (lung, pleura and mediastinum among others). [2]\nPulmonary synovial sarcoma represents 0.1%-0.5% of all lung neoplasms. [3]\nPleuropulmonary synovial sarcoma (PPSS) does not arise from the synovial membranes but receives its name due to its similarity with synovial tissue tumours under the light microscopy [4] and a specific chromosomal translocation specific to synovial sarcoma.\nMacroscopically PPSS are composed of a variety of solid, cystic and necrotic components and microscopically of a proliferation of oval to spindle-shaped tumour cells. Histologic subtypes include monophasic (the most frequent), biphasic and poorly differentiated (with poorer prognosis). [5]\nPleuropulmonary synovial sarcoma has a more aggressive clinical behaviour than soft tissue synovial sarcoma with an overall 5-year survival rate of 50%. [6]\nPatients can present with cough, shortness of breath, haemoptysis and chest wall pain [7].\nIts typical presentation on chest radiographs is a well-marginated mass with uniform opacity based either in the lung or in the pleura, sometimes with associated ipsilateral pleural effusion.\nCT characteristically shows a well-defined soft-tissue mass with heterogeneous enhancement and areas of fluid indicating necrosis or haemorrhage, sometimes associated with an ipsilateral pleural effusion but without lymphadenopathy, a finding which points more towards bronchogenic carcinoma.\nEven if calcification is seen in about 30% of para-articular tumours, PPSS usually lacks tumour calcifications. [7]\nMRI is helpful to better differentiate nodular soft tissue from multilocular fluid-filled internal components and to determine the extent of tumour invasion.The characteristical \u201ctriple sign\u201d seen on MRI imaging (gray, dark and bright) represents tumour, haemorrhage and necrosis. [8]\nDue to the rarity of PPSS, there are no guidelines on its optimal treatment. The current standard is surgery followed by chemotherapy or radiation, the latter being used after wide excision in high-grade (G2-3), deep and >5 cm lesions and in cases where R0 resections have not been achieved [9].\nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Primary, pleuropulmonary, synovial, sarcoma, Primary, and, metastatic, lung, neoplasms, Localised, fibrous, tumours, of, the, lung, and, pleura, Malignant, mesothelioma, Pleuropulmonary, blastoma, and, other, rare, parenchymal, sarcomas",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-07/fig.1a.jpg?itok=u_U0cxMq",
            "caption": "Posterior (a) and lateral (b) chest X-ray demonstrated a left-sided opacity (asterisk) in the anterior mediastinum associated with contralateral tracheal deviation."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-07/fig._1b_0.jpg?itok=QIBDk-V9",
            "caption": "Posterior (a) and lateral (b) chest X-ray demonstrated a left-sided opacity (asterisk) in the anterior mediastinum associated with contralateral tracheal deviation."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-07/fig.2.jpg?itok=Nd2vmb6Z",
            "caption": "Contrast-enhanced axial CT scan shows a pleural-based large and well-defined mass with heterogeneous enhancement, nodular soft-tissue components mixed with areas of low attenuation (asterisk) surrounded by atelectatic lung tissue (arrow) in the left hemithorax associated with contralateral shifting of the mediastinum."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-07/fig.3_a.jpg?itok=7Xk1a68J",
            "caption": "Axial T2-weighted MRI image: T2-weighted MRI image better delineates the extent of the mass and its internal heterogeneity with nodular soft tissue and multilocular fluid-filled internal components (asterisks)."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-07/fig.3b_0.jpg?itok=QHkfS-fi",
            "caption": "Sagittal T2-weighted MRI image: T2-weighted MRI image better delineates the extent of the mass and its internal heterogeneity with nodular soft tissue and multilocular fluid-filled internal components (asterisks)."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-07/fig._3c.jpg?itok=0lEdwiCD",
            "caption": "Coronal T2-weighted MRI image: T2-weighted MRI image better delineates the extent of the mass and its internal heterogeneity with nodular soft tissue and multilocular fluid-filled internal components (asterisks)."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Mediastinum"
    ],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/16405",
    "time": "23.07.2019"
  },
  "16416": {
    "case_id": 16416,
    "title": "Massive spontaneous haemothorax",
    "section": "Chest imaging",
    "age": "61",
    "gender": "male",
    "diagnosis": "Spontaneous haemothorax",
    "history": "The patient presented with sudden onset of dyspnoea and right-sided chest pain, radiating to the back and right shoulder. The patient had undergone a right-sided lung biopsy with wedge resection 3 months earlier on the suspicion on interstitial lung disease (allergic alveolitis). Upon arrival in the emergency department the clinical condition rapidly deteriorated. The patient was intubated and CT was performed.",
    "image_finding": "Supine chest X-ray (Figure 1) was performed in the emergency department after the patient arrived. The image shows a large right-sided pleural collection with mediastinal displacement to the left.\u00a0 After worsening of the clinical condition contrast-enhanced arterial phase CT of the chest was performed (Figure 2). The CT was performed 45 minutes after the chest X-ray. The CT examination showed increasing fluid in the right pleural space with HU-values >30 in keeping with haematoma. As there was no contrast extravasation, the bleeding site could not be identified. A chest tube was inserted but the pleural collection increased as shown on a new chest X-ray 1 hour after the CT examination (Figure 3). The patient was subsequently operated with ligation of a bleeding intercostal artery. The stapler line from the prior resection was unremarkable. Postoperative chest X-ray showed complete regression of the haemothorax (Figure 4).",
    "discussion": "Background\nA number of conditions can cause haemothorax with trauma being the leading cause [1,2]. In the setting of trauma rib fractures causing damage to the intercostal vessels are the most common cause of haemothorax. Iatrogenic haemothorax from thoracocentesis, thoracotomy, insertion of central venous lines, epidural anaesthesia, and pacemaker implantation have been described in the literature [2\u20134].\nSpontaneous haemothorax (non-traumatic) on the other hand is very rare, especially in patients\u00a0 not receiving anticoagulant therapy. The common aetiologies are bleeding disorders, vascular malformations, rupture of thoracic aortic aneurysm, pleural endometriosis, costal exostosis, and pleural malignancy [1].\nThe present case is an example of spontaneous haemothorax. As surgery failed to show a relation to the prior lung resection, and it was verified that the bleeding site was an intercostal artery, the most likely cause was rupture of a small intercostal artery aneurysm.\nClinical and Imaging Perspective\u00a0\u00a0 \u00a0\nClinical presentation of haemothorax resembles other diseases that cause cardiovascular compromise. The patient will present with chest pain and dyspnoea. Clinical findings include low blood pressure and rapid heart rate.\nThe primary imaging modality is conventional X-ray. Contrast-enhanced CT provides further information about the nature of the pleural fluid collection (reactive pleural collection vs. haemothorax). Viscous pleural fluids show HU-values up to 30, higher values indicate blood. Ultrasound may also be helpful for the detection of haemothorax (e.g., echogenic debris representing clots). Furthermore, CT may show the bleeding source as a site of contrast extravasation. However, in the present case it was not possible to identify the bleeding site. As the CT was only performed in an arterial phase, additional venous phase might have shown the source of bleeding.\n\u00a0\nOutcome\nArterial bleeding to the pleural space is a life-threatening condition leading to cardiovascular collapse if untreated. Chest tube insertion is the first choice of treatment to drain the accumulated blood and remove the mediastinal compression. However, thoracotomy is often needed subsequently to repair the site of bleeding. Endovascular treatment with coiling of intercostal arteries is also an option in some cases. Clinical outcome is good if proper treatment is performed. The patient had a full recovery.\nTake Home Message/ Teaching Points\n\u2022\u00a0\u00a0 \u00a0Haemothorax is a rare but important cause of acute chest pain and cardiovascular collapse\n\u2022\u00a0\u00a0 \u00a0The condition can occur spontaneously\nPatient consent:\nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Spontaneous, haemothorax, Pneumothorax, Pneumonia, Pulmonary, embolism, Acute, myocardial, infarction, Acute, aortic, syndrome",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-08/figure_1_chest_x_ray_before.png?itok=X1xA5pBO",
            "caption": "Initial chest X-ray (45 minutes before CT)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-08/figure_2_ct.png?itok=eejyF9R0",
            "caption": "CT examination. Hyperdense stapler line at the right lung represents sequelae after wedge resection."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-08/figure_3_chest_x_ray_1_h_after.png?itok=wbLL4iB-",
            "caption": "Chest X-ray (1 hour after CT)."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-08/figure_4_chest_x_ray_postoperativ.png?itok=ufFigwYK",
            "caption": "Postoperative chest X-ray."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Cardiovascular system",
      "Emergency",
      "Lung"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/16416",
    "time": "06.08.2019"
  },
  "16425": {
    "case_id": 16425,
    "title": "Pulmonary alveolar proteinosis",
    "section": "Chest imaging",
    "age": "31",
    "gender": "female",
    "diagnosis": "Pulmonary alveolar proteinosis",
    "history": "A 31-year-old female teacher, non-smoker, with no relevant past medical history and HIV-negative, presented with a 3-month history of progressive dyspnoea and cough with minimal mucoid sputum. Physical examination revealed crackles in pulmonary auscultation, and the rest of the examination was unremarkable. Laboratory workup showed an elevated value of lactate dehydrogenase.",
    "image_finding": "A chest radiograph was initially performed, which revealed bilateral ground-glass opacities, more expressive in the middle and lower lung fields. High resolution computed tomography (HRCT) of the thorax showed bilateral alveolar ground-glass attenuations with superimposed interlobular septal thickening, in a mosaic pattern called \u201ccrazy-paving\u201d. There were no other noteworthy imaging findings. The radiological manifestations were unspecific and a bronchoscopy with a transbronchial biopsy was performed for clarification. A histopathologic diagnosis of pulmonary alveolar proteinosis was made. The bronchoalveolar lavage fluid showed abundant acelular material. The patient underwent whole lung lavage without significant improvement.",
    "discussion": "Pulmonary alveolar proteinosis (PAP) is a rare disease characterised by alveolar accumulation of lipoproteinaceous material, which blends with periodic acid-Schiff (PAS) [1, 2].\u00a0 It may be congenital, primary or idiopathic and less commonly it presents secondarily to various conditions, that can be divided into three categories: lung infections, haematological diseases or conditions that alter the patient's immunity and\u00a0 exposure to various types of chemicals, such as silica particles [2].\n\u00a0\nThe underlying pathophysiological mechanism corresponds to an alteration of pulmonary surfactant homeostasis and lung immune function. Idiopathic PAP has antibodies against granulocyte-macrophage colony-stimulating factor (GM-CSF), which results in decreased surfactant degradation and its accumulation [3]. PAP is more frequent during the third and fourth decades of life [4]. A strong relationship with smoking is established, with men being more affected than women [3, 5]. The clinical presentation of PAP is unspecific. Frequently, respiratory symptoms are moderate and have an insidious onset. Dyspnoea and dry or minimally productive cough are the most common presenting symptoms. Physical examination is commonly normal, but may reveal auscultatory crackles, clubbing and cyanosis. The predominant abnormality in serologic tests is an increased lactate dehydrogenase level [3].\nThe typical chest radiography findings are central, bilateral and symmetrical alveolar opacities yielding a \u201cbutterfly\u201d distribution pattern, with relative sparing of the apices and costophrenic angles. A less common appearance may correspond to asymmetrical opacities, extensive diffuse consolidation and a mixed alveolar-interstitial or nodular pattern. The most common findings on chest HRCT include ground-glass opacities with geometric distribution and smooth thickening of the interlobular septa, which together result in the so-called \"crazy-paving\" pattern, which is highly suggestive but not pathognomonic. The thickened interlobular septa are present only within the areas of ground-glass opacities and correspond to septal oedema. The distribution is typically bilateral and, unlike secondary forms, there is no predominance of any specific lung region. There is often a marked discrepancy between the patient's clinical and radiological manifestations, which are more pronounced [2-5]. Treatment depends on the form of PAP: pulmonary support or lung transplantation in the congenital disease; removal of causative agent in the secondary PAP and whole-lung lavage and GM-CSF supplementation, with varying degrees of effectiveness, in the idiopathic form [3, 5]. Prognosis is variable, ranging from clinical improvement with treatment to a chronic and terminal course that results from respiratory failure or pulmonary infection [1, 4].\nWritten patient consent for this case was waived by the Editorial Board. Patient data may have been modified to ensure patient anonymity.",
    "differential_diagnosis": "Pulmonary, alveolar, proteinosis, Organizing, pneumonia, Pneumocystis, pneumonia, Cardiogenic, pulmonary, oedema, -, Diffuse, alveolar, haemorrhage",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-08/figure_1_1.jpg?itok=L03qoDIb",
            "caption": "Chest radiography, posteroanterior view, showed symmetric, perihilar ground-glass opacities, predominant in middle and lower lung fields."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-08/figure_2a_0.jpg?itok=wAyVzjCY",
            "caption": "HRCT scan of the thorax with axial sections (lung window) demonstrates bilateral widespread ground-glass opacities with focal areas of sparing and strikingly prominent septal lines, corresponding to a \u201ccrazy paving\u201d pattern."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-08/figure_2b_0.jpg?itok=lBzy0WJ3",
            "caption": "HRCT scan of the thorax with axial sections (lung window) demonstrates bilateral widespread ground-glass opacities with focal areas of sparing and strikingly prominent septal lines, corresponding to a \u201ccrazy paving\u201d pattern."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-08/figure_2c.jpg?itok=JaLhZptV",
            "caption": "HRCT scan of the thorax with axial sections (lung window) demonstrates bilateral widespread ground-glass opacities with focal areas of sparing and strikingly prominent septal lines, corresponding to a \u201ccrazy paving\u201d pattern."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-08/figure_2d.jpg?itok=eAzb1QNw",
            "caption": "HRCT scan of the thorax with axial sections (lung window) demonstrates bilateral widespread ground-glass opacities with focal areas of sparing and strikingly prominent septal lines, corresponding to a \u201ccrazy paving\u201d pattern."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-08/figure_3a_0.jpg?itok=77k2wffg",
            "caption": "HRCT scan of the thorax with coronal section (lung window) demonstrates the diffuse distribution of the \u201ccrazy-paving\u201d pattern."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-08/figure_3b_0.jpg?itok=rPD-EIBI",
            "caption": "HRCT scan of the thorax with sagittal section (lung window) demonstrates the diffuse distribution of the \u201ccrazy-paving\u201d pattern."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Thorax"
    ],
    "imaging_technique": [
      "CT",
      "CT-High Resolution"
    ],
    "link": "https://www.eurorad.org/case/16425",
    "time": "07.08.2019"
  },
  "16435": {
    "case_id": 16435,
    "title": "CT imaging features of paravertebral mediastinal malignant peripheral nerve sheath tum",
    "section": "Chest imaging",
    "age": "42",
    "gender": "male",
    "diagnosis": "Malignant peripheral nerve sheath tumour (Schwannoma)\n                    \n\n                        Ganglioneuroma\n                    \n\n                        Neuroblastoma or ganglio-neuroblastoma\n                    \n\n                        Lung adenocarcinoma\n                    \n\n                        Malignant Nerve sheath tumour (Schwannoma) arising from intercostal nerve (tumour staging: T3N1M0)",
    "history": "42-year-old male patient presented with complaints of posterior chest pain and tingling on inspiration for 2 months. No fever, cough, haemoptysis, trauma. Mild intermittent shortness of breath was noted. On examination there was no obvious localised swelling, warmth or redness. Mild tenderness on deep palpation was noted. The patient is a chronic smoker. No other systemic symptoms. Laboratory studies were within normal limits. The physician advised CECT chest to evaluate further.",
    "image_finding": "CT thorax shows well-defined soft tissue density lobulated solid mass lesion within the superior segment of the right upper lobe in the right paravertebral/subpleural location. It shows heterogeneous internal post-contrast enhancement with few tiny necrotic areas within (Fig. 1, 2). The lesion shows osseous infiltration into adjacent right posterior 5th and 6th ribs and 5th intercostal space (Fig. 2, 4). On sagittal image, the lesion shows tapering end posteriorly within intercostal space (Fig. 3). No obvious bony erosions or destruction within adjacent vertebra or widening of neural foramina. No obvious posterior chest wall extension or paraspinal muscle infiltration of the lesion. An enlarged partially necrotic lymph node was noted in the precarinal region (Fig. 6). No other significant abnormality is noted within the rest of both lung parenchyma, mediastinal great vessels and axillary region. Unfortunately we were unable to perform an MRI scan of the thorax as the patient had declined.",
    "discussion": "Posterior mediastinal masses in paravertebral location can be seen arising from sympathetic ganglia, nerve roots, lymph nodes, parasympathetic chain, thoracic duct, descending thoracic aorta, small vessels and the vertebrae. Most masses in the posterior mediastinum (paravertebral location) are neurogenic in nature. These can arise from the sympathetic ganglia (e.g. neuroblastoma) or from the nerve roots (e.g. schwannoma or neurofibroma).\nPeripheral nerve sheath tumour can be benign or malignant. It arises from nerve sheaths of peripheral nerves. It can be found anywhere predominantly in limbs, Paravertebral mediastinum, along with chest wall or posterior neck soft tissue.\u00a0 The benign tumour is slow-growing and non-infiltrative whereas rapid growth or infiltration into adjacent structures or organs indicates malignant transformation [1]. Posterior mediastinal nerve sheath tumours are most common posterior mediastinal masses. Most of the tumours are benign. However, malignant transformation is rare. Clinically it presents as localised pain or radiating pain with or without visible posterior chest swelling and tenderness. Chest pain on phases of respiration or dyspnoea are also an atypical presentation. Systemic metastasis is very rare but most commonly spreads by haematogenous route to the lungs [3]. Most of the tumours present as part of the Neurofibromatosis -I (NF-I) spectrum [1].\nImaging features: Nerve sheath tumour appears as well-defined homogeneous or heterogeneous solid elongated or oval/rounded mass lesion within the posterior mediastinum in paravertebral location. Small tumours may appear as homogeneous isodense or hypodense mass lesion with tapering end whereas large tumors show heterogeneous density due to internal haemorrhage, necrosis or cystic degeneration on CT imaging [1, 2]. MRI imaging modality is the gold standard for diagnosis due to better soft tissue contrast. It can better detect the neural foraminal extension of the tumour. These tumours appear isointense in T1W and variable hyperintense in signal intensities on T2W and Fat saturated MRI images.\u00a0 Heterogeneous central or target-like peripheral contrast enhancement are typical characteristics on CT and MRI imaging because of variable internal vascular myxoid, cellular and fibrous contents [3]. Split fat sign can be seen in the benign form (rim of displaced perilesional fat which surrounds a neurovascular bundle) as it is lost in malignant transformation [2, 1]. PET-CT study shows intense internal FDG uptake indicating malignant transformation. However, trace uptake can also be seen within benign tumours. Imaging studies can\u2019t differentiate between benign and malignant nerve sheath tumours except for infiltration into adjacent structures. Diagnosis has to be confirmed by tissue biopsy and histopathological analysis [1]. CT and MRI imaging modalities can only detect size and extent of the tumours, the adjacent vertebral, rib or chest wall infiltration and are useful for for pre-operative planning.\u00a0\u00a0 \u00a0\nThe treatment strategy includes primarily surgical excision with or without localised radiation therapy of neoadjuvant chemotherapy. Neoadjuvant chemotherapy is reserved mainly for inoperable lesions by reducing tumour size and extent preoperatively to make them operable. Postoperative localised radiation therapy is given to reduce local recurrence in case of partially resected aggressive tumours [1]. Multimodality treatment approach should be applied in case of infiltrating or metastatic tumours.\nIn our case, the tumour was biopsied under CT guidance and the patient was operated with almost complete resection of the tumour and post-operative radiotherapy application. An enlarged precarinal lymph node was also biopsied under guidance of bronchoscopy and turned out to be positive.\nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Malignant, peripheral, nerve, sheath, tumour, (Schwannoma), Ganglioneuroma, Neuroblastoma, or, ganglio-neuroblastoma, Lung, adenocarcinoma, Malignant, Nerve, sheath, tumour, (Schwannoma), arising, from, intercostal, nerve, (tumour, staging:, T3N1M0)",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-08/plain.jpeg?itok=qOoRhBzq",
            "caption": "Plain CT (axial) showing solid infiltrating mass lesion measuring about 67 x 55 mm in maximum axial and 63 mm in maximum cephalo-caudal dimensions within superior segment of right lower lobe in right paravertebral location."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-08/contrast.jpeg?itok=WyTbHLPz",
            "caption": "Post-contrast study showing heterogeneous intralesional contrast enhancement."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-08/sagittal_2.jpeg?itok=MrDamk9u",
            "caption": "Sagittal scan shows tapering end of lesion within adjacent right 5th intercostal space."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-08/bone_window.jpeg?itok=w9FF4gvy",
            "caption": "Bone window shows adjacent osseous destruction within posterior 5th rib."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-08/coronal.jpeg?itok=L24j43nc",
            "caption": "Coronal plane (post-contrast)."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-08/enlarged_lymph_node.jpeg?itok=5eZFSmaD",
            "caption": "Coronal post-contrast CT image showing partially necrotic enlarged pre-carinal lymph node (shown by thin arrow)"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Neuroradiology peripheral nerve",
      "Thorax"
    ],
    "imaging_technique": [
      "CT",
      "CT-High Resolution"
    ],
    "link": "https://www.eurorad.org/case/16435",
    "time": "09.08.2019"
  },
  "16436": {
    "case_id": 16436,
    "title": "Tracheobronchopathia osteochondroplastic",
    "section": "Chest imaging",
    "age": "66",
    "gender": "male",
    "diagnosis": "Tracheobronchopathia osteochondroplastica",
    "history": "65-year-old man with a history of recurrent respiratory infections. Previous episode of cancelled surgery due to lack of conditions for orotracheal intubation, with tracheal stenosis being diagnosed by the anaesthesiologist in the operating room. Physical examination showed no abnormalities. Pulmonary function tests demonstrated normal outputs and pulmonary volumes with a flow-volume curve typical of fixed airway obstruction.",
    "image_finding": "Multidetector computed tomography (CT) of the chest showed the trachea with irregular lumen, zones of marked calibre reduction and multiple calcified nodules that protrude into the tracheal lumen. These nodules arose from the anterolateral wall of the trachea and spared the posterior tracheal membrane, involving the whole length of the trachea and being more exuberant in the caudal two thirds.",
    "discussion": "Tracheobronchopathia osteochondroplastica is an uncommon idiopathic benign disorder of the large airways, typically affecting the lower two-thirds of the trachea and proximal portions of the primary bronchi. [1]\nThe hallmark of this condition is the nodularity of the cartilaginous tracheobronchial anterolateral walls, with sparing of the posterior wall, resulting of abnormal chondrification and ossification of cartilages. [1, 2]\nEpidemiologically, this disease has no differences in gender distribution and presents between the fourth and the seventh decade of life. [3, 4] It can be asymptomatic or associated to nonspecific respiratory symptoms such as chronic (and productive) coughs and haemoptysis, reported as the most common. [5, 6, 7]\nPulmonary function tests are affected by the location of the lesions and the degree of airway obstruction. In mild cases the results may be normal, but in symptomatic patients or in patients with more extensive disease they usually demonstrate obstructive pattern. [8, 9] \u00a0\nAccording to some authors the bronchoscopy remains the gold standard for recognition of TO, allowing to evaluate the extent and severity of the disease. [10, 11]\nHowever, CT scan is an important imaging modality for the diagnosis and follow-up of these patients, being positive in about 81% of cases. [5] The characteristic CT scan findings are the presence of submucosal nodules, usually multiple, and sessiles with or without calcifications, easily identified on CT, for its protrusion into the airway lumen. [12] The sparing of the posterior membranous wall and the deformation of the cartilaginous tracheal rings in absence of external compression are considered pathognomonic findings. [5]\nRelapsing polychondritis, a rare autoimmune disease, is one of the differential diagnoses that must be taken into account, as it shares some CT imaging findings of TO. It is characterised by smooth thickening, sometimes with diffuse calcification of the cartilaginous parts of the tracheobronchial tree, also sparing the posterior wall, but is distinguished from TO because it is not associated with the presence of submucosal nodules. Another distinguishing feature is the fact that relapsing polychondritis is often manifested by ear and nose chondritis, arthritis, eye inflammation and audiovestibular damage, manifestations absent in the clinical case presented. [13]\nIn the presented case, there were suspicions for this diagnosis when considering the clinical history, with it being later established by the findings in the CT.\nThere is no specific treatment for TO, usually varying from symptomatic management, bronchoscopic intervention to operative correction depending on the severity of airway obstruction. [6]\nTake Home Message / Teaching Points\n-\u00a0\u00a0 \u00a0CT is currently the noninvasive primary exam to evaluate the trachea, since it allows for the evaluation of the morphology of the wall and lumen through multiplanar images in a short span of time.\n-\u00a0\u00a0 \u00a0The posterior wall of the trachea and the central bronchi are typically spared, and the presence of multiple submucosal nodules with deformation of the cartilaginous tracheal rings in absence of external compression are pathognomonic findings of TO at CT.\nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Tracheobronchopathia, osteochondroplastica, Relapsing, polychondritis, Tracheobronchial, amyloidosis, Endobronchial, sarcoidosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-08/1a_1.jpg?itok=lnx6lTNA",
            "caption": "Posterioanterior (PA) and lateral (L) chest radiographs show diffuse narrowing of the intrathoracic trachea."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-08/1b_1.jpg?itok=BXdVH7p5",
            "caption": "Posterioanterior (PA) and lateral (L) chest radiographs show diffuse narrowing of the intrathoracic trachea."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-08/2a_0.png?itok=LsfA62HI",
            "caption": "Transverse CT images in mediastinal window setting show irregular narrowing of the tracheal lumen with calcified nodules in the anterolateral walls."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-08/2b_0.png?itok=WJ4KJUMy",
            "caption": "Transverse CT images in mediastinal window setting show irregular narrowing of the tracheal lumen with calcified nodules in the anterolateral walls."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-08/2c_0.png?itok=E9-Lxj0n",
            "caption": "Transverse CT images in mediastinal window setting show irregular narrowing of the tracheal lumen with calcified nodules in the anterolateral walls."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-08/2d.png?itok=9pQgxal3",
            "caption": "Transverse CT images in mediastinal window setting show irregular narrowing of the tracheal lumen with calcified nodules in the anterolateral walls."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-08/3a_0.png?itok=6WGXz4NX",
            "caption": "Transverse CT images in bone window setting show tracheal lumen with calcified nodules in the anterolateral walls."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-08/3b.png?itok=4RY_oF4r",
            "caption": "Transverse CT images in bone window setting show tracheal lumen with calcified nodules in the anterolateral walls."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-08/3c.png?itok=w-XBx19s",
            "caption": "Transverse CT images in bone window setting show tracheal lumen with calcified nodules in the anterolateral walls."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-08/4a.png?itok=S2hncs9F",
            "caption": "Coronal CT image in bone window setting shows irregular narrowing of the airway with calcified nodules in the anterolateral walls."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-08/5a.jpg?itok=BLtxIqN9",
            "caption": "Sagittal CT image in bone window setting shows tracheal lumen with calcified nodules in the anterolateral walls."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/16436",
    "time": "09.08.2019"
  },
  "16464": {
    "case_id": 16464,
    "title": "A case of idiopathic pulmonary fibrosis",
    "section": "Chest imaging",
    "age": "64",
    "gender": "female",
    "diagnosis": "Idiopathic pulmonary fibrosis",
    "history": "A 64-year-old female patient complaining of cough with scarce yellowish sputum, severe exertional dyspnoea and weakness in the last 3 weeks and treating with aminopenicillins and ipratropium bromide+fenoterol for 7 days with minimal effect. Her lung function had progressively deteriorated during last 2 years. She had stopped smoking 6 years ago.\nClinical examination revealed dyspnoea and tachypnoea with multiple predominantly bibasal crackles, O2 saturation was 85%, restrictive changes were identified at spirometry.",
    "image_finding": "Inspiratory chest CT showed inhomogeneous decrease of pneumatisation, multiple foci of irregularly spaced reticulation, honeycombing pattern (clustered cystic air spaces of variable diameters, occasionally up to 15 mm, with thick, dense walls) and traction bronchiectasis. The latter is defined as irregular bronchial dilatation surrounding retractile pulmonary fibrosis. It is important that all the reticular abnormalities are predominantly in subpleural zones and there is craniocaudal gradient of the lesions, seen on coronal images.\nAlso sliding hiatal hernia (no contrast enema was given) is observed.\nDescribed features are consistent with usual interstitial pneumonia (UIP) pattern. Considering the appropriate anamnesis and clinical findings, idiopathic pulmonary fibrosis (IPF) was diagnosed.",
    "discussion": "Background\nIPF is a chronic, progressive, fibrotic interstitial lung disease of unknown cause [1]. Repeated alveolar micro-injury superimposed on pro-fibrotic epigenetic reprogramming, impaired mechanisms of alveolar epithelium repair and dysfunction of surfactant leads to development of fibrosis [3-5].\nIPF requires differentiation with alternative causes of pulmonary fibrosis, preferentially with connective tissue disorders (e.g. rheumathoid arthritis, antisynthetase and Sjogren's syndromes), chronic hypersensitivity pneumonitis, occupational lung diseases and drug toxicity [1,2].\nClinical Perspective\nA diagnosis of IPF requires multidisciplinary discussion among clinician, radiologist, pathologist and other specialists if it\u2019s needed (e.g. in cases of connective tissue disorders suspected). Especially when clinical history or radiological patterns are not definite. A diagnostic search begins with clinician\u2019s work, who has to establish a probability of interstitial lung diseases (ILD) presence and exclude their known causes like occupational exposure, connective tissue disorders, drug addiction. The probability of the diagnosis is increased in male patients, smokers, over 60 y/o with a family history of ILD and/or comorbid lung pathology [1,2,6].\nPhysical examination can reveal unexplained exertional dyspnoea, progressing with time, chronic dry cough, fine high-pitched bibasilar inspir\u00acatory crackles (so called velcro-like sounds).\nSpirometry typically detects restrictive changes and plethysmography - a reduction in diffusing capacity of the lung for carbon monoxide [1,2,5].\nIn our case, a diagnosis of IPF was proposed at the stage of clinical examination due to the anamnesis and clinical findings. Although in a differential list, there was also pneumonia, chronic bronchitis and COPD.\nAfter revising CT results according to ATS/ERS guidelines, serological testing was provided, and connective tissue diseases were excluded.\nImaging perspective\nHigh-resolution CT protocols are required with the thinnest collimation and should include both inspiratory and expiratory images.\nAll consequences of pathophysiologic processes can be clearly seen on chest CT. Fibrotic changes implicate interstitium inside the secondary pulmonary lobule, which appears on CT as intralobular reticular pattern with irregular thickening of the interstitium. Because of aberrant alveolar repair and continuous micro-injuries, acinar structure is completely destroyed and alveoli become deformed. They evolve into cysts of different sizes and shapes, surrounded by walls of variable thickness. In total all these changes are named as honeycombing pattern.\nPatchy, basal subpleural predominant distribution of honeycombing, fit by presence of reticular abnormalities, traction bronchiectasis or bronchioloectasis represents UIP pattern. In some cases, these lesions may be associated with ground glass opacity (GGO). If all features of UIP except for honeycombing are presented, such pulmonary lesion is regarded as probable UIP pattern. In both cases definite diagnosis of IPF can be made, considering appropriate anamnesis (patients over 60 years, smokers, with progressive deterioration of lung function, absence of other potential causes of ILD) and clinical data (worsening of dyspnoea, cough with sputum, restrictive changes at spirometry). When there is no strong evidence of UIP pattern \u2013 only subtle reticulation with basal subpleural predominant distribution and probable mild GGO is presented, intermediate for UIP pattern should be assigned. In such cases, and when an alternative diagnosis is suggested, a biopsy is required [1,2,4,5]. Although according to ATS/ERS guidelines even in cases of probable UIP pattern with inappropriate anamnesis and clinical data biopsy is recommended [6].\nIn the described case there are quite extensive areas of GGO, which match up with honeycombing distribution and aren\u2019t as pronounced as reticulation abnormalities. Such changes may be regarded as demonstration of fibrotic changes and as sign of infection. The letter is more probable in our case in the background of clinical examination.\n\nTreatment\nAs first-line therapy, Nintedanib e.g. pirfenidone, having a number of anti-inflammatory and antifibrotic effects, are recommended [1 3-5].\nSeveral options for non-pharmacologic treatment are available: smoking cessation, supplemental oxygen therapy, administration, special complex of pulmonary rehabilitation exercises, and age-appropriate vaccines [1,4,5].\nTake home massages:\n1.\u00a0\u00a0 \u00a0At least brief knowledge of IPF pathogenesis is crucial for understanding the nature of pathologic findings from the CT image.\n2.\u00a0\u00a0 \u00a0Since IPF has no single pathognomonic feature, it should be diagnosed based on complex assessment of anamnesis, symptoms, chest CT data and pathologic findings.\n3.\u00a0\u00a0 \u00a0In cases of typical or probable UIP patterns, considering exact IPF anamnesis and clinics, no biopsy is required for diagnosis.\nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Idiopathic, pulmonary, fibrosis, Non-specific, interstitial, pneumonia, Chronic, obstructive, pulmonary, disease, Pneumonia, Chronic, bronchitis, Chronic, hypersensitivity, pneumonitis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-09/1.jpg?itok=pXsV3ryN",
            "caption": "Subpleural predominant severe reticular abnormality with irregularly thickened interstitium; few subpleural foci of honeycombing"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-09/2.jpg?itok=uu6xHQgB",
            "caption": "Inhomogeneous pneumatisation, areas of ground glass opacity, more prominent in the right lung, subpleural foci of honeycombing and traction bronchiectasis of lobar bronchi"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-09/3.jpg?itok=1Qd4-xur",
            "caption": "Extended honeycombing pattern, predominantly in the lower lobes with traction bronchiectasis in all regions"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-09/4.jpg?itok=DMkD8YPq",
            "caption": "Chest is emphysematous, areas of subpleural honeycombing pattern, spread reticulation abnormality and traction bronchiectasis"
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-09/5.jpg?itok=Ja0nOozJ",
            "caption": "Chest is emphysematous, demonstrative lower-lobe predominant honeycombing distribution."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-09/6.jpg?itok=EtLu7Axa",
            "caption": "Visualisation of sliding hiatal hernia"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/16464",
    "time": "18.09.2019"
  },
  "16486": {
    "case_id": 16486,
    "title": "Spontaneous pneumomediastinum",
    "section": "Chest imaging",
    "age": "21",
    "gender": "male",
    "diagnosis": "Primary spontaneous pneumomediastinum, subcutaneous emphysema and pneumorrhachis",
    "history": "A 18-year-old male patient with a medical history of ADHD, anorexia, bradycardia, and MRI-confirmed cerebral ischaemic stroke caused by vasoconstrictor syndrome, presented with sudden right-sided chest pain and dyspnoea. No trauma in history. Physical examination revealed blue and red petechiae on truncus and legs. Inconspicuous vital signs.",
    "image_finding": "Chest X-ray showed air in the mediastinum, as well as free air in the supra-clavicular soft tissues. The findings were consistent with respectively pneumomediastinum and subcutaneous emphysema. CT of the neck, thorax and upper-abdomen showed mediastinal emphysema, as well as emphysema in the abdominal retroperitoneum, and in the subcutaneous thoracic - and supra-clavicular tissue. Air in the spinal canal was also detected. The cause was suggested to be rupture of the oesophagus, and an X-ray of the oesophagus with contrast was performed. A leakage could not be detected.",
    "discussion": "Pneumomediastinum is the presence of air within the mediastinum. It can be divided into spontaneous pneumomediastinum that is not preceded by trauma, surgery, or known pathology, or secondary pneumomediastinum, that is caused by specific pathology. It often presents with sudden onset of symptoms, most commonly chest pain, followed by dyspnoea, cough, neck pain and dysphagia [1-3]. Subcutanoeus emphysema is revealed in over half the patients [3]. Asthma, and asthma exacerbations has been found to be one of the most prominent risk factors for spontaneous pneumomediastinum [4]. In children, spontaneous pneumomediastinum can both be a consequence of an asthma exacerbation and a sign of a first asthma attack [4]. Pre-disposing risk factors such as a history of smoking, recent history of upper respiratory infection or strenuous physical activity has also been reported [3]. The pathophysiologic mechanism is suggested by Macklin et al (1944) to be alveolar rupture caused by increased intrathoracic pressure, with passage of air into the interstitium followed by migration of air toward the mediastinum, and further on towards the subcutaneous tissue of thorax, neck and abdomen, resulting in subcutaneous emphysema [5]. Pneumorrhachis, which is air in the spinal canal, can often be detected as well, and is caused by migration of air from the posterior mediastinum to the epidural space via the posterior surface due to lower resistance and lack of fascia [6]. A plain chest X-ray is a sensitive tool in diagnosing pneumomediastinum [1, 3]. Radiological signs to look for are the \u201cring sign\u201d, which is air surrounding the pulmonary artery or either of its main branches, or the \u201cthymic sail sign\u201d, a sign more common in paediatric patients, resulting from an elevated thymus due to mediastinal air [3]. Often, a CT is performed, adding additional value when there are only small amounts of air in the mediastinum, and when differentiating spontaneous and secondary pneumomediastinum by trying to detect a potential underlying cause of the disease [1, 2]. Additional testing with bronchoscopy, oesophagoscopy or oesophagography can act as supplement when trying to detect an underlying cause, but is generally found to have limited value [1, 2]. However, it is recommended in highly suspicious cases of aerodigestive organ injury, such as Boerhaave`s syndrome or tracheobronchial tree rupture [2]. In most cases, spontaneous pneumomediastinum has a relatively benign clinical course, and responds well to conservative treatment with analgesia and rest [1, 2]. Written informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Primary, spontaneous, pneumomediastinum,, subcutaneous, emphysema, and, pneumorrhachis, Secondary, pneumomediastinum, Pneumothorax, Pneumopericardium, Pneumoperitoneum",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-10/0016486/16486_1_1.jpg?itok=WqPnnAgQ",
            "caption": "A plain chest X-ray showing pneumomediastinum, and subcutaneous emphysema"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-10/0016486/16486_2_1.jpg?itok=l2hMKn1-",
            "caption": "A plain chest X-ray showing pneumomediastinum, and subcutaneous emphysema"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-10/0016486/16486_3_1.jpg?itok=fmEEEwRU",
            "caption": "Axial computed tomographic image of the neck and thorax. There is supraclavicular, axillary and pre-tracheal emphysema, as well as pneumorachis"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-10/0016486/16486_4_1.jpg?itok=goJccMSe",
            "caption": "Axial computed tomographic image of the abdomen showing intraperitoneal free air"
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-10/0016486/16486_5_1.jpg?itok=wUsvTj35",
            "caption": "Coronal computed tomographic image of the neck, thorax and abdomen. There is supraclavicular, axillary and mediastinal emphysema"
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-10/0016486/16486_6_1.jpg?itok=4xBuQMW5",
            "caption": "Coronal computed tomographic image of the thorax and abdomen. There is axillary and mediastinal emphysema, as well as intraperitoneal free air"
          }
        ]
      },
      {
        "number": "Figure 7",
        "subfigures": [
          {
            "number": "Figure 7",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-10/0016486/16486_7_1.jpg?itok=PYIdHWGe",
            "caption": "Sagittal computed tomographic image of the thorax and abdomen. There is subcutaneous emphysema, as well as intraperitoneal free air"
          }
        ]
      },
      {
        "number": "Figure 8",
        "subfigures": [
          {
            "number": "Figure 8",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-10/0016486/16486_8_1.jpg?itok=XWVLt3c7",
            "caption": "A plain chest X-ray showing regression of pneumomediastinum and subcutaneous emphysema"
          }
        ]
      },
      {
        "number": "Figure 9",
        "subfigures": [
          {
            "number": "Figure 9",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-10/0016486/16486_9_1.jpg?itok=mu3_Zrwk",
            "caption": "A plain chest X-ray showing regression of pneumomediastinum and subcutaneous emphysema"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Mediastinum"
    ],
    "imaging_technique": [
      "Conventional radiography"
    ],
    "link": "https://www.eurorad.org/case/16486",
    "time": "08.10.2019"
  },
  "16497": {
    "case_id": 16497,
    "title": "Allergic bronchopulmonary aspergillosis: high-attenuation mucous plugging",
    "section": "Chest imaging",
    "age": "27",
    "gender": "male",
    "diagnosis": "Allergic bronchopulmonary aspergillosis",
    "history": "A 27-year-old male patient presented at the emergency room with cough and dyspnoea with three weeks of evolution, associated with fever and chest pain for the last two days. On auscultation, there were diminished breath sounds over the right chest, associated with crackles. The patient had a history of asthma.",
    "image_finding": "The chest radiograph showed an opacity with lobulated contours in the right mid zone (para-hilar) (Fig. 1). Therefore, a computed tomography (CT) was performed, revealing large cystic and varicose bronchiectasis, almost all distributed centrally in the right upper lobe, that were occluded by mucoid impaction, resulting in bronchocele with the typical \u201cfinger in glove\u201d-sign (Figs. 2 and 3). These mucous plugs have high density, greater than the soft tissue attenuation (Fig. 4). There are bronchial wall thickening and air-fluid levels inside the ectatic airways. The pulmonary parenchyma exhibits ground-glass opacities, associated with centrilobular nodules (Fig. 5). These imaging findings are typical of allergic bronchopulmonary aspergillosis, which were corroborated with clinical and laboratory data (elevated total serum IgE and specific IgE and IgG to Aspergillus fumigatus). In addition, the patient underwent bronchoscopy, that showed purulent secretions emerging from the right upper lobar bronchus, with isolation of Aspergillus fumigatus.",
    "discussion": "Allergic bronchopulmonary aspergillosis (ABPA) is a pulmonary disorder characterised by a hypersensitivity reaction to Aspergillus spp, involving type I (IgE-mediated) and type III (IgG-mediated) immunologic responses. [1,2,3] This entity is most commonly encountered in adults before the age of 40 years, with longstanding asthma, that is the most important contributing factor (occurs in 0.25-11% of asthmatic patients). It is seen occasionally associated with cystic fibrosis and other underlying bronchiectatic diseases.[2] Patients generally experience symptoms of recurrent asthma exacerbations (wheezing, cough and dyspnoea). Occasionally, chest pain, fever, expectoration of dark mucous plug and haemoptysis may be associated. [3,4] The established major criteria for the diagnosis of ABPA include history of asthma, immediate skin reactivity to Aspergillus, elevated total serum IgE (>1000 ng/ml), elevated IgE or IgG to Aspergillus and central bronchiectasias. [2,4] The disease progression may be divided into five phases: acute presentation; resolution with clearing of pulmonary abnormalities and decline in serum IgE; recurrence; development of dependence on corticosteroids; and rarely leading to pulmonary fibrosis. [3] The diagnosis is frequently missed on chest radiographs, since it is normal in almost half of the cases. CT is preferable for its higher sensitivity and specificity. [1,2] The radiological findings consist primarily of central bronchiectasis (cystic or varicose) and mucoid impaction of underlying bronchiectatic airway, forming large bronchoceles, typically with involvement of the upper lobes. On imaging, it corresponds to tubular branching opacities extending from the hilum with the appearance of \u201cfinger in glove\u201d, that may be associated with air-fluid levels in dilated bronchi. Pulmonary collapse may be seen as a consequence of endobronchial mucoid impaction. [1,2,5] Hyperattenuating mucus on CT scans has been reported as a diagnostic criterion for ABPA, corresponding an attenuation superior to 70 Hounsfield Unit (denser than the para-spinal muscles). It is currently attributed to the fungal metabolism by calcium salts and metals (iron and manganese) and desiccated mucus. [1,2,4,6] The presence of hyperdense mucous plugging impaction has been shown as a 100% specific criterion of ABPA and thus may be considered pathognomonic. [2,6,7] Other CT findings in acute exacerbation of ABPA include bronchial wall-thickening, centrilobular nodules (as tree-in-bud pattern), consolidation and mosaic pattern with air trapping. [1,2,5,6] Treatment of ABPA aims to control inflammation and prevent further injury to lungs, based on the combination of oral corticosteroids and anti-fungal medications. The prognosis is excellent in stages I to III and rarely progress clinically. [7,8] Written informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Allergic, bronchopulmonary, aspergillosis, Cystic, fibrosis, Refractory, asthma, Eosinophilic, pneumonia, Churg-Strauss, syndrome, Williams, Campbell, syndrome",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-10/0016497/16497_1_1.png?itok=3u3UGkGS",
            "caption": "Posteroanterior chest radiograph shows an opacity with lobulated contours in the right mid zone (para-hilar)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-10/0016497/16497_2_1.png?itok=BLc-Vyzc",
            "caption": "Contrast-enhanced CT scan (axial and coronal views) showing tubular branching opacities extend from the hilum and involving the right upper lobe, with the typical appearance of \u201cfinger in glove\u201d, corresponding to cystic and varicose bronchiectasis with mucoid impaction (bronchoceles)."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-10/0016497/16497_2_2.png?itok=9tU2ysT0",
            "caption": "Contrast-enhanced CT scan (axial and coronal views) showing tubular branching opacities extend from the hilum and involving the right upper lobe, with the typical appearance of \u201cfinger in glove\u201d, corresponding to cystic and varicose bronchiectasis with mucoid impaction (bronchoceles)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-10/0016497/16497_3_1.png?itok=vlQyCnUY",
            "caption": "Contrast-enhanced CT scan (axial and coronal views) demonstrating cystic and varicose bronchiectasis with mucoid impaction, associated with air-fluid levels and bronchial wall thickening. There is partial pulmonary collapse of the upper right lobe."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-10/0016497/16497_3_2.png?itok=Ki15utPF",
            "caption": "Contrast-enhanced CT scan (axial and coronal views) demonstrating cystic and varicose bronchiectasis with mucoid impaction, associated with air-fluid levels and bronchial wall thickening. There is partial pulmonary collapse of the upper right lobe."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-10/0016497/16497_3_3.png?itok=bjEiqylV",
            "caption": "Contrast-enhanced CT scan (axial and coronal views) demonstrating cystic and varicose bronchiectasis with mucoid impaction, associated with air-fluid levels and bronchial wall thickening. There is partial pulmonary collapse of the upper right lobe."
          },
          {
            "number": "Figure 3d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-10/0016497/16497_3_4.png?itok=WXKy7AwB",
            "caption": "Contrast-enhanced CT scan (axial and coronal views) demonstrating cystic and varicose bronchiectasis with mucoid impaction, associated with air-fluid levels and bronchial wall thickening. There is partial pulmonary collapse of the upper right lobe."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-10/0016497/16497_4_1.png?itok=t2wT_949",
            "caption": "Unenhanced CT scan (axial view) showing hyperattenuating mucus inside the bronchiectasis, denser than the para-spinal skeletal muscle."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-10/0016497/16497_4_2.png?itok=4ojOH9C5",
            "caption": "Unenhanced CT scan (axial view) showing hyperattenuating mucus inside the bronchiectasis, denser than the para-spinal skeletal muscle."
          },
          {
            "number": "Figure 4c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-10/0016497/16497_4_3.png?itok=i-UgsNXx",
            "caption": "Unenhanced CT scan (axial view) showing hyperattenuating mucus inside the bronchiectasis, denser than the para-spinal skeletal muscle."
          },
          {
            "number": "Figure 4d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-10/0016497/16497_4_4.png?itok=Rr953Icv",
            "caption": "Unenhanced CT scan (MIP-reconstruction) showing hyperattenuating mucus inside the bronchiectasis, denser than the para-spinal skeletal muscle."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-10/0016497/16497_5_1.png?itok=t8uQdU7-",
            "caption": "CT scan (axial view) showing ground-glass opacity, associated with centrilobular nodules."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Respiratory system",
      "Thorax"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/16497",
    "time": "09.10.2019"
  },
  "16511": {
    "case_id": 16511,
    "title": "Congenital lobar emphysema/Congenital lobar overinflation",
    "section": "Chest imaging",
    "age": "45",
    "gender": "female",
    "diagnosis": "Lobar emphysema",
    "history": "A 45-year-old lady presented with left-sided chest pain. Clinical examination and blood tests were normal. Chest X-ray was performed to exclude a pneumothorax. There is past medical history of childhood chest infections. There is no other significant past medical history and no previous imaging available from her childhood.",
    "image_finding": "Plain film of chest was performed in A&E, which demonstrated a large lucency of the left upper lobe with tracheal displacement and was reported as bulla (Fig. 1). A CT was performed to further assess the compression due to the bulla. Axial views of the lung window demonstrated an expanded left upper lobe (Fig. 2. CT). Sagittal views of the lung window demonstrated no bullae or pneumothorax, and mediastinum was displaced to the opposite side (Fig. 2,3). There was compression of the lingular segment (Fig. 4) but bronchi remained patent. The lower lobes were not compressed and had equal volume (Fig.5).",
    "discussion": "Lobar emphysema or - more correctly - lobar overinflation as it is recently described, is a rare condition more common in male neonates. The left upper lobe is most commonly affected. It is one entity out of a spectrum of congenital lung malformations, and it may be associated with other malformations [1, 6]. When there is any double about imaging findings it is prudent to confirm them with CT, as in this case, instead of proceeding to chest drain insertion [2]. It is uncommon to find a long term follow-up of such cases into adulthood [2]. The management of symptomatic cases is usually surgical and not controversial. The management of asymptomatic cases or incidental findings of an unrelated cause is conservative (observation) or surgical. We live in a world of patient choice so it is fair to state that modern management is guided by patient choice; in our case the patient had opted for conservative management of infections as and when they occurred, and the condition has not affected her life adversely to warrant surgical intervention. The role of imaging is to support patients opting for conservative management when there are no underlying structural abnormalities like cysts or bullae, or to support the surgical team when they are present [2,3]. Imaging also plays a valuable role in the preoperative assessment of this condition [4]. It is also important to make patients aware of the diagnosis, and to document it in medical notes if and when they need anaesthetic intervention [5]. Written patient consent for this case was waived by the Editorial Board. Patient data may have been modified to ensure patient anonymity.",
    "differential_diagnosis": "Lobar, emphysema, Bullae, Pneumothorax, Bronchial, atresia, (air, trapping, in, the, segment, distal, to, the, atresia), Congenital, pulmonary, airway, malformation, (CPAM), Pulmonary, arterial, hypoplasia, Pulmonary, hypoplasia, Swyer-James, syndrome, Filamin, A, mutation",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-10/0016511/16511_1_1.jpg?itok=jmfjGmMQ",
            "caption": "Chest X-ray demonstrates left upper lobe lucency"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-10/0016511/16511_2_1.jpg?itok=u26ABt1g",
            "caption": "CT axial lung window axial views shows left lucency"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-10/0016511/16511_3_1.jpg?itok=vmX1M9k_",
            "caption": "CT sagittal lung window images demonstrates compressed but patent left lower lobes"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-10/0016511/16511_4_1.jpg?itok=ecAv90q6",
            "caption": "CT coronal soft-tissue window image demonstrates mediastinal displacement"
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-10/0016511/16511_5_1.jpg?itok=ilBR2QUg",
            "caption": "CT axial lung window images through bases demonstrates patent and equal lower lobes"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Paediatric",
      "Thorax"
    ],
    "imaging_technique": [
      "CT",
      "Digital radiography"
    ],
    "link": "https://www.eurorad.org/case/16511",
    "time": "11.10.2019"
  },
  "16512": {
    "case_id": 16512,
    "title": "A case of acute dyspnoea after subtotal Ivor Lewis oesophagectomy",
    "section": "Chest imaging",
    "age": "72",
    "gender": "male",
    "diagnosis": "Hydro-pneumothorax due to an anastomotic leak and oesophago-pleural fistula",
    "history": "A 72-year-old male patient underwent subtotal Ivor Lewis oesophagectomy with gastric conduit for oesophageal tumour (T2/N0/M0) of the middle third of the oesophagus. Two weeks after surgery the patient presented with sudden dyspnoea and fever, associated with gasping and absence of vesicular breath sounds in the right hemithorax.",
    "image_finding": "The immediate postoperative course was unremarkable. The routine fluoroscopic examination performed in standing position on the 6th day after surgery, before refeeding, did not show any leak (Fig. 1). After the onset of dyspnoea and fever, mechanic ventilation, septic protocol, and chest X-ray were immediately performed. Chest X-ray showed diffuse hypolucency of the right hemithorax (Fig. 2). The endoscopic examination failed to demonstrate any leak and CT was performed on the same day. CT examination included unenhanced and intravenous contrast-enhanced scans (Figs 3,4). A scan with iodinated oral contrast medium (diatrizoate meglumine diluted 1/3, Fig. 5) was acquired later, due to initial technical difficulties in positioning the NG tube. The CT findings allowed to reach the diagnosis of hydro-pneumothorax due to an anastomotic leak and oesophago-pleural fistula. The patient was immediately transferred to surgery where he underwent gastric conduit resection and cervical oesophagostomy.",
    "discussion": "Background: Oesophagectomy is used to treat several oesophageal diseases, mostly oesophageal cancer. The most common surgical techniques are transthoracic oesophagectomies, such as the Ivor Lewis and McKeown techniques, and transhiatal oesophagectomy. \u00a0These techniques include different choices of replacing conduit (i.e. stomach, colon). [1] The possible post-surgical complications are leakage, stricture, delayed emptying or dumping syndrome. [1] In particular, leaks have been reported to occur in 10-44% and mostly within the first 10 days after surgery. [1] They are caused by poor tissue apposition or infarcted tissue. [1]\nClinical perspective: A post-oesophagectomy leak may be asymptomatic if small, otherwise it may lead to respiratory problems and unstable haemodynamics. [1] Clinical presentations may vary according to the defect's size, the way the leak is contained or drained, and the degree of the associated sepsis. [2] \u00a0Patients with oesophageal anastomotic leak have a 3 times higher death risk than patients without this complication. [2] \u00a0\nImaging perspective: Fluoroscopic imaging with either water-soluble contrast alone or followed by barium sulphate is routinely performed to rule out an anastomotic leak in the post-operative period, before the time of refeeding. [1]\u00a0A leak is demonstrated by the presence of extraluminal contrast. Both fluoroscopic imaging and CT scanning with oral contrast have high specificity (98%) in detecting anastomotic leaks. However, the high negative predictive value (97%) and the trend toward greater sensitivity of CT suggest its role in ruling out anastomotic leak. [3], Moreover, CT is often the favoured examination since it also allows the elimination of other causes of sepsis (such as pulmonary complications). [2] On CT, a leak is demonstrated by the presence of extraluminal contrast, mediastinal fluid, and gas collections [1,3] although small volumes of fluid and gas can be normal findings in the early postoperative period. It should be noted, however, that there is a general lack of consensus with great discrepancies existing \u00ad\u00ad\u00adin imaging diagnosis, management, and survival. \nTherapeutic options: In case of sepsis, patients should be immediately transferred to intensive care for resuscitation and antimicrobial therapy. Surgical or radiological drainage is needed, and, in the case of underlying necrosis, immediate re-intervention is required with gastric conduit resection and oesophagostomy. [2]\nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Hydro-pneumothorax, due, to, an, anastomotic, leak, and, oesophago-pleural, fistula, Pneumonia",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-10/0016512/16512_1_1.JPG?itok=jvoX9SJq",
            "caption": "Fluoroscopy with iodinated oral contrast medium acquired on the 6th day after surgery. The images a),b), and c) show a normal appearance of the oesophago-gastric anastomosis, a chest tube in pleural space and surgical clips in the site of the posterolateral thoracotomy on the right hemithorax."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-10/0016512/16512_1_2.JPG?itok=fjjs4oRV",
            "caption": "Fluoroscopy with iodinated oral contrast medium acquired on the 6th day after surgery. The images a),b), and c) show a normal appearance of the oesophago-gastric anastomosis, a chest tube in pleural space and surgical clips in the site of the posterolateral thoracotomy on the right hemithorax."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-10/0016512/16512_1_3.jpg?itok=E99URvew",
            "caption": "Fluoroscopy with iodinated oral contrast medium acquired on the 6th day after surgery. The images a),b), and c) show a normal appearance of the oesophago-gastric anastomosis, a chest tube in pleural space and surgical clips in the site of the posterolateral thoracotomy on the right hemithorax."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-10/0016512/16512_2_1.JPG?itok=FFYynpsI",
            "caption": "Supine AP chest X-ray after the sudden onset of dyspnoea on the 14th day after surgery.  Notice decreased lucency and absence of lung markings in the right hemithorax."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-10/0016512/16512_3_1.JPG?itok=fkmlyBE4",
            "caption": "Unenhanced chest CT: a) lung window, b) mediastinal window. The images show right hydro-pneumothorax, left pleural effusion, and atelectasis of the right lung. An air bubble (black arrow) is present in the perianastomotic area and a fluid collection (red arrow) can be seen between the right scapula and the chest wall."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-10/0016512/16512_3_2.jpg?itok=ITkgQaX6",
            "caption": "Unenhanced chest CT: a) lung window, b) mediastinal window. The images show right hydro-pneumothorax, left pleural effusion, and atelectasis of the right lung. An air bubble (black arrow) is present in the perianastomotic area and a fluid collection (red arrow) can be seen between the right scapula and the chest wall."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-10/0016512/16512_4_1.JPG?itok=4QzosgCR",
            "caption": "Chest CT after iv administration of contrast material. Bilateral pleural effusions, right lung atelectasis and fluid collection between the scapula and the chest can be seen."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-10/0016512/16512_5_1.JPG?itok=Q-ui8aOZ",
            "caption": "Chest CT after oral administration of contrast material. The images a) and b) demonstrate the presence of an anastomotic leak by showing contrast and air in the right pleural space."
          },
          {
            "number": "Figure 5b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-10/0016512/16512_5_2.JPG?itok=7ugHFmBa",
            "caption": "Chest CT after oral administration of contrast material. The images a) and b) demonstrate the presence of an anastomotic leak by showing contrast and air in the right pleural space."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Emergency"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT",
      "Fluoroscopy"
    ],
    "link": "https://www.eurorad.org/case/16512",
    "time": "15.10.2019"
  },
  "16529": {
    "case_id": 16529,
    "title": "Fibrosing mediastinitis causing unilateral recurrent laryngeal nerve dysfunction.",
    "section": "Chest imaging",
    "age": "45",
    "gender": "female",
    "diagnosis": "Fibrosing mediastinitis causing unilateral recurrent laryngeal nerve dysfunction",
    "history": "A 45-year-old healthy woman with no significant medical history presented with gradually worsening dysphonia and hoarseness.\nPhysical examination revealed flaccidity of the left vocal fold and loss of abduction and adduction.\nTransbronchial biopsy showed a dense fibrohyaline tissue without any suspicious findings for malignancy.\nGood response and long-term disease control was achieved with high-dose steroids followed by maintenance steroid and methotrexate therapy.",
    "image_finding": "CT and MRI chest and neck evaluation (Fig. 1-3) demonstrated a soft-tissue attenuation, non-calcified and diffusely enhancing mass in the middle mediastinum extending:\n- to the infracarinal space and the aortopulmonary window, affecting the left laryngeal recurrent nerve (that exits from the vagus at the level of the aortic arch, passes through the aortopulmonary window and ascends to the superior mediastinum to reach the tracheoesophageal groove)\n- to the left carotid space surrounding the origin of the supra-aortic vessels, the left carotid artery and infiltrating the left jugular vein, affecting the course of the vagus nerve (that descends with the carotid artery sheath into the upper mediastinum).\nNo bronchial or other cervical/mediastinal vessel narrowing were noted.\nThe secondary anteromedially rotation of the left aryepiglottic cartilage and the related medial position of the posterior vocal cord margin were noted. (Fig. 2)\nCervical involvement was also confirmed by US Doppler. (Fig.4)",
    "discussion": "Fibrosing mediastinitis (FM), also called idiopathic mediastinal fibrosis or sclerosing mediastinitis, is a rare non-malignant and progressive acellular collagen and fibrous tissue invasive proliferative condition within the mediastinum. \nFM typically affects patients between 13 and 65 years with a strong predilection for young females [1]\nFM has two major subtypes: \n-The granulomatous form: Related to tuberculosis and histoplasmosis infection and due to immune-mediated hypersensitivity reaction (in one-third of cases with histopathologic overlap with IgG4-related disease [2])\n-The non-granulomatous form (idiopathic reaction to autoimmune syndromes, sarcoidosis, radiation and drugs such as methysergide) (3),frequently associated with other fibrosing conditions such as Riedel thyroiditis, retroperitoneal fibrosis, sclerosing cholangitis, orbital pseudotumour, etc. [4].\nHistopathology shows paucicellular fibrous tissue containing patchy infiltrates of mononuclear cells. [5]\nThere are two main presentation forms: \n-Focal (80%): Typically seen in granulomatous forms as a localised mass of soft-tissue attenuation, frequently with stippled or dense calcifications and usually located in paratracheal or subcarinal compartments of mediastinum or in pulmonary hilum.\n-Diffuse (20%): Typically seen in non-granulomatous forms as a diffusely infiltrating, non-calcified soft-tissue mass affecting multiple mediastinal compartments.\nClinical symptoms depend upon the compression of the surrounding structures of the mediastinum (chest pain, cough, breathlessness, pneumonia, dysphagia, etc). Complications such as superior vena cava syndrome, pulmonary hypertension and massive haemoptysis have been described. [6,7,8]\nCT is a useful modality to assess the extent and the severity of involvement and to evaluate lung parenchyma that can show regional or diffuse oligaemia (in cases of pulmonary arteries encasement) and congestion and oedema with septal and bronchial wall thickening (in cases of pulmonary veins encasement).\nSignal intensity shown on MRI can be variable depending on the presence of calcification or dense fibrotic scars (hypointense both on T1 and T2-weighted images) and inflammatory activity (hypo-isointense on T1-weighted images and hyperintense on T2-weighted images related to muscle and with variable contrast enhancement) [2].\nUltrasound can be used to evaluate possible cervical vessels involvement as shown in our case.\nDefinitive diagnosis requires biopsy (preferred to fine needle aspiration cytology due to extensive areas of fibrosis) to exclude malignancy.\nPrognosis depends mainly of structures involved. FM can have an unpredictable course with both exacerbation of symptoms and spontaneous remission being reported.\nTreatment options include antifungal agents in cases of histoplasmosis-related fibrosis, corticosteroids and stents placement/palliative surgery to relieve oesophageal, airway and vascular. In cases of localised forms, surgery can be curative. [8]\nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Fibrosing, mediastinitis, causing, unilateral, recurrent, laryngeal, nerve, dysfunction, Lymphoma, Metastatic, carcinoma, Mesothelioma, Germ, cell, neoplasms",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-10/0016529/16529_1_1.jpg?itok=x75kVxmm",
            "caption": "Contrast-enhanced chest CT scan (a: arterial phase; b-f: venous phase) shows a soft-tissue attenuation non-calcified mass in the middle mediastinum with diffuse contrast enhancement in the venous phase (b-f), surrounding the origin of the supra-aortic vessels and extending to the aortopulmonary window and the infracarinal space. No bronchial /vessel infiltration or narrowing was noted."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-10/0016529/16529_1_2.jpg?itok=unF_cz82",
            "caption": "Contrast-enhanced chest CT scan (a: arterial phase; b-f: venous phase) shows a soft-tissue attenuation non-calcified mass in the middle mediastinum with diffuse contrast enhancement in the venous phase (b-f), surrounding the origin of the supra-aortic vessels and extending to the aortopulmonary window and the infracarinal space. No bronchial /vessel infiltration or narrowing was noted."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-10/0016529/16529_1_3.jpg?itok=fsqo0Q8c",
            "caption": "Contrast-enhanced chest CT scan (a: arterial phase; b-f: venous phase) shows a soft-tissue attenuation non-calcified mass in the middle mediastinum with diffuse contrast enhancement in the venous phase (b-f), surrounding the origin of the supra-aortic vessels and extending to the aortopulmonary window and the infracarinal space. No bronchial /vessel infiltration or narrowing was noted."
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-10/0016529/16529_1_4.jpg?itok=3YafTjlo",
            "caption": "Contrast-enhanced chest CT scan (a: arterial phase; b-f: venous phase) shows a soft-tissue attenuation non-calcified mass in the middle mediastinum with diffuse contrast enhancement in the venous phase (b-f), surrounding the origin of the supra-aortic vessels and extending to the aortopulmonary window and the infracarinal space. No bronchial /vessel infiltration or narrowing was noted."
          },
          {
            "number": "Figure 1e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-10/0016529/16529_1_5.jpg?itok=Pwo3vcu6",
            "caption": "Contrast-enhanced chest CT scan (a: arterial phase; b-f: venous phase) shows a soft-tissue attenuation non-calcified mass in the middle mediastinum with diffuse contrast enhancement in the venous phase (b-f), surrounding the origin of the supra-aortic vessels and extending to the aortopulmonary window and the infracarinal space. No bronchial /vessel infiltration or narrowing was noted."
          },
          {
            "number": "Figure 1f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-10/0016529/16529_1_6.jpg?itok=GlrjhYSQ",
            "caption": "Contrast-enhanced chest CT scan (a: arterial phase; b-f: venous phase) shows a soft-tissue attenuation non-calcified mass in the middle mediastinum with diffuse contrast enhancement in the venous phase (b-f), surrounding the origin of the supra-aortic vessels and extending to the aortopulmonary window and the infracarinal space. No bronchial /vessel infiltration or narrowing was noted."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-10/0016529/16529_2_1.jpg?itok=nsBOCZc5",
            "caption": "Contrast-enhanced neck CT scan (a and c: arterial phase; b and d: venous phase) shows a similar soft-tissue attenuation mass with diffuse contrast enhancement during the venous phase (b and d) surrounding the left carotid artery (without lumen narrowing) and infiltrating the left yugular vein (with lumen narrowing)."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-10/0016529/16529_2_2.jpg?itok=tGMBtT4e",
            "caption": "Contrast-enhanced neck CT scan (a and c: arterial phase; b and d: venous phase) shows a similar soft-tissue attenuation mass with diffuse contrast enhancement during the venous phase (b and d) surrounding the left carotid artery (without lumen narrowing) and infiltrating the left yugular vein (with lumen narrowing)."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-10/0016529/16529_2_3.jpg?itok=AKiniWX9",
            "caption": "Contrast-enhanced neck CT scan (a and c: arterial phase; b and d: venous phase) shows a similar soft-tissue attenuation mass with diffuse contrast enhancement during the venous phase (b and d) surrounding the left carotid artery (without lumen narrowing) and infiltrating the left yugular vein (with lumen narrowing)."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-10/0016529/16529_2_4.jpg?itok=MV-3gbBI",
            "caption": "Contrast-enhanced neck CT scan (a and c: arterial phase; b and d: venous phase) shows a similar soft-tissue attenuation mass with diffuse contrast enhancement during the venous phase (b and d) surrounding the left carotid artery (without lumen narrowing) and infiltrating the left yugular vein (with lumen narrowing)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-10/0016529/16529_3_1.jpg?itok=F2H3sRiz",
            "caption": "T1-weighted MR images (a. and b.) and corresponding contrast-enhanced fat-saturated T1-weighted images (c. and d.) show the isointensity of the lesion compared to the muscles (a.and b.) and its diffuse contrast-enhancement (c. and d.)."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-10/0016529/16529_3_2.jpg?itok=rlT5Ntww",
            "caption": "T1-weighted MR images (a. and b.) and corresponding contrast-enhanced fat-saturated T1-weighted images (c. and d.) show the isointensity of the lesion compared to the muscles (a.and b.) and its diffuse contrast-enhancement (c. and d.)."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-10/0016529/16529_3_3.jpg?itok=OWznmeUW",
            "caption": "T1-weighted MR images (a. and b.) and corresponding contrast-enhanced fat-saturated T1-weighted images (c. and d.) show the isointensity of the lesion compared to the muscles (a.and b.) and its diffuse contrast-enhancement (c. and d.)."
          },
          {
            "number": "Figure 3d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-10/0016529/16529_3_4.jpg?itok=kkFz3aa6",
            "caption": "T1-weighted MR images (a. and b.) and corresponding contrast-enhanced fat-saturated T1-weighted images (c. and d.) show the isointensity of the lesion compared to the muscles (a.and b.) and its diffuse contrast-enhancement (c. and d.)."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-10/0016529/16529_4_1.jpg?itok=eXZ3tONB",
            "caption": "Doppler neck ultrasonography (a. axial; b sagittal) confirmed the infiltration of the left jugular vein and the soft tissue mass surrounding the left common artery (c.) without significantly luminal narrowing."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-10/0016529/16529_4_2.jpg?itok=rTJz8ptE",
            "caption": "Doppler neck ultrasonography (a. axial; b sagittal) confirmed the infiltration of the left jugular vein and the soft tissue mass surrounding the left common artery (c.) without significantly luminal narrowing."
          },
          {
            "number": "Figure 4c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-10/0016529/16529_4_3.jpg?itok=dusVYASW",
            "caption": "Doppler neck ultrasonography (a. axial; b sagittal) confirmed the infiltration of the left jugular vein and the soft tissue mass surrounding the left common artery (c.) without significantly luminal narrowing."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-10/0016529/16529_5_1.jpg?itok=HU8M5aO5",
            "caption": "Photomicrograph (haematoxylin-eosin stain) demonstrates paucicellular eosinophilic collagen with scattered inflammatory cells"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Head and neck"
    ],
    "imaging_technique": [
      "CT",
      "MR",
      "Ultrasound-Colour Doppler"
    ],
    "link": "https://www.eurorad.org/case/16529",
    "time": "23.10.2019"
  },
  "16532": {
    "case_id": 16532,
    "title": "Subacute hypersensitivity pneumonitis",
    "section": "Chest imaging",
    "age": "38",
    "gender": "female",
    "diagnosis": "Hypersensitivity pneumonitis, subacute form",
    "history": "A 39-year-old woman, non-smoker, with unremarkable medical anamnesis, working in a factory in a lacquering furniture department for a year. She complained on subfebrile fever over the last 10 days and gradually worsening fatigue, weight loss, dyspnoea at rest, unproductive cough for the last 6-8 months.\nSlight decrease of vesicular breath sounds and fine end-inspiratory bilateral crackles, restrictive changes of pulmonary function and significantly decreased diffusion capacity of the lungs were revealed. Blood tests were normal.",
    "image_finding": "CT scans (Fig. 1) show mosaic attenuation with multiple varying areas of lung attenuation. There are extended zones of ground glass opacities (GGO), more pronounced in S1/2 of the left lung. Also, there is an interlobular reticulation, mostly in S1/2 of the left lung and multiple subpleural coarse fibrous strands.\nIntrathoracic and axillar lymph nodes are not enlarged.",
    "discussion": "Background\nHypersensitivity pneumonitis (HP) is caused by exaggerated immune response, either in the form of immune-complex hypersensitivity (acute HP) or Th2 immune response (subacute, chronic HP), to inhalation of different organic antigens: fungi, yeasts, mycobacteria, bacteria, animal proteins or chemicals [1-3].\nClinical perspective\nClinically HP is divided into acute, subacute and chronic phenotypes. Sometimes it is difficult to distinguish the latter two.\nAcute HP typically manifests with flu-like symptoms, similar to respiratory viral or mycoplasmal infection, non-productive cough, tachypnoea and bibasilar inspiratory crackles, sometimes accomplished by respiratory insufficiency and leukocytosis. The peak of the disease is 12\u201324 hours after exposure and it resolves within 48 hours.\nContinued low-level antigenic exposure induces an insidious development of subacute HP with unproductive cough, dyspnoea, fatigue and weight loss. It can gradually progress into chronic form with increase of fibrosis, deterioration of pulmonary function and flare-ups, remaining acute HP. Histologically HP represents specific lymphocytic alveolitis. By the course of disease, interstitial infiltrates, cellular bronchiolitis and poorly formed granulomas, which are classically present in subacute form, evolve into prominent centrilobular fibrosis, surrounded by lymphocytic infiltrates and small granulomas/giant cells [4]. In advanced stages a course of disease can mimic idiopathic pulmonary fibrosis (IPF) or non-specific interstitial pneumonia (NSIP) [1,4,5,6].\nPresence of HP is confirmed by using a combination of pulmonary CT and non-radiologic diagnostic methods. To assess sensitisation to particular known antigen specific antibodies can be determined. Presence of lymphocytic alveolitis can be confirmed by bronchoalveolar lavage (BAL). The latter is characterised by very high total cell count with lymphocyte percentage >50% with additional presence of mast cells, plasms cells and foamy macrophages. Transbronchial biopsy is only held in cases when differential with IPF should be provided [1,2,4].\nTherefore, in our case differential diagnosis list included HP, NSIP and pneumocystis pneumonia. The latter was excluded due to negative PCR (polymerase chain reaction) results and normal immune status of the patient. However, CT data and clinics, although a bit protracted, were appropriate for this diagnosis.\nImaging perspective\nTypical CT findings in acute and subacute HP include GGO, bilateral, usually prevailing in lung apices, air-trapping and ground-glass centrilobular nodules (\u2265 5mm). Simultaneous presentation of patchy GGO areas, hypoattenuated and normal regions is referred to as headcheese sign, highly specific for HP. Centrilobular nodules reflect presence of cellular bronchiolitis and/or peribronchiolar interstitial inflammation [4,5,7,8].\nAs fibrosis develops, architectural distortion, mainly in upper and middle-lung, and traction bronchiectasis are revealed, which makes CT appearance highly similar to NSIP. Honeycombing may also occur, sometimes resembling IPF [6,8].\nIn our patient, the most significant finding was mosaic attenuation pattern in conjunction with only mild signs of fibrosis (and inappropriate anamnesis), so diagnosis of NSIP seemed of less probability. In addition, suitable anamnesis, clinical data and results of BAL (increase of total cell count and elevation of lymphocytes up to 58%) let us confirm a diagnosis of HP. No biopsy was provided.\nOutcome\nExposure to a causative antigen should be avoided. Corticosteroids are applied in acute and subacute HP, but there is no effective treatment for progressive fibrosis.\nOur patient was treated with prednisone for 3 months with good response. On repeated CT scan (8th day of treatment, figure 2) decrease of GGO extension as well as reduction of interlobular reticulation was noticed.\nTake home messages\nHP is a complex pulmonary syndrome, which diagnosis is based on identification of antigen source together with appropriate clinical and imaging data.\nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Hypersensitivity, pneumonitis,, subacute, form, Non-specific, interstitial, pneumonia, Pneumocystis, pneumonia, Viral, (CMV), pneumonia, Desquamative, interstitial, pneumonia",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-10/0016532/16532_1_1.jpg?itok=Nb0EksQk",
            "caption": "Axial CT scan. Areas of GGO, more prominent in S1/2 of the left lung, alternating with zones of normal attenuation, and mild interlobular reticulation."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-10/0016532/16532_1_2.jpg?itok=mS3hDYMb",
            "caption": "Axial CT scan. Mosaic attenuation pattern with numerous fibrotic strands."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-10/0016532/16532_1_3.jpg?itok=ty0ES6oK",
            "caption": "Sagittal CT reformation. GGO, more prominent in dorsal segments of the left lung with multiple fibrous bands."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-10/0016532/16532_2_1.jpg?itok=RWdWYGvP",
            "caption": "CT scans on the 7th day of treatment. Significant decrease of GGO severity."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-10/0016532/16532_2_2.jpg?itok=MGOfXFOG",
            "caption": "Axial CT scan. GGO is less prominent."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT",
      "CT-High Resolution"
    ],
    "link": "https://www.eurorad.org/case/16532",
    "time": "23.10.2019"
  },
  "16548": {
    "case_id": 16548,
    "title": "Young male with dyspnoea - Complication of an endemic disease",
    "section": "Chest imaging",
    "age": "30",
    "gender": "male",
    "diagnosis": "Scrub typhus associated interstitial pneumonia",
    "history": "A 30-year-old male patient presented with complaints of fever since 15 days and shortness of breath since 4 days, which increased progressively. Patient\u2019s SpO2 was 67% on presentation. Laboratory findings revealed leukocytosis and mild hyperbilirubinaemia. Viral panel for influenza, H1N1, EBV, dengue and blood smears for malarial parasites were negative. Scrub typhus antibodies (IgM) were positive.",
    "image_finding": "HRCT chest was done which revealed diffuse ground glass opacification of bilateral lung fields with subpleural sparing. There was presence of interlobular septal thickening in bilateral lungs. Multiple enlarged axillary lymph nodes were present bilaterally. Features were suggestive of interstitial pneumonitis with secondary alveolar damage.",
    "discussion": "In the setting of an endemic region and other causes of fever ruled out, with positive antibodies, the diagnosis of scrub typhus was made. Antibiotic treatment with macrolides was started and patient responded well to the treatment. Oxygen saturation at room air improved to 96%. A repeat HRCT done one week later showed resolution of ground glass opacities in bilateral lungs (right> left).\nBackground: Scrub typhus, also known as tsutsugamushi disease, is an acute febrile illness caused by infection with Orientia tsutsugamushi and is endemic in eastern Asia and Pacific region.\nClinical perspective: The classic case description includes an eschar\nat the site of chigger feeding, regional lymphadenopathy, and a maculopapular rash. But, the eschar is seen less commonly in South Asians, especially those who are dark skinned. A diagnosis can be made in the presence of a significant increase in the serum antibody titer measured either with the Weil-Felix agglutination test or with indirect immunofluorescence. [1]\nImaging perspective: High-resolution CT depicts bilateral abnormalities, predominantly in the lower zone of the lung. Common findings include interlobular septal thickening, axial interstitial thickening, ground-glass opacity, and centrilobular nodules. Consolidation and large nodules are less common findings [2,3]. CT findings of scrub typhus may reflect cellular infiltration, oedema, and haemorrhage caused by vasculitis or may be due to interstitial oedema secondary to cardiac involvement [2]. However, literature on chest radiographs seen in scrub typhus is scant and described in small cohorts.\nOutcome: Scrub typhus in severe cases can lead to complications involving vital organs such as lungs, as was the case in our patient. The classical diagnostic clue of rash and eschar might not always be present or may not visible especially in South Asian population.\nTake home message: Pulmonary complications might occur in scrub typhus infections and a high index of suspicion is needed in endemic areas. Knowledge of radiologic findings in the chest in cases of scrub typhus helps in early identification of complications, reducing morbidity and mortality.\nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Scrub, typhus, associated, interstitial, pneumonia, Viral, pneumonia, Intravascular, coagulopathy, Septicaemia, Transfusion, reaction",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-10/0016548/16548_1_1.jpg?itok=lRLZ0Z3x",
            "caption": "Initial HRCT (axial section) showing diffuse ground glass opacities in bilateral lungs (asterisk) with subpleural sparing (yellow arrows)."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-10/0016548/16548_1_2.jpg?itok=uZXO-4tt",
            "caption": "Coronal section showing the same findings as 1a."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-10/0016548/16548_2_1.jpg?itok=Q5dCV6HI",
            "caption": "Enlarged axillary lymph nodes."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-10/0016548/16548_3_1.jpg?itok=Rsb0HfjS",
            "caption": "Follow-up HRCT after one week of antibiotic treatment shows resolution of parenchymal opacities."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-10/0016548/16548_3_2.jpg?itok=6Gci_H0o",
            "caption": "Coronal section of HRCT lung after one week of antibiotic therapy."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT-High Resolution"
    ],
    "link": "https://www.eurorad.org/case/16548",
    "time": "31.10.2019"
  },
  "16560": {
    "case_id": 16560,
    "title": "Mounier-Kuhn syndrome: A rare clinical and radiologic condition",
    "section": "Chest imaging",
    "age": "36",
    "gender": "male",
    "diagnosis": "Mounier-Kuhn syndrome",
    "history": "A 36-year-old man presented with chronic productive cough and history of recurrent lower respiratory infections. Physical examination was unremarkable. The patient was non-smoker with no occupational or environmental exposure to respiratory irritants. There was no family history of a similar illness. The results of blood analysis were within normal limits.",
    "image_finding": "A chest radiograph (posteroanterior and lateral views) were initially performed, which revealed tracheobronchomegaly, multiple ill-defined opacities, predominantly in the right-lower lobe, and increased linear opacities, more visible in the left pulmonary base, which represent thickened bronchial walls or tram tracks, due to cylindrical bronchiectasis (Fig. 1). High-resolution computed tomography (HRCT) of the thorax confirmed tracheobronchomegaly, that manifests not only by dilatation of the trachea and bronchi (Figs. 2-5), but also by protrusion of redundant musculomembranous tissue between the cartilaginous rings, resulting in a scalloped appearance of the air columns (Figs. 4 and 5). On axial view, a small diverticulum is also visible in the left wall of the trachea (Fig. 3). Additionally, scattered cylindrical bronchiectasis were identified, some of them with parietal thickening and endoluminal mucoid content (Fig. 6).",
    "discussion": "Tracheobronchiomegaly, also known as Mounier-Kuhn syndrome (MKS), is a rare condition, characterised by pathological dilation of the trachea and major bronchi with recurrent chest infections [1-5]. It was first described in 1932 by Mounier-Kuhn. [1-4] Aetiology remains unknown, with most cases occurring sporadically, but familial cases have been described with a possible recessive inheritance [4]. Nevertheless, it has been documented an association with Ehlers-Danlos and Marfan syndromes, cutis laxa, Kenney-Caffe syndrome, severe upper lobe fibrosis such as sarcoidosis, cystic fibrosis and others [2-5].\nAirway histological examination of individuals with tracheobronchiomegaly demonstrated muscle, elastic, and cartilaginous tissue atrophy, resulting in increased tracheal and main bronchial diameters and mucociliary clearance impairment. Dilatation of the tracheal cartilage rings allows the tissue between them to protrude out of the trachea and central bronchi, leading to diverticula. Such diverticula can be observed in a localised or diffuse manner along the entire length of the central airways, a condition known as tracheobronchial diverticulosis [1-3]. \nIt is mainly observed in men between the 3rd and 5th decade of life. Clinical manifestations are nonspecific and the diagnosis is made radiologically. Patients with MKS are usually diagnosed as having bronchiectasis and chronic bronchitis [2-4]. Pulmonary function tests reveal an enlarged dead space [5]. MKS has three subtypes. In type 1, there is minimal dilation of the trachea and major bronchi; in type 2 there is distinct dilation and diverticula; and in type 3 the diverticula and sacculations extend to the distal bronchi [3,4]. \nThe most frequent imaging findings consist of tracheal and main bronchial dilation and the presence of tracheobronchial diverticula.\u00a0 The diagnosis of tracheobronchiomegaly is made when the diameter of the trachea exceeds 3 cm, the right main bronchus exceeds 2,4 cm and the left main bronchus exceeds 2,3cm [3,5]. Chest X-ray is able to demonstrate dilation of the trachea and main bronchus, but CT better assesses pathological complications, including bronchiectasis, fibrosis, emphysema, and recurrent infections [1-3]. Additionally, dynamic inspiratory and expiratory series should be conducted to demonstrate commonly associated tracheobronchomalacia, with respiration-dependent collapse of the trachea and bronchi.\nAsymptomatic patients do not require treatment, but smoking cessation is encouraged. In symptomatic patients, treatment is usually conservative with antibiotics, physiotherapy and postural drainage. Surgical treatment by resection or stenting usually is not used due to widespread nature of disease [1-4]. \nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Mounier-Kuhn, syndrome, Williams-Campbell, syndrome, Chronic, obstructive, pulmonary, disease, Normal, aging",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-11/0016560/16560_1_1.jpg?itok=nA6WFUVN",
            "caption": "Chest radiography, posteroanterior view, shows tracheomegaly (arrowheads), multiple ill-defined opacities predominantly in the right-lower lobe and increased linear opacities, more visible in the left pulmonary base, that represent thickened bronchial walls or tram tracks (arrows) due to cylindrical bronchiectasis."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-11/0016560/16560_1_2.jpg?itok=jDAJyUqR",
            "caption": "Chest radiography, lateral view, confirms the tracheomegaly (arrowheads)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-11/0016560/16560_2_1.JPG?itok=GmX-_G0t",
            "caption": "Computed tomography of the thorax with axial sections (mediastinal window) demonstrates marked increase in tracheal diameter, compatible with tracheomegaly."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-11/0016560/16560_3_1.JPG?itok=tPwtEjZf",
            "caption": "Computed tomography of the thorax with axial sections (lung window)"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-11/0016560/16560_4_1.JPG?itok=eFLZuNhA",
            "caption": "HRCT scan of the thorax with coronal section (lung window) demonstrates tracheomegaly with tracheal wall-irregularity and scattered cylindrical bronchiectasis, particularly evident in the middle lobe."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-11/0016560/16560_4_2.JPG?itok=vhq0ENd3",
            "caption": "HRCT scan of the thorax with sagittal section (lung window) demonstrates the tracheomegaly with irregularity of the tracheal wall."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-11/0016560/16560_5_1.JPG?itok=8kmMk6Pq",
            "caption": "HRCT scan of the thorax with axial section (lung window) demonstrates dilation of the right (R) and left (L) main and segmental bronchi and cylindrical bronchiectasis (arrow)."
          },
          {
            "number": "Figure 5b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-11/0016560/16560_5_2.JPG?itok=HrMBCTZ-",
            "caption": "HRCT scan of the thorax with coronal section (lung window) demonstrates dilation of the main and segmental bronchi and cylindrical bronchiectasis (arrow)."
          },
          {
            "number": "Figure 5c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-11/0016560/16560_5_3.JPG?itok=lyvfVmFV",
            "caption": "HRCT scan of the thorax with coronal section (lung window) demonstrates dilation of the main and segmental bronchi and cylindrical bronchiectasis."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-11/0016560/16560_6_1.JPG?itok=vNz2MHfK",
            "caption": "HRCT scan of the thorax with axial section (lung window) shows multiple bronchiectasis of cylindrical morphology (arrows)."
          },
          {
            "number": "Figure 6b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-11/0016560/16560_6_2.JPG?itok=9JA8aK3v",
            "caption": "HRCT scan of the thorax with axial section (lung window), shows a dilated bronchus in the left lower lobe that demonstrates lack of tapering."
          },
          {
            "number": "Figure 6c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-11/0016560/16560_6_3.JPG?itok=eUEWHFH6",
            "caption": "HRCT scan of the thorax with axial section (lung window), through the left lower lobe shows a number of examples of the \u201csignet-ring sign\u201d, which is present when a dilated bronchus (large arrows) is associated with a much smaller pulmonary artery (small arrows). Some bronchial walls are thickened and air-fluid levels are visible within the abnormal bronchi (arrowhead)."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Anatomy"
    ],
    "imaging_technique": [
      "CT",
      "CT-High Resolution"
    ],
    "link": "https://www.eurorad.org/case/16560",
    "time": "08.11.2019"
  },
  "16568": {
    "case_id": 16568,
    "title": "Pulmonary alveolar proteinosis in a 24-year-old woman",
    "section": "Chest imaging",
    "age": "24",
    "gender": "female",
    "diagnosis": "Pulmonary alveolar proteinosis",
    "history": "During an annual routine inspection, pathological findings in the lungs occurred in a fluoroscopy of a 24-years-old woman. The patient took a course of antibacterial therapy with no significant dynamics (Fig.1a,b). T-SPOT.TB (blood test for tuberculosis (TB) screening, also known as an interferon gamma release assay) was negative, and anti-neutrophil cytoplasmic antibodies (ANCAs) test was negative. Pulmonary function tests showed moderate impairment of diffusion capacity without any restrictive impairment.",
    "image_finding": "Then the patient underwent computed tomography (CT) which showed intralobular and interlobular septal thickening and ground glass with geographic distribution showing a crazy paving pattern\u00a0 (Fig. 2a,b,c).",
    "discussion": "Background:\nPulmonary alveolar proteinosis (PAP) is a rare diffuse lung disease that results from the accumulation of lipoproteinaceous material in the alveoli and alveolar macrophages due to abnormal surfactant homoeostasis. The principal abnormalities in adult PAP result from poor\nsurfactant clearance and altered surfactant homoeostasis in the lung due to impaired alveolar\u00a0 macrophage function. Attenuated alveolar macrophage maturation is typically caused by inadequate granulocyte\u2013macrophage colony-stimulating factor (GM-CSF) signaling, which is \u00a0\ncrucial for the development\u00a0 of the full range of alveolar macrophage metabolic and immune functions [1].\nClinical Perspective: Symptoms of PAP are nonspecific. 50\u201390% of patients with PAP report progressive dyspnoea. Almost one third of the patients can be asymptomatic, as was the case in this patient [2]. Pulmonary function tests typically reveal restrictive impairment, reduction of the diffusing capacity of the lungs for carbon monoxide (DLCO), or both. The key to diagnosis is broncoscopy and histopathology [1,2]. Broncho-alveolar lavage of the patient demonstrated characteristic opalescent fluid with homogeneous merging high-fluorescent complexes in the alveoli. Pathognomonic morphological manifestation for this disease is the presence of Schiff-positive granular masses in the alveolar lumens.\nImaging Perspective: Chest radiographs typically show bilateral alveolar infiltrates.\u00a0 There are two diagnostic features which combination on high-resolution chest CT (HRCT) is highly indicating for PAP, though not pathognomonic: ground glass opacities and interlobular and intraocular septal thickening. These changes are of either patchy or geographic distribution and may have a slightly lower lobe predilection [3].\nOutcome: There are no international consensus guidelines for treatment of PAP [1]. Depending on the severity of a disease it includes whole-lung lavage on a regular basis, use of recombinant GM-CSF, corticosteroids, rituximab and plasmapheresis. The clinical course of PAP is highly variable, ranging from spontaneous resolution to death (due to progressive respiratory failure or infection). Although with proper treatment, and prevention of complications such as infections, a Japanese cohort study reported a 100% 5-year survival rate, with an infection rate of only 5% [1,4].\nTake Home Message / Teaching Points: PAP is a rare disease. Radiographic features are very variable and non-specific, though HRCT findings allow us to suspect PAP. In most cases they are much more severe than the clinical presentation would suggest.\nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Pulmonary, alveolar, proteinosis, Pulmonary, oedema, Alveolar, haemorrhage, Organising, pneumonia, Acute, respiratory, distress, syndrome, Pneumocystis, pneumonia, Lipoid, pneumonia, Pneumonic, type, adenocarcinoma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-11/figure_1a.jpg?itok=7iZseilo",
            "caption": "Chest radiograph in posteroanterior (a) and lateral (b) views showing alveolar infiltration in lower lobes of both lungs and in the middle lobe of the right lung."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-11/figure_1b.jpg?itok=So55GfL8",
            "caption": "Chest radiograph in posteroanterior (a) and lateral (b) views showing alveolar infiltration in lower lobes of both lungs and in the middle lobe of the right lung."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-11/figure_2a.jpg?itok=o3EgRCG6",
            "caption": "Axial CT scan of the thorax shows ground glass opacities (a) and interlobular and intraocular septal thickening with geographic distribution, predominantly in the lower lobes of both lungs (b,c)."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-11/figure_2b.jpg?itok=Q8I990cC",
            "caption": "Axial CT scan of the thorax shows ground glass opacities (a) and interlobular and intraocular septal thickening with geographic distribution, predominantly in the lower lobes of both lungs (b,c)."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-11/figure_2c.jpg?itok=xJ5EuRPL",
            "caption": "Axial CT scan of the thorax shows ground glass opacities (a) and interlobular and intraocular septal thickening with geographic distribution, predominantly in the lower lobes of both lungs (b,c)."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Respiratory system"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/16568",
    "time": "12.11.2019"
  },
  "16574": {
    "case_id": 16574,
    "title": "Decompression illness: Diving into an uncommon pathology",
    "section": "Chest imaging",
    "age": "42",
    "gender": "male",
    "diagnosis": "Decompression illness",
    "history": "A 42-year-old man with no previous illness, was admitted for persistent cough, dyspnoea and headache several hours after recreational diving with rapid ascent.",
    "image_finding": "The chest CT scan showed diffuse ground-glass attenuation involving the most anterior aspect of the upper lobes, the right middle lobe and the medial segments of the lower lobes. The periphery of the lung parenchyma was not involved. There was no thickening of the interlobular septa or consolidation. No pneumothorax, pneumomediastinum, pleural or pericardial effusion or lymphadenopathy. (Fig. 1)\nThe patient was treated with hyperbaric oxygen therapy. The follow up CT performed two weeks later demonstrated resolution of prior diffuse ground-glass attenuation areas (Fig. 2).",
    "discussion": "Decompression illness is the result of intra-or extravascular bubbles formed due to reduction of environmental pressure. It includes two pathophysiological syndromes: the arterial gas embolism and the decompression sickness [1, 2].\nArterial gas embolism occurs when expanding gas stretches and ruptures alveolar capillaries (pulmonary barotrauma) allowing alveolar gas to enter the arterial circulation [1].\nDecompression sickness (DCS) starts with the formation of extravascular and intravascular bubbles when the sum of the dissolved gas tensions exceeds the local absolute pressure. In diving, this is possible by the increase in the tissue inert gas partial pressure that occurs when the gas is respired at high pressure. Supersaturation arises during decompression if the rate of ambient pressure reduction exceeds the rate of inert gas washout [1]. Both the arterial gas embolism and the decompression sickness, are precipitated by rapid ascent, related to the change from a high pressure state to a low pressure state [1, 2, 3].\nArterial gas embolism is presented as dry cough, retrosternal pain and dyspnoea (due to pulmonary barotrauma), and can also present as altered consciousness and confusion (related to cerebral air embolism) [1, 3]. On the other hand, DCS is divided in two types. Type I consists of joint pain and cutaneous presentations. Type II incorporates a myriad of cardiopulmonary and central nervous system manifestations. Symptoms might present with some delay; most cases(90%) will start within the first 3 hours [3]. Pain is the most frequently reported manifestation of DCS, particularly around larger joints, usually at periarticular location [1, 2, 3].\nDue to its uncommon frequency and to the fact that most of the cases are clinically diagnosed, little is known about the radiological aspects of decompression illness. The differential diagnosis includes near-drowning and immersion pulmonary oedema [4, 5].\nPulmonary barotrauma is presented as diffuse ground-glass attenuation areas, while the immersion pulmonary oedema may add pleural effusion and/or interlobular septal thickening [3, 4]. Near-drowning is radiographically indistinguishable from pulmonary oedema from other causes [5].\nThe main treatment of decompression illness includes the administration of 100% oxygen at 1 atmosphere in a hyperbaric chamber, plus supportive care if needed [1, 3].\nTake home messages: due to its specific treatment, although decompression illness is rare, it should be included in the differential diagnosis of diving accidents.\nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Decompression, illness, Near-drowning, Immersion, pulmonary, oedema, Alveolar, haemorrhage",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-11/0016574/16574_1_1.PNG?itok=gUMzsdSl",
            "caption": "Axial CT image showing diffuse ground-glass attenuation areas in the anterior segments of upper lobes, right middle lobe and medial segments of inferior lobes."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-11/0016574/16574_1_2.JPG?itok=IMV258x0",
            "caption": "Coronal view demonstrating diffuse ground-glass attenuation areas in the anterior segments of upper lobes and right middle lobe."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-11/0016574/16574_2_1.PNG?itok=dxcPw6UI",
            "caption": "Follow-up axial CT image showing resolution of the diffuse ground-glass opacities."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-11/0016574/16574_2_2.PNG?itok=gElixkGo",
            "caption": "Coronal view demonstrating resolution of the diffuse ground-glass attenuation areas."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Professional issues"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/16574",
    "time": "13.11.2019"
  },
  "16582": {
    "case_id": 16582,
    "title": "sinophilic granulomatosis with polyangiitis",
    "section": "Chest imaging",
    "age": "26",
    "gender": "male",
    "diagnosis": "Eosinophilic granulomatosis with polyangiitis (EGPA)",
    "history": "A 26-year-old male patient was evaluated with a recent onset of low-grade fever, cough and shortness of breath.The man is a baker, nonsmoker, allergic to some drugs and common allergens.\nHe suffered from bronchial asthma, eczema at hands and feet and nasal polyposis.\nHis past medical history showed a previous episode of pericarditis.",
    "image_finding": "It was performed a chest X-ray that reported subtle peripheral opacities with apical predominance.\nThe blood cell count showed leukocytosis and eosinophilia and it was recommended therapy with oral antibiotic and aerosol with corticosteroids and b2 agonist for one week. It gave no symptom resolution.\nTherefore, due to the persistence of the symptoms with the patient, a chest CT was performed. It revealed bilateral ground-glass consolidations mainly subpleural and located prevalently in the upper lobes and several enlarged mediastinal lymph nodes with short-axis diameter <10mm [1].",
    "discussion": "Our patient underwent further tests: the bronchoalveolar lavage (BAL) showed high white blood cell count in the fluid with 30% of eosinophils (normal value <1%) and 11% of lymphocytes (normal value <10%).\nMoreover, a punch biopsy\u00a0 was performed of a dyschromic area within the known eczema. The histological report described features consistent with eosinophilic granulomatosis with polyangiitis (EGPA), also known as Churg-Strauss syndrome.\n\u00a0\nEosinophilic lung diseases are a heterogeneous group of diseases that are characterised by excessive infiltration of eosinophils within the lung interstitium and alveoli and may be idiopathic, secondary or related to vasculitis such as EGPA.\nThey share overlapping features and the diagnosis is based on pulmonary opacities on a chest radiograph or chest CT and peripheral eosinophilia. Tissue eosinophilia at transbronchial lung biopsy and increased eosinophils in bronchoalveolar lavage (BAL) fluid (normal eosinophils\u2019 count is less than 1%) are indicated if the clinical, radiological and laboratory findings are uncharacteristic. In particular, a biopsy is often performed to try to find eosinophils, eosinophilic granulomas, and vasculitis in order to rule out the idiopathic form.\nEGPA is a small vessel systemic vasculitis that may affect various organs. The lung is the most commonly involved organ, followed by the skin. Approximately 50% of the patient with EGPA has a past history of asthma. They may also suffer from paranasal sinus abnormalities, diarrhoea, skin purpura and joint pain. Most severe symptoms may regard central nervous system (neuropathy), kidneys and heart.\nThe American College of Rheumatology stated that the presence of four or more of these six criteria is required to diagnose EGPA: asthma, eosinophilia > 10% on differential white blood cell count, mononeuropathy or polyneuropathy, non-fixed pulmonary infiltrates on imaging, paranasal sinus abnormality and biopsy containing a blood vessel with extravascular eosinophils. [2]\nEffectively the reported case showed 5/6 signs (chronic asthma, nasal polyps, opacities on CT, eosinophilia and significant punch biopsy) plus cutaneous purpura and a past pericarditis episode.\nEGPA has a low mortality rate, but patients with extra-lung involvement require additional immunosuppression. Cardiac involvement in EGPA can occur in about 60% of the cases and it is the leading cause of mortality in EGPA.\u00a0 [3,4]\nThe typical chest radiographic findings in EGPA are peripheral consolidations involving mainly the upper lobes bilaterally and, eventually, a small pleural perfusion. Sometimes it appears as bilateral non-segmental consolidation or reticulonodular opacities.\nThere is a considerable overlap of CT findings among the various eosinophilic lung diseases. The most common CT findings in EGPA include patchy ground-glass opacity or multiple areas of consolidations with no segmental distribution. The distribution is unilateral or bilateral, patchy and peripheral or subpleural, often predominant in the upper or central lung regions. In our case, we recognised a bilateral patchy ground-glass pattern with upper lobe predominance.\nLess common features include centrilobular nodules and smooth septal thickening (crazy paving)\u00a0 but they aren\u2019t present in our CT.\nLung volume is preserved. Less common findings include pericardic/pleural effusion and enlarged mediastinal lymph nodes. [5,6]\nEGPA may simulate CEP. The latter has more homogeneous peripheral airspace consolidations, while the ground-glass opacity in CEP are less frequent and generally appear only in later stage diseases. Lastly CEP usually affects middle-aged people and has a female predilection [7].\nThe case we discussed illustrates typical EGPA-features: clinically we observe the anamnesis showing chronic asthma, nasal polyposis, past pericarditis and onset respiratory symptoms. Imaging illustrates a ground-glass pattern attributable to eosinophilic pneumonia and, in addition to this, laboratory (peripheric eosinophilia, BAL and biopsy) confirms the diagnosis.\nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Eosinophilic, granulomatosis, with, polyangiitis, (EGPA), Chronic, eosinophilic, pneumonia, Sarcoid, granulomatosis;, Wegener, granulomatosis, Slowly, resolving, bacterial, infection, Drug, toxicity, (amiodarone-induced, lung, disease), Organising, pneumonia",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-11/0016582/16582_1_1.jpg?itok=6gzbH7V1",
            "caption": "PA and lateral chest radiographs report subtle peripheral opacities with apical predominance"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-11/0016582/16582_1_2.jpg?itok=faln0CUQ",
            "caption": "PA and lateral chest radiographs report subtle peripheral opacities with apical predominance"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-11/0016582/16582_2_1.jpg?itok=nLTZvMa-",
            "caption": "Axial CT images in lung window setting show peripherical ground-glass pattern with an upper lobe predominance"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-11/0016582/16582_2_2.jpg?itok=Tdu4N5rW",
            "caption": "Axial CT images in lung window setting show peripherical ground-glass pattern with an upper lobe predominance"
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-11/0016582/16582_2_3.jpg?itok=7j1bEBU8",
            "caption": "Axial CT images in lung window setting show peripherical ground-glass pattern with an upper lobe predominance"
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-11/0016582/16582_2_4.jpg?itok=mUberikK",
            "caption": "Axial CT images in lung window setting show peripherical ground-glass pattern with an upper lobe predominance"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-11/0016582/16582_3_1.jpg?itok=X2GsgFuo",
            "caption": "Axial CT image in lung window setting shows enlarged mediastinal lymph nodes"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-11/0016582/16582_4_1.jpg?itok=04M0eAhE",
            "caption": "Coronal CT images in lung window setting show diffuse and peripherical ground glass pattern"
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-11/0016582/16582_4_2.jpg?itok=5dLf-1VQ",
            "caption": "Coronal CT images in lung window setting show diffuse and peripherical ground glass pattern"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Respiratory system"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/16582",
    "time": "20.11.2019"
  },
  "16583": {
    "case_id": 16583,
    "title": "Cryptogenic organising pneumonia mimicking lung malignancy",
    "section": "Chest imaging",
    "age": "55",
    "gender": "female",
    "diagnosis": "Cryptogenic organising pneumonia",
    "history": "A 55-year-old female patient with a 60 pack-per-year smoking history, presented with a two-month history of dry cough and pleuritic chest pain. She denied febrile episodes, haemoptysis, dyspnoea or weight loss. Her sister had been diagnosed with lung cancer. Physical examination was unremarkable and blood showed elevated inflammatory markers.",
    "image_finding": "Chest X-ray demonstrated a soft tissue density focal nodule with an irregular outline in the left middle lung zone (Fig. 1). This was a new finding, not present on CXR taken two years prior. Due to the presence of a raised D-dimer, a CT pulmonary angiogram was performed, which excluded pulmonary embolism. It however demonstrated a 2cmx2cm spiculated nodule in the apical segment of the left lower lung lobe (Fig. 2a) corresponding to the lesion seen on CXR. Another 1.7cmx1.6cm nodule was seen in the medial basal segment of left lower lung lobe (Fig. 2b), together with a 2.3cmx1.3cm nodule at the base of the right lower lobe (Fig. 2c). CT lung biopsy was requested on the basis that these lesions could represent malignancy. Differential diagnosis of cryptogenic organising pneumonia was suggested at multidisciplinary discussion, given the multifocality of the disease process on CT.",
    "discussion": "Background: Cryptogenic organising pneumonia (COP) is an idiopathic type of organising pneumonia resulting from an inflammatory process affecting both alveoli and distal bronchioles, with the primary area of damage being in the alveolar wall. This condition was formerly referred to as bronchiolitis obliterans organising pneumonia. However, due to the fact that bronchiolitis obliterans is a commonly absent finding, this term is no longer in use. The diagnosis of COP requires the exclusion of secondary causes, such as connective tissue disease, drug toxicity, infection, malignancy and graft-versus-host disease. [1,2]\nClinical perspective: COP predominantly occurs in the 5th to 6th decade of life, with non-smokers being affected twice as often as smokers. [2] Clinical manifestations are non-specific.\nImaging perspective: Imaging features vary considerably. Typical findings consist of confluent bilateral areas of peripheral parenchymal consolidation with subpleural sparing. Consolidation is accompanied by traction bronchiectasis and parenchymal distortion and is often migratory. Ground glass opacification (GGO) is also seen and is usually bilateral and random in distribution. GGO may also manifest as the classic reverse halo- or \u2018atoll\u2019-sign; an area of central ground glass opacification with a surrounding crescentic or complete ring of denser perilobular consolidation.\u00a0 Less commonly, COP may manifest as single or multiple pulmonary nodules that may mimic malignancy.\u00a0 COP nodules are mostly bilateral, often have irregular margins and may even manifest cavitation. Another described manifestation is the perilobular pattern, where thick, ill-defined linear opacities with a polygonal or arcade appearance are seen around the interlobular septa. [3,4]\nOutcome: Whether a diagnosis of COP is to be accepted without histology is subject to debate; however the diagnosis of COP without a biopsy can rarely be justified. [5] Treatment in mild cases may be conservative with monitoring, as some cases are self-resolving. However, when symptoms are persistent, as in most cases, treatment with corticosteroids is indicated. COP responds rapidly to steroid treatment but can recur, especially in older women. [6,7] In our case, due to clinical suspicion of COP, the patient was started on prednisolone, following CT-guided biopsy. Histology confirmed this as the diagnosis. At outpatient review, the patient reported marked improvement in her symptoms. Follow-up CXR performed 8 weeks later demonstrated resolution of the left-middle lung zone nodule (Fig. 3).\nTake home message/teaching points: This case serves to highlight how clinical, biochemical and imaging features of COP are rather non-specific when considered separately. However, when combined, the diagnosis becomes more evident. Multidisciplinary discussion is therefore paramount and image-guided biopsy should clinch the diagnosis.\nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Cryptogenic, organising, pneumonia, Adenocarcinoma, Eosinophilic, pneumonia, Pulmonary, lymphoma, Pulmonary, vasculitis, Sarcoidosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-11/0016583/16583_1_1.jpg?itok=7bg8L0LJ",
            "caption": "Chest radiograph demonstrating a focal pulmonary nodule in the left-middle lung zone, initially   assumed to represent a primary lung cancer."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-11/0016583/16583_2_1.jpg?itok=CJ_IuWTf",
            "caption": "CT pulmonary angiogram demonstrating a 2cmx2cm solid pulmonary nodule with spiculated outline in the apical segment of the left-lower lobe of lung."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-11/0016583/16583_2_2.jpg?itok=znL6Ml3u",
            "caption": "CT showed a further 1.7cmx1.6cm solid pulmonary nodule in the left-lower lung lobe which was occult on CXR."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-11/0016583/16583_2_3.jpg?itok=pKTUnhec",
            "caption": "An additional 2.3cmx1.3cm triangular shaped solid nodule was noted in the periphery of right-lower lobe of lung, abutting the pleura."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2019-11/0016583/16583_3_1.jpg?itok=BMDGuOg3",
            "caption": "CXR taken after 8 weeks of steroid treatment, demonstrating complete resolution of the left-midzone nodule."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/16583",
    "time": "27.11.2019"
  },
  "16608": {
    "case_id": 16608,
    "title": "Computed tomography findings of rare isolated giant pulmonary arteriovenous malformation",
    "section": "Chest imaging",
    "age": "24",
    "gender": "male",
    "diagnosis": "Sporadic pulmonary arteriovenous malformation",
    "history": "A 24-year-old male patient admitted to chest diseases clinic with dyspnoea, which had been intermittent for about a month. There was no history of fever, chest pain, or recent chest trauma or thoracic surgery. He did not experience similar symptoms in the past. Physical examination and laboratory study results were normal.",
    "image_finding": "Chest X-ray showed a tubular lesion in the right middle zone. Contrast-enhanced multidetector chest CT was performed for further characterisation of the lesion.. Axial (Figs. 1, 2), coronal multiplanar reconstruction (MPR) (Fig. 3), axial maximum intensity projection (MIP) (Fig. 4) and three-dimensional volume rendered (VRT) (Fig. 5) CT images were taken. They showed tortuous tubular homogeneously hyperdense giant mass-measured 90x37 mm, extending from the right pulmonary hilum to peripheral part of the middle lobe. It was compatible with pulmonary arteriovenous malformation that drained to the right superior pulmonary vein fed by the right interlobar artery. Diameter of feeder artery and drainage vein was 12 mm. Patient underwent surgery and diagnosis has been proven.",
    "discussion": "Pulmonary arteriovenous malformation\u00a0(PAVM) is a rare most commonly congenital malformation with abnormal communication between pulmonary arteries and veins [1]. It is generally considered direct highflow, low-resistance fistulous connections between the pulmonary arteries and veins. It was first described at autopsy in 1897 [2]. Autosomal dominant hereditary haemorrhagic telangiectasia (HHT) known as Osler-Weber-Rendu disease that is characterised by epistaxis, mucocutaneous and visceral telangiectasia with a family history is seen more than 60 % of patients with PAVM [3,4,5]. PAVM is rarely seen isolated without HHT, such as in our case. PAVMs are usually asymptomatic, and the majority is detected incidentally. The most common initial symptom is haemoptysis. Cerebrovascular accident, transient ischaemic attack, and brain abscesses may occur in these patients. [3,4,6]. Also, convulsions, haemothorax, haemoptysis, and pneumothorax may be seen [3,7,8,9]. X-ray findings may be nonspecific. CT is the non-invasive imaging modality for diagnosis. Non-contrasted CT images show a homogeneous, well-circumscribed nodule up to several centimeters in diameter or the presence of a serpiginous mass connected with blood vessels [3,10]. Occasionally associated phleboliths may be seen as calcifications. Contrast filling of feeding artery, the aneurysmal part, and the draining vein is seen on contrast-enhanced images. Sensitivity and specificity of PAVM detection in contrast-enhanced 16-detector CT has been reported at 83% and 78%, which compares favourably with digital subtraction pulmonary angiography of 70 and 100% [3,11]. Three-dimensional (3D) CT images are also useful for diagnosis. In a study of 33 consecutive patients with 37 PAVM, non-contrasted 3D helical CT scanning allowed full analysis of 76% of PAVM, compared with only 32% with unilateral pulmonary angiography. Unilateral angiography was often limited because of superimposed vessels. Concomitant analysis of 3D images with cross-sectional images improved accuracy to 95%. Hyperselective pulmonary angiography allowed analysis of 100% of PAVM, but required additional contrast agent and radiation [3,12]. Treatment options include transcatheter coil embolisation and surgery. Teaching point: PAVM is a rare clinical entity that can cause bleeding, pneumothorax and long term chronic hypoic problems due to right-left shunt. It is generally seen with HHT. It\u2019s rarely seen as sporadic. CT is non-invasive imaging modality for this entity. Written informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Sporadic, pulmonary, arteriovenous, malformation, Abnormal, systemic, vessel, Bronchoceles, Highly, vascular, parenchymal, mass, Pulmonary, varix, Retroperitoneal, varices",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-02/0016608/16608_1_1.jpg?itok=_a_k0Y5t",
            "caption": "Axial image with mediastinal window of chest CT shows tortuous tubular mass extending from the right pulmonary hilum to peripheral part of the middle lobe compatible with arteriovenous malformation that drained to the right superior pulmonary vein (thin arrows) fed by the right interlobar artery (thick arrows)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-02/0016608/16608_2_1.jpg?itok=TSX39A9H",
            "caption": "Axial CT image with parenchymal window of Fig. 1 shows tortuous tubular mass extending from the right pulmonary hilum to peripheral part of the middle lobe compatible with arteriovenous malformation that drained to the right superior pulmonary vein (thin arrows) fed by the right interlobar artery (thick arrows)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-02/0016608/16608_3_1.jpg?itok=HD8bEj7-",
            "caption": "Coronal MPR CT image shows tortuous tubular mass extending from the right pulmonary hilum to peripheral part of the middle lobe compatible with arteriovenous malformation (arrows) that drained to the right superior pulmonary vein fed by the right interlobar artery."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-02/0016608/16608_4_1.jpg?itok=LN--bZ7g",
            "caption": "Axial MIP CT image shows tortuous tubular mass extending from the right pulmonary hilum to peripheral part of the middle lobe compatible with arteriovenous malformation that drained to the right superior pulmonary vein (thin arrows) fed by the right interlobar artery (thick arrows)."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-02/0016608/16608_5_1.jpg?itok=ZBTC0khj",
            "caption": "3D VRT image shows tortuous tubular mass extending from the right pulmonary hilum to peripheral part of the middle lobe compatible with arteriovenous malformation (arrows) that drained to the right superior pulmonary vein fed by the right interlobar artery."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax",
      "Vascular"
    ],
    "imaging_technique": [
      "CT",
      "CT-Angiography"
    ],
    "link": "https://www.eurorad.org/case/16608",
    "time": "18.02.2020"
  },
  "16630": {
    "case_id": 16630,
    "title": "volution of CT Images in a patient recovered from COVID-2019",
    "section": "Chest imaging",
    "age": "22",
    "gender": "male",
    "diagnosis": "Coronavirus disease-19 (COVID-19)",
    "history": "A male patient, 22-years-old, fever (38.5C) and sore throat for 3 days. The patient had traveled within China in January 2020. Laboratory examination results were normal at admission.",
    "image_finding": "An axial chest CT examination obtained on day three after the onset of symptoms was normal (Fig. 1). Chest CT obtained on day seven after the onset of symptoms shows multiple patchy ground-glass opacities in both lower lobes, as well as consolidation (Fig. 2). CT examination obtained on day nine shows improvement in the extent of ground-glass opacities and consolidation, with subpleural curvilinear lines (Fig. 3). CT examinations obtained on day 14 and 18 show almost healing of the consolidations and ground-glass opacities (Fig. 4, 5). CT scan obtained on day 22 shows completely healing of the consolidations and ground-glass opacities (Fig. 6).",
    "discussion": "Background: \nCOVID-19 is a new infectious disease that currently occurs mainly in China, with a small number of cases in other countries [1]. Statistical analysis on 483 patients reveals that the estimated average, mode and median incubation periods are 7.4, 4 and 7 days; Incubation periods of 92% patients were no more than 14 days [2]. While Char Leung thought the duration of quarantine should be extended to at least 3 weeks [3]. The Chinese government proposes that all people be isolated at home, and the rise in the number of infections is significantly reduced. However, there are news reports that a large increase in the number of infections caused by gatherings in South Korea has shown that prevention and control of the disease is very important. The early symptoms of the patient were fever, dry cough and fatigue [4]. Laboratory tests show that the white blood cell count is not high or decreased, and there may be a decrease in lymphocyte count. Epidemiological history and symptoms are of great help in the diagnosis of COVID-19. 2019-nCOV mainly invades lower respiratory tract infections, and CT image changes are highly characteristic [5, 6]. In this report, we present the chest CT abnormalities found on consecutive examinations obtained in the same patient.\nClinical Perspective:\nCurrent treatments have shown that the antiviral treatment of COVID-19 combined with traditional Chinese medicine decoction is effective.\nOutcome: \nInitially laboratory studies on January 23 showed normal white blood cell count and lymphocyte cell count and the chest CT examination obtained on day three after onset of the symptoms shows normal (Fig. 1). In light of the clinical presentation, the patient was diagnosed with suspected novel coronavirus pneumonia. During hospitalisation, the laboratory studies showed lymphopenia. Several additional laboratory tests were abnormal, including C-reactive protein (41.6 mg/L; normal range, 0\u201310 mg/L), serum amyloid A protein (146.3 mg/L; normal range,0-10mg/L); serum interleukin-6 (11.2pg/ml; normal range 0.373-0.463ng/L); lymphocyte subgroups: CD4+T-lymphopenia (149/\u03bcl; normal range 450-1440/\u03bcl), CD8+T-lymphopenia (132/\u03bcl; normal range 320-1250/\u03bcl). CT examination obtained on day seven after the onset of symptoms shows multiple patchy ground-glass opacities and consolidation in both lower lobes. CT examination obtained on day nine shows decreased ground-glass opacities and consolidation, with subpleural curvilinear lines. CT examinations obtained on day 14 and 18 show almost healing of the consolidations and ground-glass opacities. On day 22 the CT images are normal.\nThe patient was treated with antiviral drugs ((Celiba) lopinavir / ritonavir), Chinese medicine decoction and nasal cannula oxygen (concentration: 30%). The patient was discharged on day 24 after onset of the symptoms. \nEssentials for radiologists:\nThe CT images of the novel coronavirus pneumonia are characterised by peripheral ground-glass opacities and consolidation. However, this manifestation is not specific; COVID-19 infection is a diagnosis of exclusion until a specific lab test is obtained.\nTake Home Message:\nCT examination plays an important role in displaying the occurrence, development, and healing of the novel viral infection in the lungs of the COVID-19 patient. \nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Coronavirus, disease-19, (COVID-19), Upper, respiratory, tract, infection, Bacterial, pneumonia, Hypersensitivity, pneumonitis, (HSP)",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03/0016630/16630_1_1.jpg?itok=f2fSA976",
            "caption": "Axial chest CT examination obtained on day three after the onset of symptoms is normal."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03/0016630/16630_2_1.jpg?itok=yHDfs6Cx",
            "caption": "Note progression of disease on day seven after the onset of symptoms, with multiple patch ground-glass opacities (black arrows) in bilateral lower lobes, as well as consolidation (white arrows)."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03/0016630/16630_2_2.jpg?itok=auG4JfYg",
            "caption": "Note progression of disease on day seven after the onset of symptoms, with multiple patch ground-glass opacities (black arrows) in bilateral lower lobes, as well as consolidation (white arrows)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03/0016630/16630_3_1.jpg?itok=PRuY_ELI",
            "caption": "CT examination obtained on day nine shows improvement in the extent of ground-glass opacities and consolidation (black arrow), with subpleural curvilinear lines (white arrow)."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03/0016630/16630_4_1.jpg?itok=gcD7oMFP",
            "caption": "CT examination obtained on day 14 shows almost healing of the consolidations and ground-glass opacities (white arrows)."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03/0016630/16630_5_1.jpg?itok=H1spcajn",
            "caption": "CT examination obtained on day 18 shows that the consolidations and ground-glass opacities are almost healed."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03/0016630/16630_6_1.jpg?itok=YoERqC6S",
            "caption": "CT examination obtained on day 22 shows healing of the consolidations and ground-glass opacities."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Thorax"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/16630",
    "time": "04.03.2020"
  },
  "16631": {
    "case_id": 16631,
    "title": "COVID-19 patient with initially negative RT-PCR",
    "section": "Chest imaging",
    "age": "39",
    "gender": "female",
    "diagnosis": "Coronavirus Disease-19 (COVID-19)",
    "history": "A female patient, 39-years-old, fever (38.1\u2103) and dry cough for seven days. A chest CT obtained two days after the onset of the symptoms shows nodular ground-glass opacity and consolidation (white arrows) scattered in the lower lobe of the left lung (Fig. 1a). Laboratory studies showed leukopenia (white blood cell count, 2.57\u00d7109/L, normal range 4.0\u00d7109-10.0\u00d7109/L) and lymphokine IL-6 level was increased (25.7 pg/ml, normal range 0.1-2.9 pg/ml). Several additional laboratory tests were abnormal, including C-reactive protein (CRP, 7.9 mg/L; normal range <5.0 mg/L), D-dimer concentration (0.71mg/L, normal range <0.5mg/L) and Serum Amyloid A (SSA) concentration (84.2mg/L, normal range <10.0mg/L).",
    "image_finding": "Figs. 1a-1d CT shows dynamic changes on unenhanced CT of patient on day two, nine, 11 and 17 after the onset of symptoms, separately. Fig. 1a shows nodular ground-glass opacity and consolidation (white arrows) scattered in the lower lobe of the left lung. Fig. 1b shows consolidation of right lower lobe and healing of the consolidations and ground-glass opacity (white arrow). Figs. 1c and 1d CT show that lesions almost disappeared (white arrow).\nFollow-up and outcome\nThe patient was admitted to hospital on January 24, 2020 and the temperature was normal after admission. The RT-PCR of the patient\u2019s sputum for the SARS-COV-2 nucleic acid on January 25 was negative while positive on January 27. Laboratory studies on January 29 showed leukopenia (2.5\u00d7109/L), normal lymphocyte cell count (1.44\u00d7109/L) and normal CRP. Several additional laboratory tests were abnormal, including albumin reduction (ALB, 36.9g/L, normal range 60-80 g/L), pre-albumin reduction (PALB, 13.7mg/dl, normal range 28-36 mg/dl), retinol binding protein reduction (RBP, 21.9mg/L, normal range 26.7-57.9mg/L), lactic dehydrogenase increased (LDH, 295U/L, normal range \u2264252U/L), hypophosphataemia (0.68mmol/L, normal range \u22650.8mmol/L), lymphokine IL-6 level was increased (9.9 pg/ml). The RT-PCR of the patient\u2019s sputum for the SARS-COV-2 nucleic acid on January 29 and February 1 were negative while positive on February 2 (Fig. 2). CT follow-ups show healing of the consolidations and ground-glass opacities on January 26, , February 3 and February 8 after the onset of the symptoms (Figs. 1b-1d). Laboratory studies on February 13 showed normal white blood cell count (5.3\u00d7109/L), lymphocyte cell count (1.44\u00d7109/L), CRP (0mg/L) and IL-6 (2.3pg/ml). The patient was treated with antiviral drugs ((Celiba) lopinavir / ritonavir, 500mg peros bid, January 28, from 2020 to February 2, 2020), traditional Chinese medicine decoction (1 dose peros bid, from February 6 to February 21) and oxygen therapy (inhale oxygen through a nasal cannula supportive care, oxygen concentration: 30%, from January 24 to February 21). No adverse reactions were found during treatment. After treatment, the patient's respiratory symptoms improved significantly, and the chest CT inflammation was significantly reduced. The RT-PCR of the patient\u2019s sputum for the SARS-COV-2 nucleic acid on February 13, February 18 and February 20 were negative, which met the discharge standard.",
    "discussion": "Background:\nCOVID-19 is a new type of infectious disease that mainly affects the lungs. More than 70,000 patients in China have been infected with SARS-CoV-2 (formerly called 2019-nCOV) by March 3, 2020 [1-3]. Real-time fluorescence polymerase chain reaction (RT-PCR) of the patient\u2019s sputum positive for the SARS-CoV-2 nucleic acid is the basis of novel coronavirus pneumonia (NCP) diagnosis [4]. A chest computed tomography (CT) scan is the main examination for lung lesions, playing a vital role in the clinical diagnosis, observation of curative effect, and prognostic evaluation of this disease.\nClinical Perspective:\nThe isolation and confirmation of COVID-19 pathogens is critical to the clinical diagnosis, treatment and prevention of the disease. Sometimes, a patient undergoing unenhanced chest CT may show ground-glass opacities scattered in the subpleural area of the lungs at an early time when the RT-PCR of the patient's sputum for SARS-COV-2 nucleic acid is still negative.\nEssentials for radiologists:\n1.\u00a0 Novel coronavirus pneumonia at early stage (1-5 days) is characterised by ground-glass opacity and consolidation in the basal and peripheral of bilateral lungs.\n2.\u00a0 As the disease progresses, crazy paving and consolidation become the dominant CT findings, peaking around 9\u201313 days followed by slow clearing at approximately 1 month and beyond [5].\n3.\u00a0 Pleural effusions and mediastinal lymphadenopathy are rare in COVID-19 patients.\n4. The radiologist should preferably know that the disease requires differential diagnosis with lobular pneumonia, idiopathic pulmonary fibrosis (IPF) and organising pneumonia. Lobular pneumonia manifests as patchy consolidation with poorly defined airspace opacities, usually involving several lobes. Laboratory studies will find leukocytosis and neutropenia. IPF is the most common idiopathic interstitial pneumonia and has the second-worse prognosis of all. Clinical symptoms of IPF include dry cough and dyspnoea. IPF usually affects patients >50 years old. Laboratory studies are normal. Organising pneumonia is a nonspecific response to injury characterised by granulation polyps which fill the distal airways, producing peripheral chronic rounded and nodular consolidation.\nTake Home Message:\nChest CT plays an important role in the diagnosis and follow-up of this new type of viral pneumonia, first by supporting early diagnosis and patient isolation when RT-PCR may not yet be positive.\nWritten patient consent for this case was waived by the Editorial Board. Patient data may have been modified to ensure patient anonymity.",
    "differential_diagnosis": "Coronavirus, Disease-19, (COVID-19), Lobular, pneumonia, Idiopathic, pulmonary, fibrosis, (IPF), Organising, pneumonia",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03/0016631/16631_1_1.jpg?itok=W7XSkMCs",
            "caption": "Shows nodular ground-glass opacity and consolidation (white arrows) scattered in the lower lobe of the left lung on day two after the onset of symptoms."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03/0016631/16631_1_2.jpg?itok=sQCugp6Z",
            "caption": "Shows consolidation of right lower lobe and healing of the consolidations and ground-glass opacity (white arrow) on day nine after the onset of symptoms."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03/0016631/16631_1_3.jpg?itok=AModnJCV",
            "caption": "CT shows that lesions progressively disappeared (white arrow) on day 11 and day 17 after the onset of symptoms, separately."
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03/0016631/16631_1_4.jpg?itok=mkxOKN-4",
            "caption": "CT shows that lesions progressively disappeared (white arrow) on day 11 and day 17 after the onset of symptoms, separately."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03/0016631/16631_2_1.png?itok=PRaME1t_",
            "caption": "The timeline of patient\u2019s CT examinations and RT-PCRs for the SARS-COV-2 nucleic acid. (+): positive ; (-): positive ; \u2191: progress\uff1b\u2193: decrease or disappearance. The number in the circle (d*) represents the days after the onset of symptoms."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/16631",
    "time": "04.03.2020"
  },
  "16637": {
    "case_id": 16637,
    "title": "A patient with a clinically suspected asthma that turned out to be a bronchial atresi",
    "section": "Chest imaging",
    "age": "44",
    "gender": "female",
    "diagnosis": "Bronchial atresia",
    "history": "A 44-years-old female patient with a clinically suspected asthma and smoking habits underwent a clinical examination due to periods of mild shortness of breath, a chest radiograph was requested followed by a contrast enhanced chest-CT.",
    "image_finding": "The radiographic study showed a branching tubular opacity extending from the left hilum into the left upper lobe, a hyperlucency of the right upper lobe was also noted (Fig. 1).\n\ufeffContrast-enhanced CT of the chest was performed to further characterise the previously described radiographic findings.\nA \ufeffnon-enhancing tubular mass (finger-in-glove appearance) was seen extending cephalad from the left hilum, with surrounding \ufeffhypoattenuating pulmonary parenchyma of the apicoposterior segment of the left upper lobe (Figs. 2 and 3). No other pulmonary abnormalities were noted.",
    "discussion": "Bronchial atresia is a rare congenital abnormality of unknown cause resulting from focal interruption of a lobar, segmental or subsegmental bronchus [1].\n\ufeffThe apicoposterior segmental bronchus of the left upper lobe is the most commonly involved, being also the affected segment in this clinical case [2].\nThe proximal blind-ending bronchus is usually associated with mucus impaction (mucocele) distal to the atresia point, where the adjacent lung parenchyma may appear normal or hyperinflated. These findings are responsible for the \ufeffhilar mass-like shadow appearance on radiographs [2,4].\nOn chest radiographs and CTs, an hyperlucent / hypoattenuating lung surrounding the mucocele represents a combination of air trapping and focal parenchymal oligemia, which is secondary to a combination of intrapulmonary vascular compression and hypoxic vasoconstriction [1,4].\nPatients are usually asymptomatic, but mild symptoms may be present such as recurrent pulmonary infections, mild wheezing or dyspnoea [1].\nImaging characteristics are the key for the diagnosis with CT being one of the most sensitive methods.\nThe classic radiographic appearance is a branching tubular or nodular hypotransparent area that extends from the hilum with surrounding hyperlucent lung parenchyma. \nDifferential diagnoses include vascular anomalies or other abnormalities with mucus impaction, such as bronchial cyst, pulmonary embolism, bronchiectasis or intralobar sequestration. On contrast-enhanced CT, it is possible to rule out vascularity / enhancement within the branching hilar lesion helping to exclude a vascular or tumoral cause for the findings. Intralobar sequestration and bronchial cysts are rarely associated with hyperlucency surrounding the mass. In doubtful cases acquired proximal bronchial obstruction by tumour, foreign body or inflammatory stricture can be excluded by bronchoscopy [3].\nNowadays, bronchial atresia is considered a benign pathology that usually doesn\u2019t require treatment (it is reserved for patients with complications such as infection). To prevent complications, surgical resection used to be performed in most patients. However, this subject remains controversial [1,5].\nIn conclusion, \ufeffbronchial atresia is a rare benign congenital disease resulting from focal interruption of a lobar, segmental or subsegmental bronchus. Correct diagnosis is usually possible with contrast-enhanced chest CT. As bronchial atresia is a benign disease usually without other serious implications, most cases will not necessitate surgery. Thus, a correct diagnosis becomes particularly important [3].\nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Bronchial, atresia, Endobronchial, obstruction,, e.g., from, neoplasms, or, foreign, body, aspiration, Arteriovenous, malformation, Intralobar, sequestration, Lobar, emphysema, Bronchial, cyst",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03/0016637/16637_1_1.jpg?itok=z0tXx5aJ",
            "caption": "Radiograph shows a branching tubular area of increased opacity (arrow head), extending from the left hilum into the left upper lobe, a peripheral upper lobe hyperlucency is also noted (arrows)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03/0016637/16637_2_1.jpg?itok=f-0gaJXP",
            "caption": "Axial soft-tissue window (a,b) and lung window (c,d) contrast-enhanced CT demonstrating a non-enhancing lesion (arrow), consistent with mucus impaction of the apicoposterior left-upper-lobe bronchus (mucocele), and a decreased attenuation of the pulmonary parenchyma of the of the apicoposterior segment of the left upper lobe indicating associated air trapping (arrow head)."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03/0016637/16637_2_2.jpg?itok=8TpBfdZo",
            "caption": "Axial soft-tissue window (a,b) and lung window (c,d) contrast-enhanced CT demonstrating a non-enhancing lesion (arrow), consistent with mucus impaction of the apicoposterior left-upper-lobe bronchus (mucocele), and a decreased attenuation of the pulmonary parenchyma of the of the apicoposterior segment of the left upper lobe indicating associated air trapping (arrow head)."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03/0016637/16637_2_3.jpg?itok=d6hVuPcn",
            "caption": "Axial soft-tissue window (a,b) and lung window (c,d) contrast-enhanced CT demonstrating a non-enhancing lesion (arrow), consistent with mucus impaction of the apicoposterior left-upper-lobe bronchus (mucocele), and a decreased attenuation of the pulmonary parenchyma of the of the apicoposterior segment of the left upper lobe indicating associated air trapping (arrow head)."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03/0016637/16637_2_4.jpg?itok=GTwf4tOM",
            "caption": "Axial soft-tissue window (a,b) and lung window (c,d) contrast-enhanced CT demonstrating a non-enhancing lesion (arrow), consistent with mucus impaction of the apicoposterior left-upper-lobe bronchus (mucocele), and a decreased attenuation of the pulmonary parenchyma of the of the apicoposterior segment of the left upper lobe indicating associated air trapping (arrow head)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03/0016637/16637_3_1.jpg?itok=PYLYOpjW",
            "caption": "Coronal soft-tissue (a) and lung window (b) contrast-enhanced CT demonstrating a non-enhancing lesion (arrow) consistent with mucus impaction of the apicoposterior left-upper-lobe bronchus (mucocele) and a decreased attenuation of the apicoposterior segment of the left upper lobe indicating associated air trapping (arrow head)."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03/0016637/16637_3_2.png?itok=8xYovF9i",
            "caption": "Coronal soft-tissue (a) and lung window (b) contrast-enhanced CT demonstrating a non-enhancing lesion (arrow) consistent with mucus impaction of the apicoposterior left-upper-lobe bronchus (mucocele) and a decreased attenuation of the apicoposterior segment of the left upper lobe indicating associated air trapping (arrow head)."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Respiratory system"
    ],
    "imaging_technique": [
      "CT",
      "Digital radiography"
    ],
    "link": "https://www.eurorad.org/case/16637",
    "time": "05.03.2020"
  },
  "16638": {
    "case_id": 16638,
    "title": "Two typical carcinoid tumours in a patient with diffuse idiopathic pulmonary neuroendocrine cell hyperplasia (DIPNECH)",
    "section": "Chest imaging",
    "age": "59",
    "gender": "female",
    "diagnosis": "Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia (DIPNECH)",
    "history": "A 59-year-old woman presented with a history of dry cough for 20 years, worsening after eating. She denied fever, weight loss or other complaints. \nAmong her relevant antecedents, she reported being a former smoker with 35 pack-years of exposure, having ceased for 9 years. \nPhysical examination showed no abnormalities.",
    "image_finding": "The patient underwent posteroanterior and lateral chest simple radiographs (X-rays) (Figs. 1a and Fig. 1b), which revealed two nodules with soft-tissue radiographic density on pulmonary bases, the left one in the retrocardiac position. \nShe had a history of a severe allergic reaction to iodinated contrast media, and consequently underwent non-contrast-enhanced computed tomography (CT) (Figs. 2a, Fig. 2b and Fig. 2c) that confirmed the presence of two dominant pulmonary nodules, apparently in contact with the pericardium. Multiple bilateral small pulmonary nodules (smaller than 5 mm) were identified in maximum intensity projection (MIP) reconstructions. Pulmonary parenchyma also presented a mosaic attenuation pattern in association with the previously described nodules, which was better demonstrated at minimum intensity projection (MinIP) reconstructions. \nChest magnetic resonance imaging (MRI) (Figs. 3a-c and Fig. 6) was performed to better characterise the nodules and allowed to exclude pericardial invasion, also confirming their suspicious characteristics for neoplasia, such as restriction on DWI and marked enhancement by the paramagnetic agent.",
    "discussion": "Background: Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia (DIPNECH) is a condition characterised by diffuse hyperplasia and distribution of neuroendocrine cell aggregates throughout the respiratory tract (Figs. 4a and Fig. 4b). These cell aggregates present as a histological spectrum: neuroendocrine cell hyperplasia when smaller than 5 mm and do not invade the basement membrane, tumourlets when still smaller than 5 mm, but are associated with invasion of the basement membrane or \u2018carcinoids\u2019 if larger than 5 mm (Fig. 5) [1].\nClinical perspective: DIPNECH usually occurs in women between 50 and 70 years of age, most commonly asymptomatic. However, it can manifest clinically as chronic cough and/or dyspnoea associated with obstructive pulmonary function test, findings that are often erroneously attributed to asthma or COPD [1,2].\nImaging perspective: DIPNECH must be considered a rare differential diagnosis for the lungs\u2019 mosaic attenuation pattern, especially when in association with multiple pulmonary nodules. However, a definitive diagnosis should always be histopathological [1,3]. In the case here described, the patient underwent pulmonary segmentectomies to remove both dominant pulmonary nodules, which confirmed the diagnosis of two carcinoid tumours in association with DIPNECH.\nOutcome: Due to its rarity, so far there are no protocols that define the better conduct or follow-up of these patients with DIPNECH, however, correct diagnosis is essential, since symptomatic patients benefit from the use of specific drugs such as somatostatin analogs and should have periodic imaging follow-up, due to the increased risk of developing carcinoid tumours [2].\nTake home message: Although rare, DIPNECH should be a differential diagnosis for patients with parenchyma\u2019s mosaic attenuation pattern, especially when associated to multiple pulmonary nodules on imaging. With the advancement in quality of imaging methods and an increasing number of exams performed, the radiologist assumes a primary role in the diagnosis, management, and follow-up of patients with DIPNECH.\n\u00a0Written informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Diffuse, idiopathic, pulmonary, neuroendocrine, cell, hyperplasia, (DIPNECH), Small, airway, diseases, Chronic, thromboembolism, Pulmonary, hypertension",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03/0016638/16638_1_1.jpg?itok=p-3odtHY",
            "caption": "Chest x-ray, posteroanterior view showing two pulmonary nodules in lung bases (arrows), one in the middle lobe (silhouette-sign with right-cardiac contour) and another in a retrocardiac position."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03/0016638/16638_1_2.jpg?itok=tPPahXVr",
            "caption": "Chest x-ray, lateral view."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03/0016638/16638_2_1.jpg?itok=XS9rYAOz",
            "caption": "Non-contrast-enhanced axial chest CT, lung window, showing the pulmonary nodules in contact with mediastinum and possibly with the pericardium."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03/0016638/16638_2_2.jpg?itok=sj3XY9nS",
            "caption": "Coronal MIP reconstruction from chest CT demonstrating the presence of multiple small pulmonary nodules."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03/0016638/16638_2_3.jpg?itok=R-KpMihP",
            "caption": "Coronal MinIP reconstruction from chest CT demonstrating the diffuse pulmonary mosaic attenuation pattern."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03/0016638/16638_3_1.jpg?itok=eplR5aIX",
            "caption": "Axial T2w chest MR image showing dominant nodules with increased signal."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03/0016638/16638_3_2.jpg?itok=Lb301IHl",
            "caption": "Axial post-contrast T1w chest MR image demonstrating that the pulmonary dominant nodules presented marked enhancement by the paramagnetic agent."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03/0016638/16638_3_3.jpg?itok=nUrYmfGA",
            "caption": "DWI showed that pulmonary nodules also presented an important restriction signal."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03/0016638/16638_4_1.jpg?itok=7YdDHTtZ",
            "caption": "Nodule histopathology; immunohistochemistry demonstrates strong and marked immunoexpression of chromogranin, a glycoprotein secreted by neuroendocrine cells."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03/0016638/16638_4_2.jpg?itok=8RR9U-oS",
            "caption": "Nodule histopathology; immunohistochemistry demonstrates marked intraepithelial and basal chromogranin immunoexpression."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03/0016638/16638_5_1.jpg?itok=G-MMNRaB",
            "caption": "Nodule histopathology; haematoxylin and eosin-stained section demonstrates a cluster of neuroendocrine cells forming a pulmonary typical carcinoid."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_video/2020-03/16638%20-%206.PNG?itok=OJPVwbAo",
            "caption": "Coronal T1/T2w bright blood cine gradient echo chest MR image (BALANCED FFE technique) demonstrates that the nodules presented no signs of pericardial invasion."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Oncology",
      "Thorax"
    ],
    "imaging_technique": [
      "CT-High Resolution"
    ],
    "link": "https://www.eurorad.org/case/16638",
    "time": "06.03.2020"
  },
  "16644": {
    "case_id": 16644,
    "title": "Dysphagia in systemic sclerosis: Beyond the obvious",
    "section": "Chest imaging",
    "age": "49",
    "gender": "female",
    "diagnosis": "Dysphagia lusoria aggravated by systemic sclerosis involvement of the oesophagus",
    "history": "A 49-year-old woman diagnosed with systemic sclerosis complains of dysphagia.",
    "image_finding": "Contrast-enhanced thoracic CT showed an aberrant right subclavian artery arising distal to the left subclavian artery and passing posterior to the oesophagus \u2013 arteria lusoria. The oesophagus was mildly dilated immediately proximal to the arterial origin, and on its distal part. Mediastinal lymph node enlargement\u00a0and moderate pericardial effusion were also noted. \u00a0\u00a0\nChest HRCT showed a typical fibrotic NSIP pattern: symmetric reticulation with subpleural and peribronchovascular distribution, predominant on the lower lobes, associated with traction bronchiectasis, discrete ground glass opacities and interlobular septal thickening. A normal variant of the right upper lobe was also identified \u2013 azygos lobe. \nDuring the barium oesophagogram the oesophagus was mildly dilated (3.5 cm maximum diameter). The aberrant right subclavian artery caused an extrinsic compression on the posterior oesophagus wall, crossing diagonally upwards and to the right.",
    "discussion": "Background: Systemic sclerosis is an immune-mediated multi-systemic disease, having a higher mortality than any other rheumatic disease [1]. The definite diagnosis is established based on the 2013 criteria for the classification of systemic sclerosis by the European League against Rheumatism (EULAR), which considers the presence of interstitial lung disease (ILD).\nThe left aortic arch with an aberrant right subclavian artery is the most common aortic arch anomaly, occurring in 0.5-2.5% of people [2]. Most frequently, the artery crosses posterior to the oesophagus, although passing between the oesophagus and trachea, or anterior to the trachea is also possible. It is asymptomatic in most of the cases. When symptomatic, it usually causes dysphagia, which is then called dysphagia lusoria.\u00a0 \u00a0\nClinical perspective: Gastrointestinal tract involvement in systemic sclerosis is almost universal [1]. However, severity and clinical manifestations vary. On the other hand, dysphagia lusoria is typically a dysphagia to solids without difficulty in swallowing liquids [2]. Although oesophageal manometry is the gold standard for motility disorders, barium oesophagogram has an important role as a dynamic examination, being frequently used to evaluate dysphagia lusoria. \nImaging perspective: Thoracic CT is the most important tool to evaluate lung involvement in scleroderma, which usually manifests as NSIP. In fact, a simple semi-quantitative classification system (extent of disease below or above 20%) was shown to be of prognostic importance [3]. Mediastinal lymph node enlargement\u00a0is also a frequent finding. In addition, a dilated oesophagus on CT in a patient with systemic sclerosis is suggestive of oesophageal involvement. Cardiac involvement in scleroderma is often subclinical, but pericardial effusion is not an uncommon finding [4].\nThe presence of the arteria lusoria is described on the barium oesophagogram as a fixed narrowing on the posterior wall of the oesophagus, crossing diagonally upwards and to the right, at the level of the aortic arch \u2013 also known as the Bayonet sign [5].\nOutcome: Although surgical treatment is available for dysphagia lusoria, it is usually reserved for patients with arteria lusoria aneurysm, due to its high complication rate. Gastrointestinal manifestations of systemic sclerosis are treated conservatively. In our case, the patient improved with symptomatic therapy (proton pump inhibitors).\nTeaching points: Systemic sclerosis is a multisystemic complex disease requiring an integrated multidisciplinary approach. It is important to include all imaging findings available in order to reach the final diagnosis. Conventional imaging modalities may still play an important role in clinical practice. \nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Dysphagia, lusoria, aggravated, by, systemic, sclerosis, involvement, of, the, oesophagus, Dysphagia, due, to, systemic, sclerosis, GERD-related, dysphagia, Oesophageal, malignancy, related, dysphagia",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03/0016644/16644_1_1.jpg?itok=l7lvbdpo",
            "caption": "Axial chest HRCT at the apical level (A), showing the azygos vein lobe and respective accessory fissure (arrow); mid-lung level (B and C) where we can see subpleural reticulation, traction bronchiectasis and interlobular septal thickening; lower lung level (D) where reticulation is more exuberant"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03/0016644/16644_1_2.jpg?itok=ECopYxg4",
            "caption": "Axial chest HRCT at the apical level (A), showing the azygos vein lobe and respective accessory fissure (arrow); mid-lung level (B and C) where we can see subpleural reticulation, traction bronchiectasis and interlobular septal thickening; lower lung level (D) where reticulation is more exuberant"
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03/0016644/16644_1_3.jpg?itok=mOPkVwHd",
            "caption": "Axial chest HRCT at the apical level (A), showing the azygos vein lobe and respective accessory fissure (arrow); mid-lung level (B and C) where we can see subpleural reticulation, traction bronchiectasis and interlobular septal thickening; lower lung level (D) where reticulation is more exuberant"
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03/0016644/16644_1_4.jpg?itok=hmrTejWx",
            "caption": "Axial chest HRCT at the apical level (A), showing the azygos vein lobe and respective accessory fissure (arrow); mid-lung level (B and C) where we can see subpleural reticulation, traction bronchiectasis and interlobular septal thickening; lower lung level (D) where reticulation is more exuberant"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03/0016644/16644_2_1.jpg?itok=g6xTq-po",
            "caption": "Chest CT at levels above (A) and at the aortic arch (B) and oblique axial MPR (C) where we can see the emergence of the aberrant right subclavian artery (arrow) crossing behind the oesophagus (asterisk). Note also the presence of the atypically located azygos vein (arrowhead)"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03/0016644/16644_2_2.jpg?itok=D-zbLi4t",
            "caption": "Chest CT at levels above (A) and at the aortic arch (B) and oblique axial MPR (C) where we can see the emergence of the aberrant right subclavian artery (arrow) crossing behind the oesophagus (asterisk). Note also the presence of the atypically located azygos vein (arrowhead)"
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03/0016644/16644_2_3.jpg?itok=vkBb3plC",
            "caption": "Chest CT at levels above (A) and at the aortic arch (B) and oblique axial MPR (C) where we can see the emergence of the aberrant right subclavian artery (arrow) crossing behind the oesophagus (asterisk). Note also the presence of the atypically located azygos vein (arrowhead)"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03/0016644/16644_3_1.jpg?itok=KajZkXH2",
            "caption": "Axial chest CT with sub-aortic lymph node adenopathy (arrow)"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03/0016644/16644_4_1.jpg?itok=1uvFf8Qf",
            "caption": "Axial chest CT with moderate size chronic pericardial effusion (asterisk)"
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03/0016644/16644_5_1.jpg?itok=NX_YxxIX",
            "caption": "Barium oesophagogram (A) on left posterior oblique incidence depicting the compression (arrow) caused by the arteria lusoria (arrow in B) on the oesophagus (asterisk), with the corresponding sagittal CT reconstruction (B)"
          },
          {
            "number": "Figure 5b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03/0016644/16644_5_2.jpg?itok=_IZtUpga",
            "caption": "Barium oesophagogram (A) on left posterior oblique incidence depicting the compression (arrow) caused by the arteria lusoria (arrow in B) on the oesophagus (asterisk), with the corresponding sagittal CT reconstruction (B)"
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03/0016644/16644_6_1.jpg?itok=tyMXJG8y",
            "caption": "AP barium oesophagogram (A) depicting the Bayonet sign (arrow) on the barium filled oesophagus (asterisk). The corresponding coronal CT reconstruction (B) with the right subclavian artery (arrow) causing a deformity on the oesophagus (asterisk). Note also the pericardial effusion (arrowhead)"
          },
          {
            "number": "Figure 6b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03/0016644/16644_6_2.jpg?itok=0evGdLVS",
            "caption": "AP barium oesophagogram (A) depicting the Bayonet sign (arrow) on the barium filled oesophagus (asterisk). The corresponding coronal CT reconstruction (B) with the right subclavian artery (arrow) causing a deformity on the oesophagus (asterisk). Note also the pericardial effusion (arrowhead)"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Anatomy",
      "Arteries / Aorta",
      "Thorax"
    ],
    "imaging_technique": [
      "CT",
      "Fluoroscopy"
    ],
    "link": "https://www.eurorad.org/case/16644",
    "time": "09.03.2020"
  },
  "16645": {
    "case_id": 16645,
    "title": "Not always a truly diffuse cystic lung disease \u2013 A case of cystic transformation of lung metastases after chemotherapy",
    "section": "Chest imaging",
    "age": "28",
    "gender": "male",
    "diagnosis": "Cystic transformation of lung metastases after chemotherapy",
    "history": "A 28-year-old male patient diagnosed with testicular cancer confirmed by histology to be a teratoma mixed with yolk sac and embryonal carcinoma stage IIIB (mediastinal and retroperitoneal lymph node metastases and lung metastases) underwent chemotherapy treatment with bleomycin, etoposide and platinum (BEP), with complete response, followed by annual surveillance with CT.",
    "image_finding": "A chest CT without contrast administration was performed revealing multiple pulmonary cysts with thin wall and diffuse distribution in lung parenchyma without an anterior-posterior distribution predilection, but slightly more prevalent in the inferior portions of both lungs (Figs.1a, 1b and 4b). No solid or subsolid nodules were found nor solid areas were seen within the previously described cystic lesions.\nA comparison was made with the patient initial examination revealing multiple pulmonary solid nodules, at the exact same location as the previously described cysts (Figs. 2a, 2b, 3a and 4a).\nOn the first follow-up CT the referred lung nodules showed central cavitation (Fig. 3b).",
    "discussion": "Lung cysts are defined as round, air-filled lesions, thin-walled with a diameter greater than 1cm.\nDiffuse cystic lung diseases (DCLD) are a group of pathologies characterised by the presence of cysts in both lungs that are not necessarily equally distributed. The differential diagnosis is limited and typically includes lymphangioleiomyomatosis (LAM), pulmonary Langerhans cell histiocytosis (PLCH) and lymphoid interstitial pneumonia (LIP). However in a subset of oncologic disease cystic pulmonary metastases, although rare, should always be considered [1\u20133].\nCavitary lung lesions are relatively common regarding the spectrum of metastatic tumours, cystic lung metastases however are rare and distinct, as the former are characterised by \ufeffthickened and irregular walls due to central necrosis [1,4]. Metastatic cystic lung lesions have been reported secondary to different types of tumours as seminoma, Ewing\u2019s sarcoma, myxosarcoma, Wilms\u2019 tumour, osteogenic sarcoma, angiosarcoma, transitional cell carcinoma and teratocarcinoma [2].\nLAM is rare and usually seen in women \ufeffof childbearing age. It is usually associated with tuberous sclerosis, therefore concomitant angiomyolipomas are frequently seen. Characteristic high-resolution CT (HRCT) features are diffuse thin-walled round cysts measuring 2-10mm, surrounded by normal lung without regional sparing [3].\nLIP usually occurs in association with connective tissue diseases. On HRCT it is characterised by the presence of basal predominant thin-walled cysts, however generally it is also associated with \ufeffground-glass opacities and poorly defined centrilobular nodules [5].\nPLCH is a smoke-related disease usually presenting from 20 to 40 years. The initial HRCT findings of PLCH are centrilobular or peribronchiolar nodules. As the disease progresses, the nodules undergo cavitation and produce cystic lesions, which would be a consideration on the case presented if a history of oncologic imaging was not present [5].\nHRCT has become the gold standard in the evaluation of patients with DLCD, since the analysis of the characteristics and distribution of the cysts, as well as the clinical history, makes it possible to reach a definitive diagnosis or to narrow the differential diagnoses.\nIn the case presented and in all oncologic patients we should always have into account the previous studies as they might be the key for diagnosis. In this case, the previously known lung metastatic disease that was submitted to adjuvant therapy allowed the diagnosis. However, in cases where a previous study is not available, metastatic lung disease although rare, should always be considered as a cause of diffuse cystic lung disease, especially in the subset of chemotherapy treated patients.\nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Cystic, transformation, of, lung, metastases, after, chemotherapy, Lymphangioleiomyomatosis, Pulmonary, Langerhans, cell, histiocytosis, Lymphoid, interstitial, pneumonia, Cavitary, lung, metastasis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03/0016645/16645_1_1.jpg?itok=_q1jnn_Z",
            "caption": "Cystic thin-walled lesions are demonstrated at different lung levels in the follow-up chest examination: a \u2013 intermediate; c - basal"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03/0016645/16645_1_2.jpg?itok=eF4i-nGX",
            "caption": "Cystic thin-walled lesions are demonstrated at different lung levels in the follow-up chest examination: a \u2013 intermediate; c - basal"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03/0016645/16645_2_1.jpg?itok=H1kanC5Z",
            "caption": "Solid nodules are seen at the same locations as the cystic lesions in the follow-up examination (Fig.1): a \u2013 intermediate; c \u2013 basal"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03/0016645/16645_2_2.jpg?itok=7PuJCT8b",
            "caption": "Solid nodules are seen at the same locations as the cystic lesions in the follow-up examination (Fig.1): a \u2013 intermediate; c \u2013 basal"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03/0016645/16645_3_1.jpg?itok=8hEt1ddR",
            "caption": "Cavitary metastases (thick and irregular wall) are seen (b) at the exact same locations as the previously detected metastatic nodules seen in the initial examination (a)"
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03/0016645/16645_3_2.jpg?itok=N3rEMcJ2",
            "caption": "Cavitary metastases (thick and irregular wall) are seen (b) at the exact same locations as the previously detected metastatic nodules seen in the initial examination (a)"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03/0016645/16645_4_1.jpg?itok=vVp53vsK",
            "caption": "Cystic lesions are seen predominantly at the lung bases (b), at the same locations as the solid lesions in the initial examination (a)"
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03/0016645/16645_4_2.jpg?itok=ILCuHyeh",
            "caption": "Cystic lesions are seen predominantly at the lung bases (b), at the same locations as the solid lesions in the initial examination (a)"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Oncology"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/16645",
    "time": "09.03.2020"
  },
  "16646": {
    "case_id": 16646,
    "title": "Necrotising pneumonia and septic shock due to Klebsiella pneumoniae",
    "section": "Chest imaging",
    "age": "52",
    "gender": "male",
    "diagnosis": "Necrotising pneumonia due to Klebsiella pneumoniae",
    "history": "A 52-year-old male patient, homeless, presented with a rapid onset (days) of chest pain, haemoptysis, fever (39\u00baC) and weight loss. The laboratory studies demonstrated leukopenia and neutrophilia. Negative serologies. The patient had a history of heavy alcohol and drugs (cocaine) consumption and was a smoker with known chronic obstructive pulmonary disease (COPD).",
    "image_finding": "The chest X-ray revealed a condensation with patent bronchi at the right upper lobe (RUL) and middle lobe (ML) and bulging of the right major fissure (Fig. 1).\nChest Computed Tomography (CT) revealed a consolidation with air bronchogram at the RUL and ML (Figs. 2 and 3). Multiple parenchymal areas without contrast enhancement. Moderate centrilobular emphysema at the upper lobes, mild paraseptal emphysema and bronchial wall-thickening at the lower lobes. Mediastinal lymphadenopathies were present (Fig. 3). No pleural effusion.\nThe imaging interpretation was necrotising pneumonia probably due to Klebsiella pneumoniae (K. pneumoniae) with underlying alterations due to COPD.\nThe patient started empiric antibiotherapy, but rapidly progressed to respiratory distress and multiorgan dysfunction due to septic shock and was admitted to the intensive care unit.\nK. pneumoniae was then isolated in the bronchial secretions.\u00a0\u00a0\nBronchoscopy and transbronchial pulmonar biopsy confirmed bronchial mucosal infiltration by lymphocytes, histiocytes and polymorphonuclear cells, without neoplastic cells.",
    "discussion": "Community-acquired pneumonia is a lung infection most often caused by bacteria and viruses. It is commonly caused by gram-positive microorganisms, namely Streptococcus pneumoniae [1]. Immunosuppressed individuals or those living in degrading conditions are more sensitive to gram-negative microorganisms such as Haemophilus influenzae, Moraxella catarrhalis or K. pneumoniae. [2]\nK. pneumoniae is an aggressive microorganism, accounting for 0.5 to 5% of pneumonia cases. It can lead to cavitation (30-50% of cases) and necrotising pneumonia (NP) within a short period of time (days). [3]\nNP is a complication of pulmonary infection, where the affected parenchyma is replaced by necrotic tissue and cavitations. It is important to identify associated lung abscesses, usually well-defined small collections (<2 cm), pulmonary gangrene or thrombosis, since they are frequent complications of K. pneumoniae infection. [4]\nUsually the patient presents with fever, cough with sputum production and pleuritic chest pain. Sometimes also haemoptysis, night sweats, anorexia and weight loss are present.\u00a0\nChest X-ray (CXR) is usually the first imaging performed in the emergency department. Bacterial pneumonia typically demonstrates a lobar consolidation, with air bronchogram sign, sometimes with pleural effusions. In the case of K. pneumoniae, we may see cavitation and the bulging fissure sign, representing a displacement of the adjacent fissure that has been classically associated with K. pneumoniae consolidation. [4]\nChest CT depicts ground-glass opacities, consolidation with air bronchogram, sometimes with cavitations, reticular opacities, centrilobular nodules or interlobular septal thickening. The intravenous contrast administration is essential to reveal patchy areas of unenhanced parenchyma due to necrosis. It can also depict mature abscesses as a nodular lesion with an enhancing thickened wall. Pleural effusions and mediastinal lymphadenopathies can also accurately be characterised by CT. (4)\nMedical treatment with intravenous antibiotics is the mainstay of therapy, sometimes for long periods (2-3 months). It is important to identify associated abscess formation or empyema, because surgical treatment (drainage) may be needed in these cases, particularly when they are very large. Lung-resection can be considered when extensive necrosis is not responding to previous treatments. [5]\nProper treatment prognosis is favourable, with 90% of abscesses cured with medical treatment alone.\u00a0\nIn cases of lobar pneumonia in immunocompromised patients or those with chronic pulmonary pathology, it is important to consider less common diagnoses such as gram-negative bacteria, which tend to progress to NP.\u00a0 CT study, before and after iodinated contrast administration, is essential to identify areas within the parenchyma consolidation without enhancement due to necrosis.\nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Necrotising, pneumonia, due, to, Klebsiella, pneumoniae, Lung, abscess, Necrotising, lung, tumour, Cavitating, lung, infarcts, Pulmonary, tuberculosis, Pulmonary, fungal, infection, (aspergillosis, or, mucormycosis)",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03/0016646/16646_1_1.jpg?itok=74JOUTEM",
            "caption": "Chest X-ray posteroanterior view depicting a heterogeneous condensation with air bronchogram sign, occupying the RUL almost entirely and part of the ML"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03/0016646/16646_1_2.jpg?itok=4Vqmoy_v",
            "caption": "Chest X-ray posteroanterior lateral view depicting the heterogeneous condensation and bulging of the right major fissure (red line)"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03/0016646/16646_2_1.jpg?itok=9pQpqo_M",
            "caption": "CT acquisition at the axial plane depicted a consolidation with air bronchogram at the RUL and bulging of the right major fissure (red line), due to expansion of the infected parenchyma"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03/0016646/16646_2_2.jpg?itok=CD7YK5H5",
            "caption": "CT acquisition reconstruction at the sagittal planes representing posterior bulging of the right major fissure (red line)"
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03/0016646/16646_2_3.jpg?itok=kzJS3DtA",
            "caption": "CT acquisition reconstruction at the coronal planes depicted the consolidation and bulging of the right major fissure (red line)"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03/0016646/16646_3_1.jpg?itok=pqIWXwYR",
            "caption": "CT acquisition at the axial plane depicted an extensive consolidation with air bronchogram at the RUL (red arrow)"
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03/0016646/16646_3_2.jpg?itok=E5yrrzfM",
            "caption": "CT acquisition after intravenous administration of iodinated contrast at the axial plane depicted, within the consolidation, at least two nodular hypodense areas of non-enhancing parenchyma due to necrotising pneumonia (blue arrows). There is also a small atelectasis at the posterior aspect of right inferior lobe (green arrow) and mediastinal lymphadenopathies (yellow arrow)"
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03/0016646/16646_3_3.jpg?itok=2t3Hj_m7",
            "caption": "CT reconstruction at the coronal plane depicted the areas of non-enhancing parenchyma due to necrotising pneumonia (blue arrows)"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Respiratory system",
      "Thorax"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/16646",
    "time": "09.03.2020"
  },
  "16654": {
    "case_id": 16654,
    "title": "COVID-19 patient presenting with initial gastrointestinal symptoms",
    "section": "Chest imaging",
    "age": "56",
    "gender": "male",
    "diagnosis": "Coronavirus disease-19 (COVID-19)",
    "history": "A 56-year-old male patient with end-stage renal disease, heart failure, and tobacco cigarette smoking (5 pack year history) presented to the emergency department with nausea, vomiting, and low-grade fever (37.9\u00b0C), and was diagnosed with gastroenteritis. He subsequently developed a dry cough and myalgia, and returned 5 days later with fever (38.1\u00b0C). Laboratory studies were remarkable for mild lymphopenia (0.8\u00d7103/\u00b5L, normal range 0.9\u00d7103/\u00b5L \u2013 3.3\u00d7103/\u00b5L), elevated aspartate aminotransferase (71 IU/L, normal range 13 IU/L \u2013 39  IU/L), elevated c-reactive protein (14.6 mg/dL, normal range 0 \u2013 1 mg/dL), and elevated procalcitonin (2.37 ng/mL, normal < 0.1 ng/mL). He had traveled to South Korea approximately 7 weeks prior to presentation.",
    "image_finding": "AP chest X-ray at initial presentation demonstrated mild patchy increased interstitial markings at the bilateral lung bases without evidence of focal consolidation and stable mild cardiomegaly (Fig. 1).\nAP Chest X-ray obtained at second presentation demonstrated diffuse patchy bilateral airspace opacities (Fig. 2). \nConcurrently obtained non-contrast chest CT (Figs. 3a-f) demonstrated multifocal bilateral patchy ground-glass opacities with a predominantly peripheral distribution, mild apical-predominant centrilobular and paraseptal emphysema, and mild cardiomegaly (Fig. 3). \nAP chest X-ray on day two of admission (Fig. 4) demonstrated interval intubation, increased patchy airspace opacities, and stable mild cardiomegaly.",
    "discussion": "Background\nCoronavirus disease-19 (COVID-19) is a novel viral pandemic with increasing incidence and a wide spectrum of disease severity [1]. Many countries are currently experiencing community spread to persons without known infectious contacts.\nClinical Perspective\nCommon presenting findings include fever, cough, myalgia, and lymphopenia [2]. Recent cases have highlighted early gastrointestinal symptoms, including nausea, vomiting, and diarrhoea, which preceded respiratory symptoms [3, 4]. The relationship between smoking and COVID-19 prevalence and severity has not yet been conclusively evaluated in the limited scientific literature [5].\nImaging Perspective\nRadiographic and computed tomography (CT) imaging early in the disease course may be normal; chest CT has been described as more sensitive than chest X-ray for the detection of characteristic bilateral, peripherally-predominant ground-glass opacities [6\u201310]. It has been reported that some patients who initially have negative RT-PCR at presentation may have synchronous chest CT findings of viral pneumonia [11\u201313].\nOutcome\nCOVID-19 RT-PCR returned positive. The patient developed hypoxic respiratory failure and new onset haemoptysis on day two of admission and was intubated and transferred to the intensive care unit.\nTeaching Points. Chest imaging findings in COVID-19 infection are not specific and may overlap with other viral pneumonias, including influenza. Chest CT is more sensitive than chest X-ray for detection of ground glass opacities; however, initial imaging may be normal. Gastrointestinal symptoms may be an early presenting feature of COVID-19 infection.\nWritten patient consent for this case was waived by the Editorial Board. Patient data may have been modified to ensure patient anonymity.",
    "differential_diagnosis": "Coronavirus, disease-19, (COVID-19), Multifocal, bacterial, pneumonia, Pulmonary, oedema, Acute, respiratory, distress, syndrome, (ARDS), Hypersensitivity, pneumonitis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03//16654_1_1.png?itok=pvYAnUqD",
            "caption": "AP chest X-ray at initial presentation demonstrated mild patchy increased interstitial markings at the bilateral lung bases without evidence of focal consolidation and stable mild cardiomegaly"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03//16654_2_1.jpg?itok=6fefm16R",
            "caption": "AP chest X-ray obtained at second presentation demonstrated diffuse patchy bilateral airspace opacities and stable mild cardiomegaly"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03//16654_3_1.png?itok=6h4mkfny",
            "caption": "Non-contrast chest CT obtained at second presentation demonstrated multifocal bilateral patchy ground-glass opacities with a predominantly peripheral distribution, mild apical-predominant centrilobular and paraseptal emphysema, and cardiomegaly"
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03//16654_3_2.png?itok=aZRChZzL",
            "caption": "Non-contrast chest CT obtained at second presentation demonstrated multifocal bilateral patchy ground-glass opacities with a predominantly peripheral distribution, mild apical-predominant centrilobular and paraseptal emphysema, and cardiomegaly"
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03//16654_3_3.png?itok=90SOjCUM",
            "caption": "Non-contrast chest CT obtained at second presentation demonstrated multifocal bilateral patchy ground-glass opacities with a predominantly peripheral distribution, mild apical-predominant centrilobular and paraseptal emphysema, and cardiomegaly"
          },
          {
            "number": "Figure 3d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03//16654_3_4.png?itok=QKYkpoQh",
            "caption": "Non-contrast chest CT obtained at second presentation demonstrated multifocal bilateral patchy ground-glass opacities with a predominantly peripheral distribution, mild apical-predominant centrilobular and paraseptal emphysema, and cardiomegaly"
          },
          {
            "number": "Figure 3e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03//16654_3_5.png?itok=se4-O-F3",
            "caption": "Non-contrast chest CT obtained at second presentation demonstrated multifocal bilateral patchy ground-glass opacities with a predominantly peripheral distribution, mild apical-predominant centrilobular and paraseptal emphysema, and cardiomegaly"
          },
          {
            "number": "Figure 3f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03//16654_3_6.png?itok=bUEWykhm",
            "caption": "Non-contrast chest CT obtained at second presentation demonstrated multifocal bilateral patchy ground-glass opacities with a predominantly peripheral distribution, mild apical-predominant centrilobular and paraseptal emphysema, and cardiomegaly"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03//16654_4_1.jpg?itok=sZNT5DC-",
            "caption": "AP chest X-ray obtained on day two of admission demonstrated interval intubation, increased patchy airspace opacities, and stable mild cardiomegaly"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/16654",
    "time": "18.03.2020"
  },
  "16660": {
    "case_id": 16660,
    "title": "Rapidly progressive ARDS secondary to COVID-19 infection",
    "section": "Chest imaging",
    "age": "72",
    "gender": "female",
    "diagnosis": "Coronavirus disease-19 (COVID-19)",
    "history": "A 72-year-old woman admitted with acute respiratory failure, fever (38\u00baC) and dyspnoea.\nShe was tachypneic (30bpm), with lymphopenia and low oxygen saturation (SpO2 85%, PAFI<250).\nPatient presented to the emergency department two days earlier with fever (up to 38.6\u00baC), dry cough, odynophagia and general malaise. She was discharged from hospital because she did not present alarm criteria at that time.\nThe patient required mechanical ventilation and was admitted to intensive care. \nDuring her stay in ICU, poor evolution to respiratory distress syndrome and to multi-organic failure.\nThe patient passed away 24 hours later.",
    "image_finding": "Figure 1 (at admission). Ill-defined bilateral alveolar consolidation with peripheral distribution. \nFigure 2 (4 hours later). Radiological worsening, with affectation of lower lobes. Endotracheal tube and central venous line were required. \nFigure 3 (Day 1). Bilateral alveolar consolidation.\nFigure 4 (Day 2). Radiological worsening. Bilateral alveolar consolidation with panlobar affectation.\nFigure 5 (Day 3). Bilateral alveolar consolidation with panlobar affectation, with typical radiological findings of ARDS. 24 hours later the patient passed away.",
    "discussion": "Background\nCoronavirus disease-19 (COVID-19) is a novel viral pandemic with increasing incidence and a wide spectrum of disease severity [1]. Many countries are currently experiencing community spread to persons without known infectious contacts. In Spain, the guidelines to determine who to test for COVID-19 microbiology are changing. This implies the risk that some patients discharged from the hospital at that moment, may develop days later an ARDS.\nClinical Perspective\nCommon presenting findings include fever, cough, myalgia, and lymphopenia [2]. In some cases gastrointestinal symptoms are reported [3,4]. The evolution to ARDS secondary to COVID-19 infection is a several and life-threatening complication [5].\nImaging Perspective\nCOVID-19 infection can lead to rapidly progressive ARDS as we show in this case. The prognosis is poor and radiologic findings can go from ill-defined alveolar consolidations to bilateral consolidations with panlobar affection as seen in ARDS.\nRadiographic and computed tomography (CT) imaging early in the disease course may be normal; chest CT has been described as more sensitive than chest X-ray for the detection of characteristic bilateral, peripherally-predominant ground-glass opacities [6\u201310]. \nOutcome\nCOVID-19 RT-PCR returned positive. The patient developed hypoxic respiratory failure and new onset haemoptysis on day two of admission and was intubated and transferred to the intensive care unit.\nTeaching Points\nChest imaging findings in COVID-19 infection are not specific and may overlap with other viral pneumonias, including influenza. Chest CT is more sensitive than chest X-ray for detection of ground glass opacities [11-13]; however, is not always available. ARDS is a complication of COVID-19 infection, leading to rapidly progressive organic failure in some cases.\nWritten patient consent for this case was waived by the Editorial Board. Patient data may have been modified to ensure patient anonymity.",
    "differential_diagnosis": "Coronavirus, disease-19, (COVID-19), Multifocal, bacterial, pneumonia, Pulmonary, oedema, Acute, respiratory, distress, syndrome, (ARDS), Hypersensitivity, pneumonitis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03//16660_1_1.jpg?itok=NQr74Wq6",
            "caption": "(At admission). Ill-defined bilateral alveolar consolidation with peripheral distribution."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03//16660_2_1.jpg?itok=kBMIpFGK",
            "caption": "(4 hours later). Radiological worsening, with affectation of lower lobes. Endotracheal tube and central venous line were required."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03//16660_3_1.jpg?itok=H_2MwCwF",
            "caption": "(Day 1). Bilateral alveolar consolidation."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03//16660_4_1.jpg?itok=voeST3uK",
            "caption": "(Day 2). Radiological worsening. Bilateral alveolar consolidation with panlobar affectation."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03//16660_5_1.jpg?itok=YGL0geJk",
            "caption": "(Day 3). Bilateral alveolar consolidation with panlobar affectation, with typical radiological findings of ARDS. 24 hours later the patient passed away."
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "Conventional radiography"
    ],
    "link": "https://www.eurorad.org/case/16660",
    "time": "20.03.2020"
  },
  "16663": {
    "case_id": 16663,
    "title": "Imaging of severe coronavirus disease 2019 (COVID-19) pneumonia requiring invasive ventilation",
    "section": "Chest imaging",
    "age": "61",
    "gender": "male",
    "diagnosis": "COVID-19 pneumonia",
    "history": "A 61-year-old male non-smoking patient presented with dyspnoea (respiratory rate 25/min, peripheral capillary oxygen saturation 67%) and fever (38.3\u00b0C). Apart from pre-existing arterial hypertension, there were no risk factors or known pathogen exposure. \nBlood analysis showed normal leucocytes, elevated C-reactive protein (CRP) levels (106.3mg/l; normal range <5mg/l) and a normal procalcitonin level (0.12\u00b5g/l; normal range <0.50\u00b5g/l). Glomerular filtration rate was reduced (47ml/min). Reverse transcription polymerase change reaction (RT-PCR) for coronavirus disease-2019 (COVID-19) was positive, Influenza tests were negative.\nAs dyspnoea deteriorated, the patient was admitted to our intensive care unit. Under continuous invasive ventilation and broad-spectrum antibiotics CRP levels rose to 300mg/l and fever continued over the next 4 days. With the impending need of extracorporeal membrane oxygenation, a chest CT scan was performed.",
    "image_finding": "Chest X-ray at initial presentation showed bilateral pulmonary consolidation in mid-and lower zones (Figs. 1a and b). \u00a0\nChest CT was performed using a 128-row multidetector CT with dose modulation and iterative reconstruction algorithm (iCT, Philips, Amsterdam, Netherlands). Images were acquired in the venous phase 70 sec after intravenous injection of 70 ml contrast agent (400\u00a0mg iodine/ml). Tube voltage was set at 100 kV, tube current ranged between 53 and 83\u00a0mAs. Axial images were reconstructed in 1 mm slices with multiplanar reformations.\nCT images obtained 4 days after onset of symptoms revealed patchy and partially coalescing geographic ground glass opacities (GGOs) with a slight peripheral preponderance in the ventral parts of both lungs (Figs. 2a\u2013f). Some areas of GGOs show a discreet crazy paving pattern (Figs. 2c, d). There was almost complete consolidation with positive air bronchograms in the dorsal parts of both lungs (mainly lower lobes with slightly reduced volume, Figs. 2a\u2013c, f). Small bilateral pleural effusions were present (Fig. 2g). No thoracic lymphadenopathy was noted.",
    "discussion": "Here we present radiographic and CT images of a severe, laboratory-proven COVID-19 pneumonia in a 61-year old male patient. To our knowledge, this is one of the first imaging studies of this new airway disease published outside of China [1].\nCOVID-19 is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) [2, 3]. Since the original outbreak in Wuhan, China, in December 2019, COVID-19 has spread over multiple countries around the world causing 167,511 infections and 6,606 deaths (as of 16 March 2020), with numbers outside of China still rapidly growing [4]. On 11 March 2020, the World Health Organization (WHO) announced the outbreak a pandemic. \nThe majority of our imaging findings are consistent with numerous previous publications on CT morphology of COVID-19 pneumonia: multifocal, mostly bilateral, patchy, band-like or even coalescent GGOs as well as consolidations and crazy paving appearance have been described before, the latter two indicating a severe disease manifestation [5\u20139]. The extensive consolidation of the dorsal aspects of both lungs (mainly lower lobes) with preserved air bronchogram, however, is uncommon for COVID-19. Consolidations in COVID-19 are usually more localised, patchy or crescent-shaped [6]. The extensive consolidations in our case may be at least in part due to bacterial coinfection (despite antibiotic treatment) or preceding invasive ventilation in supine position over several days. The slight volume loss of the lower lobes and the fact that the patient\u2019s pulmonary function improved after he was turned into prone position following the CT-scan support the latter assumption. We would expect coalescent GGOs and crazy paving as in the ventral parts of the lung if aeration was more equally distributed. \nThe role of CT in diagnosis and management of COVID-19 is not yet clear. In early detection of COVID-19, CT has shown higher sensitivity compared to RT-PCR (97% vs. 60%) [10]. On the other hand, some publications indicate that also CT may be false-negative in detecting very early disease stages [9, 11]. In the present case, CT was not employed to diagnose the disease, but to exclude possible concomitant pathology like a pleural empyema, to evaluate disease extent objectively and to help optimise the therapeutic strategy. In this scenario, CT may become even more valuable with rising numbers of COVID-19 patients and limited isolation, intensive care and ventilation capacities. Moreover, it may guide possible future antiviral treatment options.\nIn conclusion, the present case illustrates a typical appearance of severe COVID-19 pneumonia requiring invasive ventilation. CT may be a useful tool not only for early diagnosis, but also for evaluation of disease extent and treatment planning in advanced stages.\nWritten patient consent for this case was waived by the Editorial Board. Patient data may have been modified to ensure patient anonymity.",
    "differential_diagnosis": "COVID-19, pneumonia, Viral, pneumonia, Bacterial, pneumonia, Acute, respiratory, distress, syndrome, (ARDS), Dystelectasis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03//16663_1_1.jpg?itok=es0IyC9R",
            "caption": "Bilateral alveolar pulmonary consolidation in right mid-and lower zones and in the left lower zone. a: pa projection. b: lateral projection."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03//16663_1_2.jpg?itok=wnLegCG2",
            "caption": "Bilateral alveolar pulmonary consolidation in right mid-and lower zones and in the left lower zone. a: pa projection. b: lateral projection."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03//16663_2_1.jpg?itok=pnPObN4A",
            "caption": "Patchy and partially coalescing geographic ground glass opacities (GGOs) with a slight peripheral preponderance in the ventral parts of both lungs (a\u2013f). Discreet crazy paving pattern in some areas of GGOs (c, d). Almost complete consolidation with positive air bronchograms in the dorsal parts of both lungs (mainly lower lobes with slightly reduced volume (a\u2013c, f). Small bilateral pleural effusions (g)."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03//16663_2_2.jpg?itok=XhOhjL4o",
            "caption": "Patchy and partially coalescing geographic ground glass opacities (GGOs) with a slight peripheral preponderance in the ventral parts of both lungs (a\u2013f). Discreet crazy paving pattern in some areas of GGOs (c, d). Almost complete consolidation with positive air bronchograms in the dorsal parts of both lungs (mainly lower lobes with slightly reduced volume (a\u2013c, f). Small bilateral pleural effusions (g)."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03//16663_2_3.jpg?itok=z_KAs0th",
            "caption": "Patchy and partially coalescing geographic ground glass opacities (GGOs) with a slight peripheral preponderance in the ventral parts of both lungs (a\u2013f). Discreet crazy paving pattern in some areas of GGOs (c, d). Almost complete consolidation with positive air bronchograms in the dorsal parts of both lungs (mainly lower lobes with slightly reduced volume (a\u2013c, f). Small bilateral pleural effusions (g)."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03//16663_2_4.jpg?itok=osQMahWE",
            "caption": "Patchy and partially coalescing geographic ground glass opacities (GGOs) with a slight peripheral preponderance in the ventral parts of both lungs (a\u2013f). Discreet crazy paving pattern in some areas of GGOs (c, d). Almost complete consolidation with positive air bronchograms in the dorsal parts of both lungs (mainly lower lobes with slightly reduced volume (a\u2013c, f). Small bilateral pleural effusions (g)."
          },
          {
            "number": "Figure 2e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03//16663_2_5.jpg?itok=avp9Lvw6",
            "caption": "Patchy and partially coalescing geographic ground glass opacities (GGOs) with a slight peripheral preponderance in the ventral parts of both lungs (a\u2013f). Discreet crazy paving pattern in some areas of GGOs (c, d). Almost complete consolidation with positive air bronchograms in the dorsal parts of both lungs (mainly lower lobes with slightly reduced volume (a\u2013c, f). Small bilateral pleural effusions (g)."
          },
          {
            "number": "Figure 2f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03//16663_2_6.jpg?itok=NkNr670W",
            "caption": "Patchy and partially coalescing geographic ground glass opacities (GGOs) with a slight peripheral preponderance in the ventral parts of both lungs (a\u2013f). Discreet crazy paving pattern in some areas of GGOs (c, d). Almost complete consolidation with positive air bronchograms in the dorsal parts of both lungs (mainly lower lobes with slightly reduced volume (a\u2013c, f). Small bilateral pleural effusions (g)."
          },
          {
            "number": "Figure 2g",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03//16663_2_7.jpg?itok=_4XParBa",
            "caption": "Patchy and partially coalescing geographic ground glass opacities (GGOs) with a slight peripheral preponderance in the ventral parts of both lungs (a\u2013f). Discreet crazy paving pattern in some areas of GGOs (c, d). Almost complete consolidation with positive air bronchograms in the dorsal parts of both lungs (mainly lower lobes with slightly reduced volume (a\u2013c, f). Small bilateral pleural effusions (g)."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/16663",
    "time": "23.03.2020"
  },
  "16664": {
    "case_id": 16664,
    "title": "COVID-19 in a young immunocompromised patient",
    "section": "Chest imaging",
    "age": "29",
    "gender": "female",
    "diagnosis": "COVID-19",
    "history": "A 29-year-old immunocompromised female patient with a 3-day history of cough and fever. Past medical history includes severe ulcerative colitis treated with Tofacitinib. The patient was admitted to the hospital ward and discharged one week after admission with complete recovery.",
    "image_finding": "Chest X-ray: Increase of parenchymal opacity in right lower lobe.\nChest CT with contrast: No pulmonary emboli. Multilobar, multifocal and bilateral confluent ground-glass opacity (some of them are rounded) and overimposed consolidation in inferior right lobe. Subtle septal thickening in right lobe with crazy paving appearance. No signs of pleural or pericardial effusion.",
    "discussion": "Our case presents a 29-year-old immunocompromised female patient with a 3-day history of cough and fever. Chest X-ray and positive SARS-CoV-2 RT-PCR confirmed COVID-19 pneumonia. The patient is in a immunocompromised state as a result of severe ulcerative colitis treated with Tofacitinib 10 mg/12 h. She was admitted to the hospital ward and a CT-scan of the chest was performed to rule out life-threatening complications due to her respiratory distress.\nShe recovered well after treatment with hidroxicloroquine and discharged one week after initial admission with complete resolution of the symptoms. Lopinavir/Ritonavir and Tocilizumab were contraindicated as they may produce diarrhoea and ulcerative colitis flare-up.\nCOVID-19 is a pandemic caused by SARS-CoV-2, a new coronavirus, which was first reported in China. Cough and fever seem like the most common symptoms but the disease could be fatal in patients with multiple comorbidities [1].\nThe diagnosis of COVID-19 could be challenging because the symptoms can overlap with other diseases such as influenza or H1N1. Radiology may play a role since the CT-scan is very sensitive [2] in initial stages of the disease and X-ray findings could be very subtle. A prompt diagnosis could help clinicians to anticipate complications in patients at risks.\nTypical CT findings include unilateral or bilateral ground-glass opacities (often rounded morphology) with or without consolidation in early phases and confluent ground-glass opacities with superimposed consolidation and septal thickening (crazy pacing) in late phases [3, 4].\nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "COVID-19, Adenovirus, SARS, MERS",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03//16664_1_1.jpg?itok=YlsCFL8T",
            "caption": "Increase of parenchymal opacity located in right inferior field"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03//16664_2_1.jpg?itok=Vb1a51pg",
            "caption": "Increase of parenchymal opacity located in right inferior lower lobe"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03//16664_3_1.jpg?itok=DPyboXod",
            "caption": "Chest CT-scan, axial view: Subpleural right upper lobe ground-glass opacity (rounded morphology)"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03//16664_4_1.jpg?itok=vt9asqyP",
            "caption": "Chest CT-scan, axial view: Subpleural right upper lobe ground-glass opacity (rounded morphology)"
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03//16664_5_1.jpg?itok=byi9hc0-",
            "caption": "Chest CT scan, axial view: Peripheral ground-glass opacities in upper-and inferior right lobes and small rounded ground-glass lesion in inferior left lobe. Subtle septal thickening with the middle lobe with crazy paving appearance"
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03//16664_6_1.jpg?itok=VuLoFnJr",
            "caption": "Chest CT-scan, axial view: Extensive ground glass opacities in inferior right lobe with overimposed peripheral consolidation. Middle and inferior left lobe rounded consolidation"
          }
        ]
      },
      {
        "number": "Figure 7",
        "subfigures": [
          {
            "number": "Figure 7",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03//16664_7_1.jpg?itok=f-83I9dz",
            "caption": "Extensive ground-glass opacities in inferior right lobe with overimposed peripheral consolidation"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/16664",
    "time": "23.03.2020"
  },
  "16667": {
    "case_id": 16667,
    "title": "Radio-clinical mismatch in two patients positive for COVID-19",
    "section": "Chest imaging",
    "age": "53",
    "gender": "male",
    "diagnosis": "COVID-19 pneumonia",
    "history": "Patient 1: A 53-year-old male patient, with no past medical history, presented to the emergency room (ER) for nausea, fatigue and headaches, 10 days after an Evangelist meeting in Mulhouse (North-East of France). No fever, cough or any respiratory dysfunction was found.\nPatient 2: A 75-year-old male patient, with history of tobacco use, diabetes and obstructive sleep apnoea, presented to the ER for new onset of cognitive impairment and confusion. The clinical exam revealed only bilateral crackles. The biological exam showed a mild hypokalaemia (2.3mmol/L).",
    "image_finding": "Patient 1 underwent a contrast chest CT-scan six days after his admission which revealed bilateral consolidation predominantly basal and peripheral, with adjacent ground-glass opacities and crazy paving pattern. Less than 25% of the parenchyma was involved. \nPatient 2 underwent a non-contrast chest CT-scan two days after his admission which revealed bilateral peripheral ground-glass opacities and consolidation. Sub-pleural intralobular reticulations with architectural distortion and traction bronchiectasis were found, involving approximately 50% of the parenchyma.",
    "discussion": "A.\u00a0\u00a0 \u00a0Background\nCoronaviruses are a broad family of enveloped RNA viruses. A new coronavirus has been identified through deep-sequencing and named SARS-CoV-2 (COVID-19) which is responsible of the current pandemic situation of pneumonia cases [1].\nB.\u00a0\u00a0 \u00a0Clinical Perspective\nThe typical presentation of COVID-19 pneumonia includes fever (in 98.6%), cough (76%) and myalgia or fatigue (44%) [1]. Currently, the gold-standard for diagnosis remains the detection of the virus by RT-PCR methods. The CT-scan could become soon the first line diagnostic tool because of its high sensibility (97%) and its relatively good NPV (83%) [2].\nC.\u00a0\u00a0 \u00a0Imaging Perspective\nThe main usual CT findings are bilateral ground-glass opacities, with basal and subpleural distribution. However, the CT has a low specificity (25%) compared to the RT-PCR [2]. Some findings may help to orientate the diagnosis of COVID-19 infection instead of other viral pneumonia based on the predominance of ground-glass opacities, peripheric and posterior distribution, reticulations, vascular thickening and the absence of lymphadenopathy and pleural effusion [3].\nD.\u00a0\u00a0 \u00a0Outcome\nIt is now known that because of its high sensitivity, CT-scans can show some abnormalities [4] even in asymptomatic patients, with signs of severity (such as traction bronchiectasis) [5,6]. However, most of the time, there is a good correlation between the clinical state of the patient and the CT findings [7-9]. Our two cases show that despite the unusual clinical presentation, the CT findings were alarming, with an extensive parenchymal involvement. However, the CT findings did not change the therapy planning, and because of good tolerance, the patients were discharged after introduction of hydroxychloroquine. \u00a0\nE.\u00a0\u00a0 \u00a0Take Home Message / Teaching Points\nA mismatch between the symptoms and the CT findings can be found. We have to be aware of this possible mismatch, especially because of the high sensitivity of CT. However, the RT-PCR remains the gold-standard and we should not forget that we are first treating patients and not images. The main point should be the clinical state of the patient and his potential comorbidities, to avoid intensive care only based on CT findings.\nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "COVID-19, pneumonia, Non-COVID-19, pneumonia, such, as, pneumococcal, or, legionella, pneumonia, Pulmonary, mucinous, adenocarcinoma, (formerly, bronchoalveolar, carcinoma), Organising, pneumonia",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03//16667_1_1.png?itok=fCBRNq5W",
            "caption": "Chest CT of patient one showing bilateral ground-glass opacities with tendency to consolidation and crazy paving with lower lung and peripheral distribution"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03//16667_2_1.png?itok=MS3o42Zi",
            "caption": "Chest CT of patient two showing peripheral ground-glass opacities, sub-pleural reticulations and traction bronchiectasis"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/16667",
    "time": "27.03.2020"
  },
  "16669": {
    "case_id": 16669,
    "title": "Severe COVID-19 infection in young patient with hypertension on ACE inhibit",
    "section": "Chest imaging",
    "age": "30",
    "gender": "female",
    "diagnosis": "Coronavirus disease-19 (COVID-19)",
    "history": "A 30-year-old female patient with a past medical history of asthma, morbid obesity (BMI 39.5), and hypertension on an angiotensin-converting enzyme (ACE) inhibitor presented with a 6-day history of fever (Tmax 38.9\u00b0C), cough, and shortness of breath. Laboratory studies were remarkable for lymphopenia (0.6\u00d7103/\u00b5L, normal range 0.9\u00d7103/\u00b5L \u2013 3.3\u00d7103/\u00b5L), elevated serum creatinine (1.3 mg/dL, normal range 0.6 mg/dL \u2013 1.2 mg/dL), elevated aspartate aminotransferase (73 IU/L, normal range 13 IU/L \u2013 39 IU/L), elevated c-reactive protein (8.6 mg/dL, normal range 0 \u2013 1 mg/dL), elevated procalcitonin (2.39 ng/mL, normal < 0.1 ng/mL), elevated interleukin-6 (197 pg/mL, normal \u2264 5 pg/mL), elevated cardiac troponin I (142 ng/L, normal < 15 ng/L), and mildly elevated d-dimer (570 ng/mL, normal < 500 ng/mL). She reported a history of contact with a COVID-positive co-worker and no recent travel. Influenza A/B RT-PCR were negative. She developed acute respiratory distress and was emergently intubated.",
    "image_finding": "AP chest X-ray after emergent intubation demonstrates bilateral upper-lobe predominant patchy and confluent airspace opacities (Fig. 1).\nCTA chest performed on presentation demonstrates bilateral patchy and diffuse ground-glass opacities with a more focal consolidative process in the right lower-lobe and upper-lobe predominant air bronchograms. There was no evidence of acute or chronic pulmonary embolism (Figs. 2a-e).\nProne portable PA chest X-ray on second day of admission demonstrates persistent airspace opacities, cardiomegaly and haziness of the cardiac borders (Fig. 3).",
    "discussion": "A. Background\nCoronavirus disease-19 (COVID-19) is a novel viral pandemic that has been reported to have a more severe course in older patients and those with comorbidities including hypertension [1, 2]. The virus invades cells by binding to the angiotensin-converting enzyme 2 (ACE2) receptor, which is expressed in epithelial cells in the lung, heart, kidney, intestine, and blood vessels [3]. It has been theorised that patients taking ACE inhibitors could have increased risk of severe infection due to upregulated ACE2 receptor expression, though there has not yet been conclusive clinical or experimental data [4\u20136].\nB. Clinical Perspective\nDyspnoea from COVID infection has been reported a median of 7 days after symptom onset and elevated d-dimer has been associated with decreased survival [1].\u00a0 D-dimer is an acute phase reactant which may be elevated in the setting of active infection/inflammation, and is not specific for acute pulmonary embolism, though cases of concomitant COVID infection and acute pulmonary embolism have been reported [7, 8]. Acute kidney injury has been reported in up to 19% of COVID patients admitted to the intensive care unit [9].\nC. Imaging Perspective\nRadiographic and computed tomography (CT) imaging may be initially normal in COVID infection, with up to 50% of patients having normal CT imaging within the first two days of symptom onset [10]. Early CT findings include multi-lobar, peripheral-predominant, patchy ground-glass opacities with or without consolidations. Additional findings can include air bronchograms, a halo sign, and crazy paving pattern [11]. \u00a0\nD. Outcome\nCOVID-19 RT-PCR was positive. The patient was initiated on hydroxychloroquine, azithromycin, and tocilizumab, positioned prone for severe ARDS, and developed worsening acute kidney injury with serum creatinine of 3.0.\nE. Teaching Points\nPatients of all ages with comorbidities including hypertension have an increased risk of developing severe COVID disease. Serum d-dimer elevation is not specific to pulmonary embolism, though cases of concomitant COVID infection and acute pulmonary embolism have been reported. ACE inhibitors could have theoretical increased risk of severe infection due to upregulated ACE2 receptor expression, though conclusive data has not yet been reported.\nWritten patient consent for this case was waived by the Editorial Board. Patient data may have been modified to ensure patient anonymity.",
    "differential_diagnosis": "Coronavirus, disease-19, (COVID-19), Multifocal, bacterial, pneumonia, Acute, respiratory, distress, syndrome, (ARDS), Hypersensitivity, pneumonitis, Pulmonary, oedema",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03//16669_1_1.jpeg?itok=yv6VSSIE",
            "caption": "AP chest X-ray after emergent intubation demonstrates bilateral upper-lobe predominant patchy and confluent airspace opacities."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03//16669_2_1.jpg?itok=UFqaOdhv",
            "caption": "CTA chest performed on presentation demonstrates bilateral patchy and diffuse ground-glass opacities with a more focal consolidative process in the right-lower lobe and upper lobe predominant air bronchograms. There was no evidence of acute or chronic pulmonary embolism."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03//16669_2_2.jpg?itok=yXhVbUOX",
            "caption": "CTA chest performed on presentation demonstrates bilateral patchy and diffuse ground-glass opacities with a more focal consolidative process in the right-lower lobe and upper lobe predominant air bronchograms. There was no evidence of acute or chronic pulmonary embolism."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03//16669_2_3.jpg?itok=4FJuFZ_0",
            "caption": "CTA chest performed on presentation demonstrates bilateral patchy and diffuse ground-glass opacities with a more focal consolidative process in the right-lower lobe and upper lobe predominant air bronchograms. There was no evidence of acute or chronic pulmonary embolism."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03//16669_2_4.jpg?itok=GzHPcLm5",
            "caption": "CTA chest performed on presentation demonstrates bilateral patchy and diffuse ground-glass opacities with a more focal consolidative process in the right-lower lobe and upper lobe predominant air bronchograms. There was no evidence of acute or chronic pulmonary embolism."
          },
          {
            "number": "Figure 2e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03//16669_2_5.jpg?itok=hF8r65sv",
            "caption": "CTA chest performed on presentation demonstrates bilateral patchy and diffuse ground-glass opacities with a more focal consolidative process in the right-lower lobe and upper lobe predominant air bronchograms. There was no evidence of acute or chronic pulmonary embolism."
          },
          {
            "number": "Figure 2f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03//16669_2_6.jpg?itok=viVgIbq3",
            "caption": "CTA chest performed on presentation demonstrates bilateral patchy and diffuse ground-glass opacities with a more focal consolidative process in the right-lower lobe and upper lobe predominant air bronchograms. There was no evidence of acute or chronic pulmonary embolism."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03//16669_3_1.jpeg?itok=MEjMfD2g",
            "caption": "Prone portable PA chest X-ray on second day of admission demonstrates persistent airspace opacities, cardiomegaly and haziness of the cardiac borders."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/16669",
    "time": "30.03.2020"
  },
  "16670": {
    "case_id": 16670,
    "title": "CT appearance of two cases of novel coronavirus pneumonia (COVID-19)",
    "section": "Chest imaging",
    "age": "63",
    "gender": "male",
    "diagnosis": "Coronavirus disease 2019 pneumonia (COVID-19)",
    "history": "We report a private practice experience of two cases of novel coronavirus pneumonia (COVID-19) patients who were referred at our attention due to the persistence of a-specific symptoms.\nCase 1\nA 63-year-old man affected by hypertension performed X-ray examination for dispnoea: he had history of two-days-fever (37.5\u00b0 C) one week before.\nPatient did not perform chemistry analysis before imaging examinations.\nX-ray exam did not show any abnormalities; but after 2 days he underwent high-resolution computed tomography (HRCT) examination as a further study.\nCase 2\nA 80-year-old woman with asthenia, fever and mental confusion, recommended by her doctor, performed X-ray of the chest. The exam showed an opacity in the right lobe, therefore HRCT diagnostic deepening was suggested. The patient reported that in the last two weeks she only met her children and did not perform chemistry analysis before.",
    "image_finding": "Non-enhanced CT exams were acquired with a Multislice-Computed Tomography\nscanner (GE Optima 64, General Electric Healthcare, Milwaukee, WI) with the\nfollowing parameters: kV 120, mAs 80-300, rotation time 0.5 sec, slice thickness\n1.25 mm.\nHRCT image of case 1 showed a rare diffuse ground-glass opacitity (GGO) with interlobular septal thickening in the subpleural area of the postero-inferior segments of both lobes with a more accentuated finding on the right (Fig. 1).\nHRCT image of case 2 reported different pattern with bilateral multifocal\nGGOs associated with consolidation areas with patchy distribution,\npredominantly peripheral/subpleuric and with greater involvement of the middle\nand lower lobes (Fig. 2).",
    "discussion": "The new coronavirus, SARS-CoV-2 (severe acute respiratory syndrome\ncoronavirus-2), is identified as causing lung infection, now called COVID-\n19 (Coronavirus disease-2019). It was first reported in the city of Wuhan in\ncentral China, but at present it has spread all over the world, therefore it has been\nclassified by the World Health Organization as pandemia. [1]\nThe infection tends to be asymptomatic or with aspecific symptoms (fever, cough,\nasthenia, diarrhoea). However, in almost 10% of cases, generally with older people with comorbidity,\nit could evolve into respiratory failure for diffuse alveolar damage\n(acute respiratory distress syndrome), multi organ failure (MOF)\nextrapolmonary and shock, up to the exitus [2-4].\nAt the early stage, X-ray examination should be normal; in the advanced stages X-ray\nof the chest shows bilateral multifocal alveolar opacifications, which tend to\nconfluence until the lung is completely opaque, with possible small association of\npleural fluid. [5]\nAt HRCT, COVID-19 pneumonia has various and nonspecific findings and patterns,\nthat may be encountered in other lung infections, such as influenza A, CMV, other\ncoronaviruses (SARS, MERS), streptococcus and pneumonia from atypical germs\n(clamydia, mycoplasma); however in literature different patterns of this\nviral infection at different stages of the disease are described.\nIn the early stage, focal or diffuse GGOs are the most common finding as reported by different studies with an incidence ranging from 57 to 98% [6-8].\nAdvanced disease is characterised by multifocal and bilateral GGOs, \u2018crazy paving\u2019 pattern, reversed halo-sign until pulmonary consolidations.\n\u2018Crazy paving\u2019 pattern is sometimes present and according to the study of Pan et al. is associated with a progression from advanced to peak stage [9].\nReversed halo-sign was found in different cases of advanced disease and its considered a sign of progression [8]\nMultifocal, patchy, or segmental consolidation, distributed in subpleural areas or along bronchovascular bundles, is usually presented and associated with progression of clinical symptoms.\nOther signs described in literature are vascular enlargement nearby the lesions, focal nodules and fibrosis [10].\nLymph node enlargement is not often encountered in patients affected by COVID-19 pneumonia.\nAccording to the study published by Pan et al. case 1 should be classified as early stage disease and the second one as progressive stage disease [9]. Patients were immediately informed of the risk of COVID-19 infection and directed to the first aid relevant facilities. The final diagnosis was made by real time \u2013 polymerase chain reaction (RT-PCR) obtained from oropharyngeal swab specimens.\nWritten patient consent for this case was waived by the Editorial Board. Patient data may have been modified to ensure patient anonymity.",
    "differential_diagnosis": "Coronavirus, disease, 2019, pneumonia, (COVID-19), Non-specific, interstitial, pneumonia, Mycoplasma, pneumonia, Viral, pneumonia, Bacterial, pneumonia, Hypersensitivity, pneumonitis, (HSP)",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03//16670_1_1.png?itok=_stX4YOv",
            "caption": "Axial (A) and coronal (B) HRCT images show diffuse ground-glass attenuation in the postero-inferior segment of the right lobe with subpleural laminar thickening; smaller alteration with similar densitometric characteristics in the corresponding left-lobe"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-03//16670_2_1.png?itok=BkJziRV9",
            "caption": "Axial HRCT images at different sections (A-B-C) reveal multifocal and bilateral GGOs and \"crazy paving\" pattern"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/16670",
    "time": "02.04.2020"
  },
  "16672": {
    "case_id": 16672,
    "title": "Severe acute respiratory disease in a young man with COVID-19 infection",
    "section": "Chest imaging",
    "age": "34",
    "gender": "male",
    "diagnosis": "COVID-19 pneumonia",
    "history": "A previously healthy 34-year-old man presented to the emergency department with a 7-day history of high fever, dry cough and dyspnoea. Laboratory tests showed elevation of C-reactive protein (45 mg/L), while white cell count was normal.",
    "image_finding": "Chest X-ray performed on admission showed only a small opacity in the right upper perihilar region (Fig. 1).\nChest CT performed two hours later, due to worsening of patient conditions, showed diffuse bilateral patchy ground-glass opacities, with both subpleural and central distribution (Fig. 2); some pulmonary consolidations were also present in posterior basal segments of the lower lobes (Fig. 3). There was no lung effusion nor mediastinal lymph node-enlargement.",
    "discussion": "At the end of 2019 a novel coronavirus was identified as the cause of a cluster of pneumonias in Wuhan (China). It rapidly spread throughout China, followed by an increasing number of cases in other countries. In February 2020, the World Health Organization designated the disease COVID-19 (coronavirus disease-2019) [1].\nThe incubation period for COVID-19 is thought to be within 14 days, with most cases occurring approximately 4 days after exposure. Common symptoms include fever, dry cough and shortness of breath; other symptoms include fatigue, headache, sore throat and haemoptysis. Older patients with comorbidities are more likely to develop respiratory failure due to severe alveolar damage. Lymphopenia is a common finding in laboratory tests [1-2].\nRadiological examinations are of great importance in the detection of the disease. Chest X-ray is not sensitive in the early stages of the infection and could miss some manifestations of the disease, which are otherwise evident on CT. Typical CT findings include multifocal bilateral ground-glass opacities associated with patchy consolidation, with predominant subpleural distribution and posterior part or lower lobe predilection. Pleural effusion and mediastinal lymph nodes enlargement are rarely reported. CT can also assess the disease severity to guide clinical management and it\u2019s useful in follow-up [3-4].\nThe final diagnosis is confirmed by a positive RT-PCR assay for COVID-19, using respiratory samples (usually nasopharyngeal or throat swabs). RT-PCR remains the reference standard for the diagnosis, but its results can be affected by sampling errors and low virus load [2].\nThe patient developed respiratory failure and was transferred to the intensive care unit. He recovered well and was discharged after three weeks after admission with complete resolution of symptoms and negative COVID-19 swab.\nTake home message\nChest CT has an important diagnostic role in COVID-19 infection, especially when confirmatory tests, such as the RT-PCR, are unavailable or undetermined.\nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "COVID-19, pneumonia, Bacterial, pneumonia, Acute, respiratory, distress, syndrome, (ARDS)",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-04//16672_1_1.jpg?itok=42mkNIGQ",
            "caption": "Chest X-ray shows a small opacity in the right upper perihilar region"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-04//16672_2_1.jpg?itok=AKK_Wwa5",
            "caption": "Chest CT, axial (a-c) and coronal (d) views, shows multifocal bilateral ground-glass opacities"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-04//16672_2_2.jpg?itok=bZSwWSL-",
            "caption": "Chest CT, axial (a-c) and coronal (d) views, shows multifocal bilateral ground-glass opacities"
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-04//16672_2_3.jpg?itok=VYqfBWRk",
            "caption": "Chest CT, axial (a-c) and coronal (d) views, shows multifocal bilateral ground-glass opacities"
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-04//16672_2_4.jpg?itok=uvS9QpXv",
            "caption": "Chest CT, axial (a-c) and coronal (d) views, shows multifocal bilateral ground-glass opacities"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-04//16672_3_1.jpg?itok=cScMNvkV",
            "caption": "Chest CT shows pulmonary consolidations in the posterior basal segments of the lower lobes"
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-04//16672_3_2.jpg?itok=8evPWTNO",
            "caption": "Chest CT shows pulmonary consolidations in the posterior basal segments of the lower lobes"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/16672",
    "time": "01.04.2020"
  },
  "16673": {
    "case_id": 16673,
    "title": "Supine vs. prone chest CT in a COVID-19 patient during mechanical ventilation",
    "section": "Chest imaging",
    "age": "72",
    "gender": "female",
    "diagnosis": "COVID-19 acute respiratory distress syndrome (ARDS)",
    "history": "A 72-year-old female patient with a history of ischaemic stroke, ocular myasthenia, arterial hyper-tension, and hypercholesterolaemia was admitted to the emergency department because of dyspnoea.\nShe reported having fever and cough for a week.\nAt admission, her pulse oximeter saturation was 84%, the tympanic temperature was 37.6 \u00b0C.\nLaboratory findings revealed elevated C-reactive protein (19.69 mg/dL, normal range 0.01-0.5 mg/dL) and mild lymphopenia (0.7X10^3/mm^3, normal range 1.0-4.0 X10^3/mm^3).\nThe patient also underwent non-contrast chest CT.",
    "image_finding": "The non-contrast chest CT performed at admission (Fig. 1) showed bilateral, symmetrical, sub-pleural ground-glass opacities (GGO), predominantly in the right lower lobe, with initial interlobular septal thickening (crazy-paving pattern).\nThere was no radiological evidence of pleural effusion or mediastinal lymphadenopathy.\nThese findings were highly suspicious for SARS-CoV-2 infection.\nAP chest X-ray (Fig. 2) on day two from admission showed interval intubation, internal jugular vein CVC, nasogastric tube, and bilateral patchy airspace opacities.\nA new chest CT scan (Figs. 3-5) was performed on day three of admission, in both supine and prone positions during mechanical ventilation.\nCompared to the prior CT, the supine scan showed a significant increase in the extent and atten-uation of the opacities with pulmonary consolidation and atelectasis of the right lower lobe.\nThe prone scan showed a partial recovery of the aerated lung parenchyma in the right inferior lobe with a small area of residual consolidation in the posterior segment of the right lower lobe.",
    "discussion": "Background\nCOVID-19 is an infectious disease that causes mild symptoms in most people; however, some patients, especially those who have comorbidities and the elderly, can progress to pneumonia and acute respiratory distress syndrome (ARDS) [1,2].\nNevertheless, also healthy and young people can develop a severe illness as it happened in Northern Italy with \u2018\u201cpatient 1\u2019, a man in his 30s [3].\nClinical Perspective\nMost patients affected by COVID-19 present primarily with fever, myalgia or fatigue, and\ndry cough [1], others may not have clinical symptoms nor radiological abnormalities at presenta-tion [4].\nAt present, the RT-PCR test is the gold standard for the final diagnosis of COVID-19 [5], even if it is burdened by a false negative rate.\nPatients who progress to ARDS and multi-organ failure could benefit from methylprednisolone to decrease the risk of death [6].\nIn patients with severe ARDS, prone ventilation has been demonstrated to improve oxygenation and respiratory compliance compared to supine positioning [7].\nImaging Perspective\nChest CT scan could be useful for diagnosis of COVID-19 in highly suspected patients, but it should not be used for screening or early diagnosis because of its low specificity that does not allow differentiation between COVID-19 pneumonia and other cases of infection [8].\nChest CT has a role in the follow-up of patients until complete recovery [9].\nPatients who develop respiratory deterioration and instability can benefit from lung ultrasonogra-phy that is more sensitive than chest X-ray for evaluation of pneumonia and\nARDS [10].\nCT scan in supine and prone position allows to investigate the modification in lung morphology with changes in body position, and leads to a description in vivo of the lung pathology in ARDS.\nOutcome\nSince admission, the patient was given antiviral treatment based on lopinavir/ritonavir. Due to the rapidity of respiratory deterioration, she however was transferred to the intensive care unit where she underwent invasive mechanical ventilation.\nMeanwhile, laboratory testing for SARS-CoV-2 returned positive.\nThe patient is currently in the intensive care unit and her clinical condition is stable.\nTake-home Message\nPatients that develop ARDS require a big effort to adjust the ventilatory strategy. [11]\nThe chest CT has a great impact on therapeutic strategy since it allows to guide response to a prone position and for making decisions related to weaning the patient form ventilatory support.\nThe addition of a prone scan may be useful to identify the most efficacious strategy for the venti-lation of these patients.\nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "COVID-19, acute, respiratory, distress, syndrome, (ARDS), Idiopathic, pulmonary, fibrosis, (IPF), Multifocal, bacterial, pneumonia, Acute, respiratory, distress, syndrome, (ARDS)",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-04//16673_1_1.jpg?itok=1W_gipsD",
            "caption": "Non-contrast chest CT obtained in the emergency department showed bilateral subpleural ground-glass opaci-ties (GGO) with crazy-paving pattern"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-04//16673_1_2.jpg?itok=liNfJ0JB",
            "caption": "The coronal view obtained at the inferior lobes showed major involvement of the right lower lobe"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-04//16673_2_1.jpg?itok=FcqCb-1O",
            "caption": "AP chest X-ray obtained on the second day of admission demonstrated diffuse bilateral opacities, tracheal cannula, na-sogastric tube, internal jugular CVC"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-04//16673_3_1.jpg?itok=RaIsJBQK",
            "caption": "Non-contrast chest CT in axial view during supine positioning obtained on the third day of admission demon-strated extensive pulmonary consolidation of the right lower lobe and patchy opacities in the upper lobe"
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-04//16673_3_2.jpg?itok=yyKyxzjb",
            "caption": "Non-contrast chest CT scan in axial view in prone positioning demonstrated recovery of aerated lung paren-chyma in the right lower lobe"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-04//16673_4_1.jpg?itok=fVCH-lKV",
            "caption": "Non-contrast chest CT in sagittal view during supine positioning obtained on the third day of admission demonstrated extensive pulmonary consolidation of the right lower lobe and patchy opacities with initial consolidation in the upper lobe"
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-04//16673_4_2.jpg?itok=6331B6zQ",
            "caption": "Non-contrast chest CT scan in sagittal view in prone positioning demonstrated recovery of aerated lung parenchyma"
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-04//16673_5_1.jpg?itok=sxkTfccW",
            "caption": "Non-contrast chest CT in coronal view during supine positioning obtained on the third day of admission demonstrated extensive pulmonary atelectasis of the right lower lobe"
          },
          {
            "number": "Figure 5b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-04//16673_5_2.jpg?itok=G1YsFlc_",
            "caption": "Non-contrast chest CT scan in coronal view in prone positioning demonstrated a small area of residual parenchymal consolidation in the posterior segment of the right lower lobe"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/16673",
    "time": "01.04.2020"
  },
  "16674": {
    "case_id": 16674,
    "title": "Typical and atypical CT findings in an RT-PCR confirmed COVID-19 patient",
    "section": "Chest imaging",
    "age": "53",
    "gender": "female",
    "diagnosis": "Coronavirus disease-19 (COVID-19)",
    "history": "A 53-year-old woman was referred to our emergency department by her general practitioner (GP) because of increasing dyspnoea and suspicion of COVID-19 infection. Symptoms started five days prior with muscle ache, sore throat, cough, general malaise and fever up to 38\u00b0C. No other remarkable medical history was noted. Laboratory results showed only a mildly increased CRP (16 mg/L). There was no hypoxaemia. She was tested for COVID-19, influenza and respiratory syncytial virus.",
    "image_finding": "In the general workup of a patient with respiratory symptoms, an AP bedside chest X-ray was performed. This demonstrated a normal size of the heart without evidence of alveolar consolidation or pleural effusion. However, there was a noticeable increase in interstitial trauma at the base of the lungs. (Fig. 1)\nThe reverse transcriptase-polymerase chain reaction (RT-PCR) was positive for the SARS-CoV-2 nucleic acid and a non-enhanced CT scan was performed two days later to evaluate the progression and extent of the disease. CT showed bilateral multifocal ground-glass opacities with a mainly peripheral distribution, more pronounced in the left lung, and interstitial septal thickening / fibrotic bands in the base of the lungs. (Figs. 2-4) The presence of mediastinal lymphadenopathies was also noted. (Figs. 5, 6)",
    "discussion": "Background\nLate 2019, a new virus emerged in Wuhan, China, causing multiple cases of severe pneumonia and several deaths. The virus, which got named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), had a worldwide outbreak in the weeks following and is currently declared a global health emergency by the World Health Organization. This infectious disease is known internationally as COVID-19. [1-3] The virus itself is transmitted by respiratory droplets, other methods of transmission are yet to be confirmed or discovered. [2]\nClinical perspective\nThe most common clinical features of the disease are fever and respiratory symptoms. The most common laboratory finding is lymphopenia. Generally, the elderly and patients with comorbidities are at risk of developing acute respiratory distress syndrome (ARDS) and the need to be admitted to an intensive care unit (ICU). [4] At the moment the mortality rate is estimated to be around 3%. [2] As the disease is easily spread and numerous people get infected, ICUs face great challenges as the number of new patients could exceed the maximum capacity.\n\u00a0RT-PCR is typically used to diagnose a COVID-19 infection. Sensitivity ranges from 60% up to 97% in the known literature. [5-7] Imaging could help us estimate a better probability of infection in patients with high clinical suspicion but a negative or unknown RT-PCR result, thus increasing the diagnostic value of CT. [8, 9] Imaging is also used to evaluate the severity of the disease and for follow-up.\nImaging perspective\nIn the very early course of the disease imaging findings may be normal. CT is more sensitive than chest radiography and shows characteristic imaging patterns. Most typical in the early stages of the disease are the bilateral ground-glass opacities that have a more peripheral and basal distribution. As the disease progresses, crazy paving and consolidation become the more dominant CT findings. Pleural effusion and mediastinal lymphadenopathy are atypical findings. [8-13]\nOutcome\nOur patient was clinically stable and was put into quarantine at home. \nTake-home messages\nThe exact role of CT imaging in COVID-19 cases is not yet clear, but it shows increasing value in diagnosing COVID-19, especially when there is high clinical suspicion with an initial negative or unknown RT-PCR. Imaging also helps to estimate the severity and monitor the course of the disease.\nLike the French Society of Radiology, the Belgian Society of Radiology recommends unenhanced CT as the preferred first imaging technique in evaluating proven or suspected COVID-19 infections when clinically necessary. Chest radiography should be limited and may only be considered in certain cases as an alternative for CT. Chest radiography does have a role in the follow-up imaging of patients admitted to an ICU with portable radiography units. [14, 15] \nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Coronavirus, disease-19, (COVID-19), Upper, respiratory, tract, infection, Bacterial, pneumonia, Influenza",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-04//16674_1_1.jpg?itok=xL7DWnT5",
            "caption": "AP bedside chest X-ray. This demonstrated a normal size of the heart without evidence of alveolar consolidation or pleural effusion. However, there was a noticeable increase in interstitial trauma at the base of the lungs"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-04//16674_2_1.jpg?itok=Ul0Buk5e",
            "caption": "Non-enhanced CT scan. Bilateral multifocal ground-glass opacities with a mainly peripheral distribution, more pronounced in the left lung"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-04//16674_3_1.jpg?itok=pLNEjNyM",
            "caption": "Non-enhanced CT scan. Bilateral multifocal ground-glass opacities with a mainly peripheral distribution, more pronounced in the left lung"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-04//16674_4_1.jpg?itok=fe73svcN",
            "caption": "Non-enhanced CT scan. Bilateral multifocal ground-glass opacities with a mainly peripheral distribution and interstitial septal thickening/ fibrotic bands in the base of the lungs"
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-04//16674_5_1.jpg?itok=nLg_GX_R",
            "caption": "Non-enhanced CT scan. Mediastinal lymphadenopathies"
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-04//16674_6_1.jpg?itok=rPIfezcJ",
            "caption": "Non-enhanced CT scan. Mediastinal lymphadenopathies"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/16674",
    "time": "01.04.2020"
  },
  "16689": {
    "case_id": 16689,
    "title": "COVID-19 household case report: Typical imaging findings",
    "section": "Chest imaging",
    "age": "83",
    "gender": "female",
    "diagnosis": "Coronavirus disease-19 (COVID-19)",
    "history": "An 83-year-old female patient, presented with fever (38C), dry cough and asthenia for four days. She denied dyspnoea, chest pain, and gastrointestinal symptoms. She lived with her daughter. Laboratory studies revealed elevated serum ferritin (401 ng/mL; normal range 12 ng/mL - 300 ng/mL), slightly increased C-reactive protein (CRP, 7.58 mg/L; normal range <5.0 mg/L). The patient was hospitalised for further care.\nLater, her 59-years-old daughter presented with fever (38.6C), dry cough, myalgia, headache. The patient was a tobacco cigarette smoker.",
    "image_finding": "The mother\u2019s non-contrast chest CT (Figs. 1a-f) demonstrated multifocal bilateral patchy ground-glass opacities with a predominantly lower and peripheral distribution. Superimposed on the ground-glass opacities a linear pattern with multiple small irregular lines was visible, consistent with crazy-paving pattern and diffuse bronchial wall thickening. No pleural effusion was found.\nThe daughter\u2019s non-contrast chest CT (Figs. 2a-d) also demonstrated multifocal bilateral patchy ground-glass opacities with a predominantly lower and peripheral distribution and thickness of interlobular septa. In addition, CT images show bilateral alveolar consolidation in the lower and back parts of both lungs. Apical-predominant centrilobular emphysema was also evident.",
    "discussion": "Background\nCoronavirus disease-19 (COVID-19) is a disease caused by severe respiratory acute syndrome \u2013 coronavirus \u2013 2 (SARS-CoV-2). It was initially reported in Wuhan, China, in December 2019, and is currently spreading worldwide [1,2]. The World Health Organization (WHO) stated that COVID-19 was a global health emergency on January 30th, 2020, and classified it as a pandemic on March 11th, 2020 [3].\nSARS-CoV-2 is the seventh known coronavirus able to infect humans. Two other remarkable examples include severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS) [3-5].\nClinical Perspective\nThe majority of patients with lower respiratory tract infections caused by COVID-19 presents with cough, fever and other non-specific symptomatology including dyspnoea, myalgia, headache and fatigue [3,4]. Some patients may also present early gastrointestinal symptoms, including vomiting, nausea, and diarrhoea, which preceded respiratory symptoms [6]. About 20% of cases are severe, and the fatality rate is approximately 3% [1,3].\nImaging perspective\nReal-time polymerase chain reaction (RT-PCR) is the current standard diagnostic method used to detect viral nucleotides from specimens obtained by nasopharyngeal swab, oropharyngeal swab, bronchoalveolar lavage, or tracheal aspirate [4,7]. Nevertheless, this method sensitivity is as low as 60-71% for detecting SARS-CoV-2, which can probably be attributed to the low viral load present in test samples [7].\nBy contrast, chest CT has revealed about 56-98% sensitivity in detecting COVID-19 even at initial presentation and can be useful in correcting false negatives acquired from RT-PCR during initial stages of infection [1,7].\nDuring the early course of infection, main lung abnormalities include peripheral focal or multifocal ground-glass opacities affecting both lungs in approximately 50%\u201375% of patients [1-3]. As the progression of the disease, crazy paving and consolidation become the major CT findings, peaking around 9\u201313 days of disease. Then, it\u2019s usually followed by a gradual clearing at near 1 month and beyond [1-3]. Pleural effusions and mediastinal lymphadenopathy are usually absent in COVID-19 patients [2].\nFinally, it is important to point out that chest CT is more sensitive than chest X-ray for the detection of ground-glass opacities [2].\nOutcome\nThoracic imaging has a crucial role in the evaluation of patients suspected of COVID-19. Prompt recognition of imaging patterns based on the infection time course is essential for not only understanding the natural history of infection but also for helping to predict patient evolution and possible complication development [3].\nTeaching points\nThe hallmark in the clinical diagnosis of COVID-19 infection includes focal or multifocal ground-glass opacities, crazy paving, and consolidation, with peripheral predominance.\nWritten patient consent for this case was waived by the Editorial Board. Patient data may have been modified to ensure patient anonymity.",
    "differential_diagnosis": "Coronavirus, disease-19, (COVID-19), Influenza, pneumonia, Organising, pneumonia, Drug, toxicity, Connective, tissue, disease",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-04//16689_1_1.jpg?itok=nkLpv1ox",
            "caption": "Axial (a,b), sagittal (c,d) and coronal (e,f) non-contrast chest CT demonstrated multifocal bilateral patchy ground-glass opacities with a predominantly lower and peripheral distribution. It is also evident associated thickness of interlobular septa in the affected areas (crazy-paving pattern) and diffuse bronchial wall thickening."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-04//16689_1_2.png?itok=2sknyBsH",
            "caption": "Axial (a,b), sagittal (c,d) and coronal (e,f) non-contrast chest CT demonstrated multifocal bilateral patchy ground-glass opacities with a predominantly lower and peripheral distribution. It is also evident associated thickness of interlobular septa in the affected areas (crazy-paving pattern) and diffuse bronchial wall thickening."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-04//16689_1_3.png?itok=6xwrwfNS",
            "caption": "Axial (a,b), sagittal (c,d) and coronal (e,f) non-contrast chest CT demonstrated multifocal bilateral patchy ground-glass opacities with a predominantly lower and peripheral distribution. It is also evident associated thickness of interlobular septa in the affected areas (crazy-paving pattern) and diffuse bronchial wall thickening."
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-04//16689_1_4.png?itok=5H8pmm7P",
            "caption": "Axial (a,b), sagittal (c,d) and coronal (e,f) non-contrast chest CT demonstrated multifocal bilateral patchy ground-glass opacities with a predominantly lower and peripheral distribution. It is also evident associated thickness of interlobular septa in the affected areas (crazy-paving pattern) and diffuse bronchial wall thickening."
          },
          {
            "number": "Figure 1e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-04//16689_1_5.png?itok=I_Of99yF",
            "caption": "Axial (a,b), sagittal (c,d) and coronal (e,f) non-contrast chest CT demonstrated multifocal bilateral patchy ground-glass opacities with a predominantly lower and peripheral distribution. It is also evident associated thickness of interlobular septa in the affected areas (crazy-paving pattern) and diffuse bronchial wall thickening."
          },
          {
            "number": "Figure 1f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-04//16689_1_6.jpg?itok=XEztzuKc",
            "caption": "Axial (a,b), sagittal (c,d) and coronal (e,f) non-contrast chest CT demonstrated multifocal bilateral patchy ground-glass opacities with a predominantly lower and peripheral distribution. It is also evident associated thickness of interlobular septa in the affected areas (crazy-paving pattern) and diffuse bronchial wall thickening."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-04//16689_2_1.png?itok=K-lRrNBP",
            "caption": "Axial (a,b), sagittal (c) and coronal (d) non-contrast chest CT demonstrated multifocal bilateral patchy ground-glass opacities with a predominantly lower and peripheral distribution, associated thickness of interlobular septa and bilateral alveolar consolidation in the lower and back parts of both lungs. Apical-predominant centrilobular emphysema was also evident."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-04//16689_2_2.png?itok=YxqU61nI",
            "caption": "Axial (a,b), sagittal (c) and coronal (d) non-contrast chest CT demonstrated multifocal bilateral patchy ground-glass opacities with a predominantly lower and peripheral distribution, associated thickness of interlobular septa and bilateral alveolar consolidation in the lower and back parts of both lungs. Apical-predominant centrilobular emphysema was also evident."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-04//16689_2_3.png?itok=qBVtXkeE",
            "caption": "Axial (a,b), sagittal (c) and coronal (d) non-contrast chest CT demonstrated multifocal bilateral patchy ground-glass opacities with a predominantly lower and peripheral distribution, associated thickness of interlobular septa and bilateral alveolar consolidation in the lower and back parts of both lungs. Apical-predominant centrilobular emphysema was also evident."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-04//16689_2_4.png?itok=vpuGlfEC",
            "caption": "Axial (a,b), sagittal (c) and coronal (d) non-contrast chest CT demonstrated multifocal bilateral patchy ground-glass opacities with a predominantly lower and peripheral distribution, associated thickness of interlobular septa and bilateral alveolar consolidation in the lower and back parts of both lungs. Apical-predominant centrilobular emphysema was also evident."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Respiratory system",
      "Thorax"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/16689",
    "time": "09.04.2020"
  },
  "16691": {
    "case_id": 16691,
    "title": "Unusual appearance of COVID-19 pneumoni",
    "section": "Chest imaging",
    "age": "61",
    "gender": "male",
    "diagnosis": "COVID-19 bilateral pneumonia",
    "history": "A 61-year-old male patient presented with three days fever and mild sore throat. Past history of diabetes mellitus and arterial hypertension. Blood analysis showed mild elevation of C-reactive protein level (11,26 mg/l ), normal LDH level, normal WBC count with neutrophylia (80,4%) and hyperglycaemia (151 mg/dl).",
    "image_finding": "Chest X-ray (antero-posterior view): consolidations in right upper lobe sharply defined at the fissure, and in lower zone of the left-lung. \nChest CT was requested in order to exclude associated pathologies and for treatment decisions; it was performed using a 16-row multidetector CT without contrast agent with volumetric acquisition (0,75 mm collimation and 1 mm reconstructed slices). Bilateral finding of multiple consolidations at random segmental distribution, the major one in the dorsal segment of right upper lobe, with evidence of air bronchogram, and extensive peripheral ground-glass opacities. Spaired lung areas show no interstitial abnormalities.\u00a0 Aspecific mediastinal lymphoadenomegalies. No pleural effusion.",
    "discussion": "Since December 2019, 41 cases of pneumonia of unknown aetiology have been confirmed in Wuhan city, Hubei Province, China.\u00a0 Dr Jianguo Xu, an academician of the Chinese Academy of Engineering who led a scientific team, announced that a new\u2010type coronavirus, tentatively named by World Health Organization as the 2019\u2010new coronavirus (2019\u2010nCoV), had caused this outbreak. [1]\nIn Italy, the first outbreak of the disease was detected on 21st february 2020 with 16 patients in Lombardia [2], and as to 29 March the total number of affected patients has increased to 97.689 [3].\nThose infected with the virus may be asymptomatic or develop flu-like symptoms, including fever, cough and dyspnoea [4].\u00a0 In more severe cases, the disease may progress to pneumonia, multi-organ failure, and exitus [5].\nChest X-ray imaging is mostly negative, especially in early stages of disease [6], or it can show diffuse interstitial abnormalities and/or multifocal consolidations until white lungs in late stages.\nCT scan is perfomed in clinical-radiological discrepancy and to help differential diagnosis. The most common findings are diffuse ground-glass opacities, especially in the first stages, with or without interlobular septa thickening (\u2019crazy paving\u2019-pattern),\u00a0 while in more severe cases coalescent consolidations, usually subpleural, are present, with air bronchogram. Pleural effusion is usually absent. [7].\nChest X-ray is the first examination to be performed, characterised by low sensibility and specificity; CT reaches a 97% sensibility, but only a 25% specificity for COVID-19 alterations [8], so the gold standard for diagnosis remains the RT-PCR, preferably from material collected from lower respiratory tract, if not available from nasopharyngeal swab.\nThe present case showed unusual findings both on the X-Ray and on the CT scan, not unequivocable, but a following nasopharyngeal swab which was positive for COVID-19. \nTeaching point: Numerous cases of confirmed COVID-19 patients have come to our attention, with heterogeneous patterns. Isolated multiple lung consolidations with air bronchogram, associated with peripheral ground-glass opacities, in immunocompetent patients without any other comorbidities, must be suspected for SARS-CoV-2 pneumonia in this pandemic state.\nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "COVID-19, bilateral, pneumonia, Viral, pneumonia, other, than, COVID, 19, Bacterial, pneumonia, Opportunistic, pneumonia, Neoplastic, lesions",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-04//16691_1_1.jpg?itok=6_59kifL",
            "caption": "Chest X-ray (antero-posterior view): consolidations in right upper lobe sharply defined at the fissure, and in lower zone of the left lung"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-04//16691_2_1.jpg?itok=Ucw4ECCu",
            "caption": "CT axial view, lung window: bilateral multiple consolidations at random segmental distribution, with evidence of air bronchogram, and extensive peripheral ground-glass opacities. Spaired lung areas show no interstitial abnormalities"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-04//16691_2_2.jpg?itok=mMB41Ebt",
            "caption": "CT axial view, lung window: bilateral multiple consolidations at random segmental distribution, with evidence of air bronchogram, and extensive peripheral ground-glass opacities. Spaired lung areas show no interstitial abnormalities"
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-04//16691_2_3.jpg?itok=Pcu26Xab",
            "caption": "CT axial view, lung window: bilateral multiple consolidations at random segmental distribution, with evidence of air bronchogram, and extensive peripheral ground-glass opacities. Spaired lung areas show no interstitial abnormalities"
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-04//16691_2_4.jpg?itok=88Rdck_T",
            "caption": "CT axial view, mediastinum window: aspecific lymphoadenomegaly"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-04//16691_3_1.jpg?itok=mtsfJTCg",
            "caption": "CT coronal view, lung window: further evaluation and definition of the lung abnormalities"
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-04//16691_3_2.jpg?itok=xFPFfMg1",
            "caption": "CT coronal view, lung window: further evaluation and definition of the lung abnormalities"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-04//16691_4_1.jpg?itok=hfrBtk1s",
            "caption": "CT sagittal view, lung window: further evaluation and definition of the lung abnormalities"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/16691",
    "time": "09.04.2020"
  },
  "16697": {
    "case_id": 16697,
    "title": "Spontaneous pneumothorax in chronic silicosis",
    "section": "Chest imaging",
    "age": "62",
    "gender": "male",
    "diagnosis": "Spontaneous pneumothorax in chronic silicosis",
    "history": "A 62-year-old man with known chronic silicosis presented with acute breathlessness and right chest pain. No history of contact with tuberculosis.",
    "image_finding": "Chest X-ray demonstrates numerous diffuse nodular opacities, some of them calcified, in apical zones of both lungs and signs of pneumothorax in right lung. (Fig. 1) Axial CT (mediastinal window) shows conglomerate masses with calcifications, which represents progressive massive fibrosis in both superior lung lobes as well as egg-shell calcification of lymph nodes along mediastinum and pulmonary hila. (Fig. 2) Axial CT (lung window) shows right-sided pneumothorax. (Fig. 3)",
    "discussion": "Silicosis is caused by inhalation of fine particles containing crystalline silicon dioxide and usually occurs in workers involved in mining, tunneling, foundry-work, ceramics manufacturing, among others. As silica is frequently found in many minerals, sources of exposure are almost exclusively occupational. [1, 2] Silicosis occurs in two clinical forms: Acute silicosis and classic silicosis (simple or complicated). Acute silicosis is less common and occurs in heavily exposed environment with a severe and progressive course. [3, 4] The classic form manifests as a chronic interstitial disease and it is classified in simple or complicated silicosis depending on imaging findings. Simple silicosis is characterised by the presence of multiple small nodules (2-5 mm in diameter), with perilymphatic distribution, and might be accompanied by calcifications; complicated silicosis consists of conglomerate opacities that can lead to progressive massive fibrosis. [4] Patients with complicated silicosis are also at increased risk of developing other complications like tuberculosis, lung cancer, cor pulmonale or broncholithiasis. Pleural involvement is quite rare but spontaneous pneumothorax is one of recognised pleural complications that can occur in such patients. It is usually unilateral, occurs late in the course of the disease and can be fatal. Spontaneous pneumothorax is usually associated with complicated silicosis with progressive massive fibrosis. [5, 6] Silicosis treatment includes removal of the exposure. If uncomplicated, silicosis usually doesn\u2019t decrease life expectancy. [3, 5] Deterioration of the clinical condition of these patients can occur due to complications like infection, pneumothorax or progressive massive fibrosis, which have a poor prognosis. [3, 5, 6] Pneumothorax should always be kept in mind as a possible and potentially fatal complication in patients with chronic silicosis.",
    "differential_diagnosis": "Spontaneous, pneumothorax, in, chronic, silicosis, Sarcoidosis, Tuberculosis, Other, pneumoconioses,, as, coal, workers\u2019, pneumoconiosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-04//16697_1_1.jpg?itok=aQb0bUrv",
            "caption": "Chest X-ray. Numerous nodular opacities and calcifications are seen in both lung apical zones as well as signs of right pneumothorax."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-04//16697_2_1.jpg?itok=zxHH27PL",
            "caption": "Axial CT (mediastinal window). Signs of progressive massive fibrosis are present as well as egg-shell calcification of lymph nodes which are frequently seen in patients with silicosis."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-04//16697_3_1.jpg?itok=TGZBbhZS",
            "caption": "Axial CT (lung window). Right-sided pneumothorax is seen."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/16697",
    "time": "15.04.2020"
  },
  "16703": {
    "case_id": 16703,
    "title": "Atypical case of pneumothorax in a young male with paragonimiasis infestation",
    "section": "Chest imaging",
    "age": "31",
    "gender": "male",
    "diagnosis": "Pulmonary Paragonimiasis with bilateral pneumothorax",
    "history": "A 31-year-old adult with shortness of breath and bilateral chest pain was admitted in emergency. The patient had a history of fever and chest pain for the last 3 months but no haemoptysis. He had a regular history of travelling abroad on and off. The chest X-Ray was done, which revealed bilateral pneumothorax. Due to a persistent decrease in saturation, a pigtail tube was inserted into the left pleural space. His white blood cell count was 26,700/mm3 with eosinophils-67%. A chest X-Ray 2 months prior to this episode with similar history of mild chest pain was normal. Then, HRCT chest was performed for further evaluation. Sputum samples were also sent from the emergency which revealed an ova of Paragonimiasis.",
    "image_finding": "The chest X-ray showed bilateral pneumothorax (left > right) with single thin-walled cavitary lesion in the right middle zone. HRCT showed that a well-defined cavitary lesion was seen in the anterior segment of the right upper lobe. The cavity was thin walled with slightly irregular borders. Minimal fluid level was noted within the cavity in the dependent aspect. There was no evidence of calcifications, fat component or solid mural nodule within the cavity. Curvilinear track was noted in the supero-lateral aspect of the cavity, which extends from the pleural surface to the wall of the cavity. Patchy areas of consolidation were seen within the bilateral lower lobes. Minimal pneumothorax was seen on bilateral pleural space. A pigtail tube within the left pleural space was noted in situ. There was no evidence of mediastinal lymphadenopathy. Pericardium appeared to be normal.",
    "discussion": "Paragnomiasis is the important food borne parasitic zoonosis caused by trematodes of genus Paragonimus (its common name is lung fluke). It is found in tropical, subtropical and temperate climates. It is endemic in many parts of Asia, Africa and South America. Mammals are the definite host for Paragonimiasis (in which sexual reproduction occurs) and the snails and crustaceans are the intermediate hosts. Humans acquire infection from the ingestion of undercooked crustaceans containing metacercariae, the larval stage of the parasite. After ingestion, the larvae reaches the intestine and penetrates the intestinal wall to reach into the peritoneal cavity. In about 8 weeks it penetrates the diaphragm and pleura to reach the lung. The parasite resides within the lung of the definite host and the fertilised eggs are expectorated from the airway which easily hatch in the water. The released eggs get into the intermediate hosts which completes the life cycle of the parasite [1]. Initial clinical presentations of the disease can mimic pulmonary tuberculosis or lung cancer in the form of chest pain, haemoptysis and pleural effusion. In the region where people eat crabs or undercooked sea foods, this disease should be suspected with any clinical presentations of chest pain or haemoptysis. So, clinical features, lab parameters and image findings should be considered for proper diagnosis [2]. Imaging findings of Paragonimiasis can be divided according to pulmonary and extra pulmonary manifestations. In pulmonary findings, most of the patients have pleural thickening (75%) with pleural effusion because of long-standing pleural inflammation. Nodular lesions are seen in the peripheral aspect of the lung parenchyma (57%) as the parasite penetrates from the pleural surface. Sometimes, the nodules may be associated with linear tracks which can be a lead for the diagnosis of parasitic infestations; hydro pneumothorax can also be seen (12.5%). Other extra pulmonary findings could be in the form of pericardial effusion, lymphadenopathy around the internal mammary arteries, non-enhancing linear tracks within the liver and spleen, ascites and omental thickening [3]. The CT findings in Paragnomiasis in a study done by Im et al. showed round low attenuation lesions (5-15mm) filled with either fluid or gas and peripheral linear tracks suggestive of worn migration tracks [4]. Non-enhancing thin-walled cavity, absence of chronic lung fibrosis, bronchiectasis and lymphadenopathy differentiate it from pulmonary tuberculosis. Similarly, non-enhancing wall and absence of the mediastinal, as well as hilar lymphadenopathy, rules out the possibility of malignancy. Clinical features and blood investigations revealing peripheral eosinophilia with supporting image findings are the key for the diagnosis of Paragonimiasis. Serological testing for anti-Paragonimiasis antibody by ELISA is the most sensitive and specific for establishing the diagnosis [5]. Pulmonary Paragonimiasis is the diagnosis of exclusion in a developing country like Nepal and is important in order to differentiate between the other cystic or cavitary lesions of lung-like tuberculosis or lung carcinoma. Therefore, correlating with history, clinical findings as well as blood profile are equally important in the diagnosis and proper treatment of Paragonimiasis infestation.",
    "differential_diagnosis": "Pulmonary, Paragonimiasis, with, bilateral, pneumothorax, Pulmonary, tuberculosis, Pulmonary, abscesses/, Septic, emboli, Lung, carcinoma, Pulmonary, aspergillosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-04//16703_1_1.jpg?itok=HQzXgdfQ",
            "caption": "Chest X-Ray PA view showing bilateral pneumothorax (left > right) with single cavitary lesion in right middle zone."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-04//16703_1_2.jpg?itok=XBCt7AR0",
            "caption": "Coronal HRCT image of right lung showing thin-walled cavitary lesion in anterior segment of right upper lobe and is associated with curvilinear track in the superior aspect extending towards the pleural surface. Minimal pneumothorax is also seen."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-04//16703_1_3.PNG?itok=vjLf2Bse",
            "caption": "Focused coronal HRCT image showing thin-walled cavitary lesion in the right upper lobe curvilinear track extending from the pleural surface. Minimal pneumothorax is seen."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-04//16703_2_1.PNG?itok=-E3CWm01",
            "caption": "Axial HRCT image showing thin-walled cavitary lesion with slightly irregular wall with minimal fluid level in the dependent aspect."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-04//16703_2_2.PNG?itok=k8Mj2LhC",
            "caption": "Axial HRCT image of the bilateral lower lobes showing consolidation with minimal bilateral pneumothorax. Pigtail tube is seen in the left pleural cavity"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-04//16703_3_1.PNG?itok=uzms7MKs",
            "caption": "Microscopic specimen of ova of Paragonimiasis from the sputum sample"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Respiratory system",
      "Thorax"
    ],
    "imaging_technique": [
      "CT",
      "CT-High Resolution"
    ],
    "link": "https://www.eurorad.org/case/16703",
    "time": "17.04.2020"
  },
  "16706": {
    "case_id": 16706,
    "title": "COVID-19: Raise your clinical suspicion \u2014 not only respiratory symptoms",
    "section": "Chest imaging",
    "age": "65",
    "gender": "woman",
    "diagnosis": "COVID-19 pneumonia infection",
    "history": "A sixty-five-year-old woman presented to the emergency department with a 5-day history of nausea and diarrhoea and a 2-day onset of non-productive cough and asthenia, without fever. Her husband had similar symptoms, and both had no epidemiological context for COVID-19 infection. She had type-2 diabetes-mellitus, arterial hypertension and chronic renal disease. Both were positive on RT-PCR test for COVID-19.",
    "image_finding": "On the emergency department, as an initial approach, the patient performed an anteroposterior chest x-ray that showed patchy areas of lung opacities on the peripherical and basal segments of the left lung. No evidence was found of pleural effusion or right lung involvement (Figure 1).\nOnce the RT-PCR was positive and the patient suffered clinical deterioration, she performed a non-enhancing thoracic Computed Tomography (CT) (Figure 2,3,4) which exhibits bilateral areas of \u201cground-glass\u201d opacification with predominant peripheric distribution associated with interlobular septal thickening, giving a typical appearance of \u201ccrazy paving pattern\u201d. In the posterior segments of both inferior lung lobes with a left side predominance, areas of parenchymal consolidation with the air-bronchogram sign are visible. No pleural effusion or pathological mediastinal or hilar lymph nodes were noticed.",
    "discussion": "Background\nOn March 11th, 2020, the World Health Organization declared the novel coronavirus infection (SARS-CoV-2) as a global pandemic with new epicentre established in Europe.[1] \u00a0At the time of writing this article, Portugal had a total of 2362 confirmed cases,[2] \u00a0and was on the mitigation phase of the infection, which means community infection can occur in the absence of an obvious epidemiological context.[3] \u00a0\nThe major diagnosis tool used for novel coronavirus infection is the Real-Time fluorescence Polymerase Chain Reaction (RT-PCR) of patient\u2019s sputum evaluation.[4] Imaging evaluation, especially chest CT, have a major role providing information about lung involvement on confirmed cases of COVID infection and also have value for diagnosis in doubtful cases, follow-up evaluation and prognostic assessment.[5]\n\u00a0\nClinical Perspective\nThe most common presenting clinical symptoms are fever and cough in addition to other non-specific ones, as dyspnoea, headache, muscle soreness and fatigue.[6] However, the knowledge about atypical symptomatology is increasing, that includes absence of fever and gastrointestinal alterations, as exemplified in this case. Therefore, it is essential to have a low clinical suspicion threshold to achieve diagnosis as earlier as possible.[7] Age and cardiovascular risk factors, as seen in this patient, are associated with poorer outcomes of COVID-19 pneumonia.[6]\nImaging Perspective\nImaging evaluation is a useful tool for early diagnosis of pulmonary infection of COVID-19.[8] Chest CT is much more sensible than chest x-ray, that can largely underestimate the disease affection, as seen in this case.[5] Some authors revealed that radiologist is capable of distinguishing COVID-19 on chest CT with high specificity and moderate sensibility.[9]\nThe most common alterations on a chest CT of COVID-19 consists on bilateral ground-glass opacities, predominately in the basal and peripheral segments, on the early stages of the disease. As the disease progresses, the number of involved lobes increase, interlobar septal thickening and ground-glass opacities are easily seen, consolidation become dominant and thickening of the bronchial wall appears. Pleural effusions and hilar/mediastinal lymphadenopathies are rare.[5, 10-11]\nKnowing the spectrum of imaging appearance of COVID-19 is essential, and future effort need to be done in determining potential outcome imaging predictors and the role of imaging features for treatment guidance.[5]\nTeaching points\n\nWith the continuous spread of infection, attention must be taken in atypical manifestations of the disease, even without evident epidemiologic context.\nRadiologists must be familiar with the imaging spectrum of disease: bilateral, inferior and peripherical ground-glass opacities, crazy paving and consolidations.\nFuture work needs to be done in understanding imaging modalities\u2019 role in therapeutic guidance and prognosis.",
    "differential_diagnosis": "COVID-19, pneumonia, infection, Atypical, pneumonia, Organising, pneumonia, Drug, toxicity, Connective, tissue, disease",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-04//16706_1_1.png?itok=TyQaF2XD",
            "caption": "Anteroposterior chest x-ray of a patient infected with COVID-19 that shows consolidations"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-04//16706_2_1.png?itok=MlPQzFM-",
            "caption": "Axial CT scans of a patient with COVID-19 pneumonia with diffuse bilateral areas of ground"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-04//16706_3_1.png?itok=DURdfp7Z",
            "caption": "Coronal CT scans of a patient with COVID-19 pneumonia with diffuse bilateral areas of ground"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-04//16706_4_1.png?itok=6BHqdgFg",
            "caption": "Sagittal CT scans of a patient with COVID-19 pneumonia with diffuse bilateral areas of ground"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/16706",
    "time": "17.04.2020"
  },
  "16708": {
    "case_id": 16708,
    "title": "COVID-19 patient with probably nosocomial infection",
    "section": "Chest imaging",
    "age": "74",
    "gender": "woman",
    "diagnosis": "Severe pneumonia with acute respiratory distress syndrome and septic shock secondary to COVID 19.",
    "history": "A 74-year-old woman with history of hypertension and heart disease, who had been discharged 10 days before knee prosthetic surgery, was admitted with 4-day history of fever, dry cough and dyspnoea. She had not left home since discharge and no family member was affected. Analysis revealed lymphopenia, elevation of C-reactive protein and a positive RT-PCR. The patient was admitted to the intensive care unit, with a favourable course.",
    "image_finding": "Chest X-ray at admission showed diffuse reticular pattern with small opacities in both basal regions (Figure 1). Axial CT performed on first day showed diffuse ground glass opacity predominantly in the lower lobes with small peripheral consolidations in a posterior distribution (figures 2 and 3). Chest X-ray on the second day showed disease progression with diffuse reticular pattern and increased density in both lungs (figure 4) Chest x-ray on the eighth day showed improvement with decreased of high density and reticular pattern, more evident in the upper left lobe (figure 5).",
    "discussion": "Background The outbreak of severe acute respiratory syndrome coronavirus 2 (SARS- CoV-2) disease in China at the end of 2019 (COVID 19) is a novel viral pandemic, that today affect to 693,282 and have caused death to 33,106 people around the world [1]. Studies suggest zoonotic origin of the infection with subsequent human-human spread through droplets or direct contact [2-4]. Infection has mean incubation period of 6.4 days with a range of 0-24 days, and hospital-related transmission and asymptomatic carriers have been described [4-6]. The mean age of people affected in China was 47-49 years, 12-15% was elderly patients and male sex comprised more than half of the cases [6]. Clinical Perspective Fever is the most common symptom described in many studies followed by dry cough and dyspnoea [4,6,7]. Most patients had a normal white blood cell count, but more than 50% had leukopenia [4,7,8] According to a summary report of many cases, 14% were severe (dyspneoa, tachypnea and blood oxygen saturation<93%) and 5% were critical (respiratory failure and shock septic) [2]. These groups were more likely to have comorbidities (at least 20%), being hypertension the most common [6]. The overall case-fatality rate was 2.3% and in elderly patients was 8-15%. [2] Imaging Perspective Chest radiographs are of little diagnostic value in early stages, whereas CT findings may be present even before symptom onset [8] and almost all patients with COVID 19 had characteristic CT features in disease process [14]. More than half of patients presented bilateral multilobar ground-glass opacification (GGO) with a peripheral distribution [8,10] sometimes with a rounded morphology [ 11, 12]. CT in the intermediate stage shows and increase in the number and size of GGOs and transformation of GGO into multifocal consolidative opacities, septal thickening and development of a crazy paving pattern [9]. Bronchiectasis, pleural thickening, subpleural involvement, pleural effusion, pericardial effusion, lymphadenopathy, cavitation, CT halo sign and pneumothorax are uncommon but Main Document 2 may be seen with disease progression [9]. Pleural effusion and lymphadenopathy was considered of poor prognosis [13]. Imaging patters corresponding to clinical improvement usually occur after week 2 of the disease [9]. Outcome The reference standard in COVID-19 diagnosis is real-time reverse transcription polymerase chain reaction (RT-PCR) of viral nucleic acid that has low sensitivity, however, chest CT has high sensitivity for diagnosis in patients with initial false negative RT-PCR results [14,15, 16], so it can be considered a useful diagnostic tool and radiologists must know the typical findings of this disease. Teaching Points The presence of ground glass opacity and peripheral consolidations of bilateral distribution in the current clinical and epidemiological context is diagnosis of COVID-19.",
    "differential_diagnosis": "Severe, pneumonia, with, acute, respiratory, distress, syndrome, and, septic, shock, secondary, to, COVID, 19., Pulmonary, oedema, Other, viral, pneumonias, Multifocal, bacterial, pneumonia, Hypersensitivity, pneumonitis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-04//16708_1_1.jpg?itok=B3R-Amd2",
            "caption": "Chest X-ray at admission showed diffuse reticular pattern with small opacities in both basal regions"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-04//16708_2_1.jpg?itok=qna2GfRb",
            "caption": "Axial CT performed on first day showed diffuse ground glass opacity with small peripheral consolidations in a posterior distribution"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-04//16708_3_1.jpg?itok=OG7b4qka",
            "caption": "Coronal CT showed diffuse ground glass opacity predominantly in the lower lobes, with small peripheral consolidations"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-04//16708_4_1.jpg?itok=wZiuKV55",
            "caption": "Chest X-ray on the second day showed diffuse reticular pattern and increased density in both lungs"
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-04//16708_5_1.jpg?itok=q5kYkGXM",
            "caption": "Chest x-ray on the eighth day showed improvement with decreased of high density and reticular pattern, more evident in the upper left lobe."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Emergency",
      "Thorax"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/16708",
    "time": "21.04.2020"
  },
  "16712": {
    "case_id": 16712,
    "title": "Barotrauma, hazardous but rare complication of mechanical ventilation",
    "section": "Chest imaging",
    "age": "34",
    "gender": "male",
    "diagnosis": "Pnemomediastinum, pneumothorax, pneumoperitoneum and subcutaneous emphysema secondary to barotrauma",
    "history": "A 34-year-old adult was admitted in the ICU due to dyspnoea, bilateral chest pain and decreased saturation with probable clinical diagnosis of severe viral pneumonia. The patient was on mechanical pressure ventilation. On day 2nd of admission in ICU, the patient suddenly deteriorated with decreased level of saturation to 78% and on examination, the patient had extensive subcutaneous emphysema over the neck and chest regions. HRCT was done for further evaluations.",
    "image_finding": "HRCT images showed extensive evidence of subcutaneous emphysema and along the fascial planes of bilateral neck as well as bilateral anterior and posterior chest wall. The large amount of air was seen within the mediastinum outlining the great vessels and pericardium. The air was dissecting superiorly to involve the neck and inferiorly to the peritoneal cavity as well as retroperitoneum. Bilateral pneumothorax was also seen (right > left). Diffuse ground glass opacities were seen within the bilateral lung fields with areas of consolidation in bilateral lower lobes. Multiple areas of tiny air lucencies were seen in the right perihilar region suggesting interstitial emphysema. Sub-pleural pocket of air was also seen in the superior segment of the right lower lobe.",
    "discussion": "Intubation and mechanical ventilation is the common aggressive procedure done in emergency, pre-operative anaesthesia and ICU settings. Indications may be to increase the oxygenation of the body through the unhealthy lung or to maintain the normal ventilation of the lung during surgical procedures. Positive pressure ventilation is a non-physiological way of maintaining the process of respiration in humans. Therefore, implementation of positive pressure ventilation in the unhealthy lung is even more risky leading to lung injury. These injuries to the lung are termed ventilator-associated lung injury (VALI) or ventilator-induced lung injury (VILI). Barotrauma is the term related to high pressure-induced injury [1]. Barotrauma is the feared complication of mechanical ventilation which increases the patients\u2019 morbidity and mortality. Acute respiratory distress syndrome (ARDS), aspiration pneumonia, chronic obstructive pulmonary disease (COPD) as well as pneumocystis carinii pneumonia are the independent risk factors of barotrauma. In the study done by Anzeuto et.al, incidence of barotrauma is approximately 2.9% in mechanically ventilated patients [2]. \nHigh pressure ventilation and global or regional overdistention of the lung is the primary cause of barotrauma [3]. As the pressure inside the alveoli increases greater than the interstitial pressure, they rupture when it reaches the maximum. The free extra-alveolar air tracks along the pulmonary interstitium i.e. along the wall of the pulmonary vessels to reach the mediastinum. From the mediastinum, it can dissect along the fascial plane to the visceral spaces around the trachea and oesophagus of the neck and this visceral space follows inferiorly to the retroperitoneal space through the oesophageal hiatus of the diaphragm. The posterolateral portion of the retroperitoneal space has anatomic continuity with the properitoneal flank (deep to transversalis fascia) to dissect into the anterior abdominal wall [4]. \nThe clinical and radiological manifestations of barotrauma can be in the form of pneumothorax, pulmonary interstitial emphysema, subcutaneous emphysema, pneumoperitoneum, pneumo-retroperitoneum, lung cysts, pneumopericardium etc. The patients present with sudden or gradual onset of dyspnoea depending upon the primary cause. Role of imaging X-ray, CT and fluoroscopy in diagnosis and management is crucial in barotrauma. Especially the CT/fluoroscopy with intra-oesophageal contrast can rule out the possibility of oesophageal perforation. In our case, oral diluted non-ionic contrast was given and oesophageal perforation was ruled out. Standard chest X-ray PA/AP and lateral view may be sufficient for the diagnosis of pneumomediastinum. However, to rule out the potential source of the extra-alveolar air that could be from the trachea, bronchi, lung, pleural space, head and neck as well as peritoneum and retroperitoneum, CT is advisable. The classic findings of extra-alveolar air are subcutaneous emphysema, thymic sail sign, pneumopericardium, ring around artery sign, continuous diaphragm sign, tubular artery sign, double bronchial artery sign, extrapleural sign and air in the pulmonary ligament [5]. \nTreatment of pulmonary barotrauma is usually supportive and conservative. Decompression of the mediastinal air or pneumothorax is done in critically ill patients. Pulmonary barotrauma is nowadays a rare complication of the ventilator support and its risk varies with the underlying disease. Lung protective strategies with proper settings of the mechanical ventilation parameters in ICU and emergency settings like tidal volume, transpulmonary pressure, positive end expiratory pressure (PEEP) can vastly minimise the complications [1]. \nWritten patient consent for this case was waived by the Editorial Board. Patient data may have been modified to ensure patient anonymity.",
    "differential_diagnosis": "Pnemomediastinum,, pneumothorax,, pneumoperitoneum, and, subcutaneous, emphysema, secondary, to, barotrauma, Traumatic, pnemomediastinum, Spontaneous, pneumothorax, Oesophageal, perforation",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-04//16712_1_1.PNG?itok=i3eFJ_ep",
            "caption": "Axial HRCT image shows extensive amount of free air space within the fascial plane and subcutaneous region of at the level of the thyroid gland (R>L).  Endotracheal tube is seen within the trachea."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-04//16712_1_2.PNG?itok=uhMzDsyd",
            "caption": "Axial HRCT image shows diffuse subcutaneous emphysema and bilateral pneumothorax. The air is outlining the trachea, oesophagus and vessels suggesting pneumomediastinum. Diffuse ground glass opacities are also seen within the visible apical segments of bilateral upper lobes and the ET tube is seen within the tracheal lumen."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-04//16712_1_3.PNG?itok=NqPwO-AF",
            "caption": "Axial HRCT image shows pneumomediastinum and right pneumothorax. Diffuse subcutaneous emphysema and air is seen dissecting within the myofascial planes. Ground glass opacities are seen in bilateral lung fields (right>left). Patchy consolidation is seen in posterior segment of the right upper lobe."
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-04//16712_1_4.PNG?itok=zwaSvdMx",
            "caption": "Axial HRCT image shows pneumomediastinum, right pneumothorax and extensive subcutaneous emphysema. Consolidation in bilateral lower lobes is seen."
          },
          {
            "number": "Figure 1e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-04//16712_1_5.PNG?itok=R63eGzyw",
            "caption": "Axial HRCT image shows pneumomediastinum, right pneumothorax and diffuse subcutaneous emphysema. Diffuse ground glass opacities are seen in bilateral lung fields and few tiny air lucencies are seen in right perihilar region suggesting interstitial emphysema. Patchy consolidation in bilateral lower lobes."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-04//16712_2_1.PNG?itok=sTDrjrtz",
            "caption": "Axial HRCT image shows subcutaneous emphysema, pneumoperitoneum (left upper quadrant) and pneumoretroperitoneum and free air is seen outlining the bilateral kidneys in the perirenal space."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-04//16712_2_2.jpg?itok=mjk26nlj",
            "caption": "Coronal HRCT image shows diffuse subcutaneous emphysema, right pneumothorax, pneumomediastinum (continuous diaphragm sign). Small pneumoperitoneum is also seen in the left hypochondrium."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-04//16712_2_3.jpg?itok=uIr7UtKf",
            "caption": "Coronal HRCT image shows subpleural bleb in the superior segment of the right lower lobe. Diffuse ground glass opacities are seen in the bilateral lung fields. Bilateral pneumothorax and subcutaneous emphysema is seen. Pneumoretroperitoneum is also seen outlining the left adrenal gland."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Respiratory system",
      "Thorax"
    ],
    "imaging_technique": [
      "CT-High Resolution"
    ],
    "link": "https://www.eurorad.org/case/16712",
    "time": "16.04.2020"
  },
  "16724": {
    "case_id": 16724,
    "title": "New coronavirus infectious disease (COVID-19)",
    "section": "Chest imaging",
    "age": "72",
    "gender": "female",
    "diagnosis": "Lobar pneumonia",
    "history": "72-year-old female came to the hospital with sore throat, cough, dyspnea, anosmia and fever for 5 days. Physical exam revealed no pathological findings. Biochemistry showed lymphopenia, decreased prothrombin activity, c-reactive protein increase and hypoxemia. RT-PCR was positive for COVID-19. No co-morbidities or risk factors were communicated.",
    "image_finding": "Chest radiography anteroposterior (AP) was the first imaging modality used.\nInterstitial lung occupation consisting on reticular-nodular pattern in both lungs, mostly in the right one, was observed [1].\u00a0 Thus, mild opacities in the superior, middle and lower right lobes were depicted. There was no pleural effusion.\nIVC CT was performed to confirm the findings. Pulmonary embolism (PE) protocol was chosen.\nCT showed multiple ground-glass opacities with bilateral, subpleural and peripheral distribution; mostly in the right lung [2] . Bronchovascular and interlobular septal thickening was also appreciated. Thus, patchy ground-glass opacities with subpleural distribution were depicted in the middle and lower left lobes [3]. \nPulmonary fibrosis or small air trapping features (tree-in-bud pattern, bronchiectasis) were not observed.\nIncreased size lymph nodes, pleural or pericardial effusion were not found in the CT.\nSupport treatment was given to the patient.",
    "discussion": "Several cases of pneumonia were reported to the World Health Organization (WHO) on December 31, 2019, from Wuhan, China. SARS-Cov-2 (COVID-19) was confirmed to be the cause.\u00a0 Coronaviruses are a family of RNA viruses that cause illness ranging from the common cold to severe diseases. Coronaviruses are zoonotic; which means that they are transmitted between animals and people. Little is known about physiopathology. Decrease in CD4T cells, lymphopenia and cytokine storm may be involved. Mild symptoms include fever, dry cough and dyspnoea. Rhinorrhoea, sneezing and sore throat have also been described. Severe cases show infection pneumonia, severe acute respiratory syndrome, kidney failure and even death. WHO declared COVID-19 a global health emergency in January 2020. RT-PCR screening is now considered the standard laboratory test for diagnosis of COVID-19. Imaging (X-ray and CT) is used to guide clinicians in individual patient management decisions, dealing with complications, follow the course of the disease and look for an alternative diagnosis. CT depicts pathological findings even before RT-PCR test becomes positive.\nFeatures of initial phase include bilateral, multilobar ground-glass opacities (GGO) with a peripheral or posterior distribution (or both), mainly in the lower lobes. Intermediate phase findings include an increase in the number or size of GGO, transformation of GGO into multifocal consolidation areas, septal thickening and development of crazy-paving pattern and organized pneumonia. Final stage is characterised by diffuse alveolar damage pattern corresponding to acute respiratory distress syndrome (ARDS). Alternative diagnosis includes lobar pneumonia, cavitation, tree-in-bud changes, pleural or pericardial effusion, pulmonary fibrosis and lymph node enlargement. \nCurrent treatment strategies are limited to quarantine, isolation and infection control measures. Several treatments are being tested, such as human immunoglobulin, interferons, chloroquine, hydroxychloroquine, remdesivir or methylprednisolone; some of them with a promising outcome. Prognosis depends on COVID-19 stage. ARDS is the most common indication for transferring patients to intensive care unit (ICU). Imaging is essential to deal with complications management. \n- COVID 19 has been considered as a global health emergency.\n- Signs vary from common viral infection symptoms to pneumonia, severe acute respiratory syndrome, kidney failure and even death.\n- CT shows bilateral, multilobar GGO with a peripheral or posterior distribution, mainly in lower lobes, crazy-paving pattern and organized pneumonia.\n- ARDS is the most common indication for transferring patients to ICU.\n- Imaging is essential to deal with complications and follow the course of the disease",
    "differential_diagnosis": "Lobar, pneumonia, Other, viral, pneumonia, Interstitial, lung, diseases, Pulmonary, fibrosis, Organized, pneumonia",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-04//16724_1_1.jpg?itok=araxXvkm",
            "caption": "AP chest X-Ray: a reticular-nodular pattern in both lungs, mostly in the right one, was observed. In addition, mild opacities in the superior,middle and lower right lobes were depicted."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-04//16724_2_1.jpg?itok=9_D609ug",
            "caption": "IVC CT: axial and coronal sections. Multiple ground-glass opacities with bilateral, subpleural and peripheral distribution; mostly in the right lung were appreciated. Hiatal hernia in the posterior mediastinum was also observed in axial section."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-04//16724_3_1.jpg?itok=ElJ5sqHw",
            "caption": "IVC CT: sagital section. Multiple ground-glass opacities with bilateral, subpleural and peripheral distribution; mostly in the right lung were observed."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/16724",
    "time": "21.04.2020"
  },
  "16734": {
    "case_id": 16734,
    "title": "Progressive massive fibrosis in a patient with silicosis",
    "section": "Chest imaging",
    "age": "56",
    "gender": "male",
    "diagnosis": "Progressive massive fibrosis in a patient with silicosis",
    "history": "56-year-old patient came with symptoms of worsening cough and progressive shortness of breath over the past four months. He has a history of working in a stone quarry for more than 15 years. He reports long-standing history of dry cough for which he was previously diagnosed as positive for tuberculosis and was treated with antitubercular drugs. There was no history of fever, haemoptysis, chest pain, joint pain, skin rash or wheeze.",
    "image_finding": "Contrast enhanced CT images and high-resolution CT showed multiple pulmonary nodules of varying sizes with confluent mass-like consolidation, parenchymal calcifications and air bronchograms in both lungs with upper lobe predominance. No significant enhancement was noted post contrast.\nConfluent fibrosis and scarring are noted in both lungs with traction bronchiectasis and reduced right lung parenchymal volume. Multiple enlarged lymph nodes with calcifications are noted in pretracheal, paratracheal, precarinal, subcarinal, prevascular, aortopulmonary window, para-cardiac and both hilar regions, the largest measuring about 37 x 20 mm in the right paratracheal and pretracheal regions. There was no evidence of pleural effusion/pericardial effusion. Pulmonary arteries, pulmonary veins and superior vena cava appeared normal. The chest wall including the ribs and soft tissue were normal.",
    "discussion": "Progressive massive fibrosis (PMF), also known as conglomerate masses, is the radiographic feature significantly associated with respiratory deficits. In PMF, small nodular areas of fibrosis associated progressively coalesce into larger (>3 cm) fibrotic masses. These masses are typically noted in the upper lungs and result in fibrotic distortion of the surrounding lung parenchyma. Progressive massive fibrosis in silicosis demonstrates fibrotic masses predominantly involving upper lobes causing upper displacement of the mediastinum. These masses have irregular margins with their lateral interfaces often parallel to the lateral chest wall. Almost all nodular pneumoconioses can cause PMF, but it is most strongly associated with silicosis. Many patients with simple silicosis (interstitial disease without PMF) are clinically asymptomatic. Nearly all patients with complicated silicosis have associated dyspnoea [1]\nSilicosis is a fatal occupational disease caused by inhalation of crystalline silica which presents with fibrosis [2, 3] .It occurs due to deposition of tiny particles of silica with diameter of 0.5 to 5 microns, in distal airways. This condition can be an occupational hazard among those employed in sand stone industry, sand blasting who have a high risk of silica exposure [3]. Factors that determine the development of disease include time of exposure, concentration of respirable dust in the atmosphere and amount of free silica in the dust. Higher biological activity of freshly crushed silica causes accelerated progression of silicosis in these workers due to greater cytotoxic effects on alveolar cell membranes [4]\nSilicosis is often confused with post primary tuberculosis due to radiological resemblance, and it is common to develop tuberculosis in silicotic patients. The differentiating features are (a) in silicosis, primarily, there is increase of bronchovascular markings followed by rounded opacities, whereas in tuberculosis rounded opacities appear earlier followed by linear opacities and (b) tubercular nodules usually occur in upper lungs, whereas silicotic nodules are localized in upper and midzone with no connection with hilum. [4] The radiological signs suggesting tuberculosis in the background of silicosis are new onset parenchymal shadows, cavitation, asymmetric opacities in upper zone that are increasing, irregular cavitation, pleural and pericardial effusion [5]. CT findings in silicosis multiple small nodules that are upper and mid lobe predominant and accompanied by calcifications, hilar and mediastinal lymphadenopathy which may precede the appearance of parenchymal nodular lesions and calcification of lymph nodes, commonly at the periphery of the node.\nPulmonary tuberculosis is reported to be higher in patients with silicosis. The imaging appearances of the lungs, with architectural distortion and fibrosis, make it difficult to assess for tuberculosis, hence clinical picture is essential to raise suspicion for the associated infection. \nThe factors to differentiate post primary tuberculosis and progressive massive fibrosis are that the latter rarely causes cavitation, associated pleural effusion and distortion of intrathoracic structures [6]\n\u00a0Since changes of early silicosis, as revealed by chest radiographs, are not characteristic of that disease alone, an occupational history is emphasized by radiologists as an essential tool for diagnosis. An adequate occupational history shows that the dust exposure has been similar in detail to exposures previously found to be hazardous. Difficulties arise when the exposure has been to unknown dust / occupation [7]. This is essential for us in our country where occupational hazard is a well-recognized entity. So far, no specific treatment for silicosis has been found. Preventing further exposure and symptomatic management are the only current options.\u00a0 Since silicosis is completely preventable, factors such as educating workers, use of personal protective equipment and periodic screening should be will help. Strict legislations should be in place to protect employees and to check compliance [8].\nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Progressive, massive, fibrosis, in, a, patient, with, silicosis, Tuberculosis, Sarcoidosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-04//16734_1_1.jpg?itok=bY0HG-c3",
            "caption": "Axial CT of thorax showing eggshell calcification within the masses and lymph nodes"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-04//16734_2_1.jpg?itok=edPmFi1U",
            "caption": "Axial CT of thorax lung window shows bilateral symmetrical masses with irregular margins"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-04//16734_3_1.jpg?itok=y1akzpkQ",
            "caption": "Another axial CT of thorax, mediastinal window shows the lateral margins of the mass lesions being parallel to the lateral chest wall"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-04//16734_4_1.jpg?itok=JQaJj5H5",
            "caption": "Coronal CT images show large conglomerate masses with nodular densities suggestive of progressive massive fibrosis"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Lymph nodes"
    ],
    "imaging_technique": [
      "CT-High Resolution"
    ],
    "link": "https://www.eurorad.org/case/16734",
    "time": "22.04.2020"
  },
  "16744": {
    "case_id": 16744,
    "title": "COVID-19: \u03a4he spectrum of imaging manifestations in a 58 year-old-male without any comorbidities.",
    "section": "Chest imaging",
    "age": "58",
    "gender": "male",
    "diagnosis": "The final diagnosis was severe pneumonia due to COVID-19",
    "history": "A 58-year old male non-smoking patient presented to our Emergency Department with progressive dyspnoea. Five days earlier, he complained of fever, sore throat and dry cough with positive RT-PCR test for COVID-19. \u00a0Medical history included chronic sinusitis without any known pathogen exposure. After 48 hours, due to worsening hypoxemia and deterioration of mental status, he was intubated on the 7th day after the initiation of symptoms.",
    "image_finding": "The chest radiography that was performed at the ED on the day of admission revealed bilateral diffuse alveolar pulmonary consolidations, especially in the right upper and middle zones (Fig. 1). Due to deterioration of his dyspnoea, a non-contrast chest CT was performed later that day using a 16-row multidetector CT to rule out life-threatening complications. CT scan revealed bilateral multifocal ground-glass opacities (GGO) in the upper lobes (Fig. 2a). Mixed GGO along with thickened interlobular septa (crazy-paving pattern) and consolidation lesions with air bronchograms especially in the upper lobes with a slight peripheral preponderance were present as well (Fig. 2b). Moreover, a lesion with reverse halo sign in the right lower lobe was also identified (Fig. 2c). Mediastinal lymphadenopathy was present (Fig. 2d), whereas there were no signs of pleural or pericardial effusion.",
    "discussion": "Coronavirus disease 2019 (COVID-19) outbreak, first reported in Wuhan, China, has been declared a global health emergency [1].\u00a0 The vast majority of infected patients present with fever, dry cough and respiratory distress. In COVID-19 diagnosis, real-time reverse transcription-polymerase chain reaction (RT-PCR) of viral nucleic acid is considered as the test of choice [2, 3]. However, since the respiratory system is the predominantly affected system, chest radiography and CT scan is highly recommended in the investigation of suspected or known COVID-19 patients. Due to the shortage and the high false-negative rate of RT-PCR many patients may not be diagnosed on time. CT may be a reliable tool in screening out patients highly suspected for COVID-19 and setting an early diagnosis [2, 4]. Recognition of the diagnostic imaging hallmarks, as well as atypical features, is crucial for efficient patient management and treatment [2].\nWhen compared to chest radiography, CT demonstrates better the extent and distribution of COVID-19 pulmonary involvement while also detecting findings even before symptoms onset [2]. A wide variety of CT manifestations in COVID-19 have been reported in several studies. The earliest and the most common radiographically visible CT finding is GGO, mainly with bilateral involvement and peripheral distribution [2, 5]. Moreover, GGO is often associated with other features or patterns, such as interlobular septal thickening (crazy-paving pattern), air bronchogram or consolidation, which is indicative of disease progression, as in the present case.\u00a0 [1] Other CT findings, more common in the later stages of the disease, include bronchiectasis, bronchial wall thickening and pleural changes (mainly pleural thickening), with various rates across the studies [6]. Furthermore, subpleural curvilinear lines can be present, which could be associated with pulmonary oedema or fibrosis due to COVID-19. Dilatation of pulmonary vessels around and within the lesions is often described in infected patients, which has been attributed to the damage and swelling of the capillary wall that is caused by the virus. The presence of nodules with halo or reverse halo sign, as in our case, constitutes another uncommon CT finding. Mediastinal lymphadenopathy, cavitation, pneumothorax and pericardial effusion are atypical CT findings and considered as significant risk factors of severe/critical COVID-19 pneumonia [7]. Performing a follow-up CT scan may also be helpful for the evaluation of prognosis of the patients as well as detection of possible complications, including Acute Respiratory Distress Syndrome (ARDS) and acute pulmonary embolism [8, 9]. \nIn conclusion, bilateral GGO and consolidation with air bronchograms opacities and crazy paving lesions with reverse halo sign are reported as the predominant imaging characteristics in the present case. CT manifestations may be correlated with the progression of COVID-19. As seen in the bibliography, radiological aggravation of the initial image is usually observed on day 7 after the onset of symptoms which is in accordance with our case [10]. It is noteworthy to mention that even middle-aged patients without any comorbidities or a significant past medical history can develop rapid progression of the disease and have a poor prognosis.",
    "differential_diagnosis": "The, final, diagnosis, was, severe, pneumonia, due, to, COVID-19, Viral, pneumonia, (Influenza, A, and, B,, CMV,, SARS-Cov,, HSV,, Adenovirus), Atypical, Bacterial, pneumonia, (, Mycoplasma,, Chlamydia), Interstitial, Lung, Disease, (COP)",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-05//16744_1_1.jpg?itok=Rpxzqenu",
            "caption": "AP chest radiography: bilateral diffuse alveolar pulmonary consolidations, especially in the right upper and middle zones."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-05//16744_2_1.jpg?itok=TdpIOq5N",
            "caption": "CT axial view, lung window: bilateral ground-glass opacities (GGO) in the upper lobes."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-05//16744_2_2.jpg?itok=hc9OZTyu",
            "caption": "CT axial view, lung window: bilateral lesions with GGO and interlobular septal thickening (crazy paving pattern). Also note the consolidation lesion in the posterior segment of the right upper lobe."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-05//16744_2_3.jpg?itok=JCI0-Mk4",
            "caption": "CT axial view, lung window: lesion in the lateral segment of the right lower lobe with GGO with a ring of denser consolidation (reverse halo sign)"
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-05//16744_2_4.jpg?itok=CdVKkc0s",
            "caption": "CT axial view, mediastinum window: lymph nodes in the aorticopulmonary window and the paratracheal space with short-axis diameter up to 1cm."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Lymph nodes",
      "Mediastinum"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/16744",
    "time": "06.05.2020"
  },
  "16745": {
    "case_id": 16745,
    "title": "Chest X-ray and CT findings of young COVID-19 patients undergoing non-invasive treatment",
    "section": "Chest imaging",
    "age": "27",
    "gender": "male",
    "diagnosis": "Coronavirus Disease-19 (COVID-19)",
    "history": "We retrospectively evaluated the imaging findings of young patients (below 50 years of age) affected by COVID-19 infection.\nSix patients in the 27-46 age range were admitted to the Emergency Room (ER) of our institution in the first half of March 2020 with the main complaint of fever (5/6) and/or cough (5/6), and with unremarkable clinical history. The results of laboratory tests were in range, except for respiratory alkalosis (3/6) and reduced leukocyte count (1/6). Reverse Transcriptase-Polymerase Chain Reaction (RT-PCR) for the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) was found positive on nasopharyngeal swab (5/6) or bronchoalveolar lavage (1/6). None of the patients required intubation; only 3 of them required respiratory support with low flow oxygen supplementation through nasal cannula (2/6), or CPAP (1/6).",
    "image_finding": "Chest X-Rays (CXR) and Computed Tomography (CT) were performed in all patients. CXR did not show typical findings for Coronavirus Disease-19 (COVID-19) and was reported as negative (3/6) or arising question of bilateral lung consolidations (3/6). The chest CT showed typical findings for interstitial pneumonia in all patients. The main finding was the presence of pulmonary areas of increased attenuation with a \u201cground-glass\u201d appearance (6/6). These areas were mainly localised in subpleural peripheral areas of the basal segments of lower lobes and sometimes associated to thickened interstitium in a \u201ccrazy-paving\u201d pattern (2/6). Pleural effusion was absent in all patients and mediastinal lymphadenopathy was present in 2 out of 6 cases. Only one patient performed a follow-up CT on the 5th day of hospitalisation that showed an increased number of hyperattenuating areas, compatible with lung consolidations. (Figure 1 and Figure 7d-7e)",
    "discussion": "Background:\n\nThe purpose of this study is to collect, analyse and report clinical data, imaging findings and prognostic assessment of COVID-19 in young adults.\nThe outbreak of SARS-CoV2 has diffused rapidly all around the world, starting from its epicentre in Hubei province. On 11th March 2020, COVID-19 was declared a pandemic. Considering its high infectivity and the human-to-human transmission pattern through infected droplets, the main applied containment measure was the complete lockdown. [1] From the pathogenetic point of view, the viral receptor is the receptor for the angiotensin converting enzyme 2 (ACE2), mainly expressed at the level of lower respiratory tract, explaining why pneumonia represents the principal clinical feature.\n\nClinical Perspective:\n\nThe clinical presentation of SARS-CoV2 infection is extremely variable, ranging from asymptomatic patients to Acute Respiratory Distress Syndrome (ARDS) or Multi-organ Failure (MOF). Similarly, the incubation period is very variable, ranging from 1 to 14 days with a faster progression in elderly people. \nClinically, it is often difficult to distinguish the COVID-19 pneumonia from other common respiratory infections because the main presenting symptoms are the same, such as fever, malaise, cough and dyspnoea. The diagnosis of COVID-19 is performed with RT-PCR on a nasopharyngeal swab or bronchoalveolar lavage. Common non-specific laboratory findings are leukopenia, especially lymphocytopenia as marker of disease severity, and an increase in inflammatory markers, such as CRP, SSA, IL-6. Recent studies demonstrated that adolescents and young adults presented less severe symptoms and fewer abnormal laboratory test results at admission: our study confirmed these results. [1, 2]\n\nImaging Perspective:\n\nIn all our cases CRX was non-diagnostic for COVID-19 infection, while typical findings were observed on the chest CT in all patient.\nIt has been reported that CXR has relatively low sensitivity in the early stages of the infection due to its intrinsic limitation in the detection of GGOs, while it can show bilateral multifocal consolidation in more advanced stages. [3] \nOne of the main advantages of performing a chest CT is the possibility of an obtain an early diagnosis, considering also the relatively low sensitivity of RT-PCR tests during the initial phase of disease: patients may show typical lung anomalies at CT scan, despite a negative RT-PCR. [4] \nThe characteristic findings at chest CT were already described. [5]\n\u00a0The CT pattern changes consistently during the disease course. The most common early CT findings are round areas of subpleural ground-glass opacities (GGOs), usually bilateral and predominantly in the lower lobes, associated with consolidations that increase in number with the progression of the disease. In advanced phases, other signs may appear, such as linear opacities, \u201ccrazy-paving\u201d pattern and a \u201creverse halo\u201d sign. Pleural effusion, nodules and lymphadenopathy are uncommon. [6] \nEven if the role of chest CT has not clearly defined yet, our imaging findings confirmed its high sensitivity in diagnosing COVID-19 [7]. Moreover, CT scan is the most direct and rapid examination test for a quick confirmation of the diagnosis and to properly adjust the treatment plan. [1] \nTherefore, we suggest to perform chest CT also on young patients that show symptoms and signs compatible with COVID-19.\n\nOutcome:\n\nThe prognosis of COVID-19 in the young population is generally good, leading to complete resolution by supportive treatments (antibiotic therapy, IV fluids and electrolytes). Worst clinical outcome is found in elderly and in patients with chronic diseases due to the development of complications, sometimes fatal, such as ARDS. The cornerstone of therapy for pneumonia is respiratory support with both non-invasive (NIV) or invasive (IV) ventilation, or extracorporeal membrane oxygenation (ECMO). Our study confirmed that younger patients have better outcome [2]: none of the 6 patients included in the report required IV or developed complications during treatment. So far, no specific treatment has been discovered, even if chloroquine/hydroxychloroquine and some antiviral drugs, such as lopinavir-ritonavir, seems to improve the clinical course. After receiving antiviral and antibiotic therapy, along with oxygen support in some cases (2/6), all the patients were discharged in stable clinical conditions (range of hospitalization: 3-11 days) with the indication to continue quarantine at home for 14 days. \u00a0 \n\nTeaching Points:\u00a0\n\nEven in young patients, chest CT can disclose typical findings of COVID-19 and thus support the diagnosis of Sars-Cov-2 infection. On the contrary, CRX has a low sensitivity and is of limited diagnostic value.\nPatients of all ages are at risk of developing a severe form of COVID-19 pneumonia and ARDS. These life-threatening conditions require intensive care unit admission and invasive ventilation. Fortunately, invasive treatment is not always necessary: its need is directly related to age, comorbidities and extent of the disease.\u00a0 \nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Coronavirus, Disease-19, (COVID-19), Viral, pneumonia, Hypersensitivity, pneumonitis, Pulmonary, oedema",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-05//16745_1_1.PNG?itok=q1Bn1mCK",
            "caption": "Summary of clinical history, imaging findings and outcome"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-05//16745_2_1.PNG?itok=Vtpr6ehX",
            "caption": "Patient 1 \u2013 CXR: Normal"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-05//16745_2_2.PNG?itok=Ai83VSD3",
            "caption": "Patient 1 - CT scan \u2013 axial view: bilateral areas of GGOs, are seen in the anterior segment of RUL and in the apical and basal segments of LLL, compatible with the early phase of an alveolar-interstitial inflammatory process."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-05//16745_2_3.PNG?itok=sZK9jVDv",
            "caption": "Patient 1 - CT scan \u2013 coronal view: bilateral areas of GGOs, are seen in the anterior segment of RUL and in the apical and basal segments of LLL, compatible with the early phase of an alveolar-interstitial inflammatory process."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-05//16745_3_1.png?itok=0wVEG2vx",
            "caption": "Patient 2 - CXR: Normal"
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-05//16745_3_2.png?itok=FoWtSgRO",
            "caption": "Patient 2 - CT scan \u2013 axial view: bilateral subpleural areas of GGOs in LLL and RLL, associated with \u201ccrazy-paving\u201d pattern for interstitial thickening"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-05//16745_4_1.png?itok=_sIbNkBg",
            "caption": "Patient 3 - CXR: Presence of two areas of parenchymal consolidations with possible inflammatory aetiology in the apical segment of the LUL and in the RLL."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-05//16745_4_2.png?itok=Cz_F7lz8",
            "caption": "Patient 3 - CT scan \u2013 axial view: bilateral and diffuse peripheral areas of GGOs and consolidations, associated with signs of thickened interstitium in the LLL. Presence of reactive lymph nodes in the right aorto-pulmonary window and in the right paratracheal area."
          },
          {
            "number": "Figure 4c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-05//16745_4_3.png?itok=zwKZYtUi",
            "caption": "Patient 3 - CT scan \u2013 coronal view: bilateral and diffuse peripheral areas of GGOs and consolidations, associated with signs of thickened interstitium in the LLL. Presence of reactive lymph nodes in the right aorto-pulmonary window and in the right paratracheal area."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-05//16745_5_1.png?itok=6-ZDZLwd",
            "caption": "Patient 4 - CXR: diffuse consolidations, particularly visible in LUL. Patient required NIV with low-flow oxygen therapy."
          },
          {
            "number": "Figure 5b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-05//16745_5_2.png?itok=7is6tK9Y",
            "caption": "Patient 4 - CT scan \u2013 axial view: bilateral areas of GGOs, mostly in the peripheral zone of LUL. Patient required NIV with low-flow oxygen therapy."
          },
          {
            "number": "Figure 5c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-05//16745_5_3.png?itok=lJqEYuau",
            "caption": "Patient 4 - CT scan \u2013 coronal view: bilateral areas of GGOs, mostly in the peripheral zone of LUL. Patient required NIV with low-flow oxygen therapy."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-05//16745_6_1.png?itok=cOlIxhC3",
            "caption": "Patient 5 - CXR: Normal"
          },
          {
            "number": "Figure 6b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-05//16745_6_2.png?itok=DrJEmQyD",
            "caption": "Patient 5 - CT scan \u2013 axial view: Bilateral peripheral areas of GGOs, the biggest in the basal posterior segment of LLL with overlapping signs of dysventilation."
          },
          {
            "number": "Figure 6c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-05//16745_6_3.png?itok=C6F62Vv8",
            "caption": "Patient 5 - CT scan \u2013 coronal view: Bilateral peripheral areas of GGOs, the biggest in the basal posterior segment of LLL with overlapping signs of dysventilation."
          }
        ]
      },
      {
        "number": "Figure 7",
        "subfigures": [
          {
            "number": "Figure 7a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-05//16745_7_1.png?itok=eYwrihZ5",
            "caption": "Patient 6 - CXR: Suspicious areas of parenchymal consolidations. Patient required NIV with low-flow oxygen therapy and CPAP."
          },
          {
            "number": "Figure 7b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-05//16745_7_2.png?itok=axLwZZZJ",
            "caption": "Patient 6 - CT scan at admission \u2013 axial view: multiple peripheral areas of GGOs diffused in the pulmonary lobes. Presence of few mediastinal reactive lymph nodes. Patient required NIV with low-flow oxygen therapy and CPAP."
          },
          {
            "number": "Figure 7c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-05//16745_7_3.png?itok=Gqdn0NLI",
            "caption": "Patient 6 - CT scan at admission \u2013 coronal view: multiple peripheral areas of GGOs diffused in the pulmonary lobes. Presence of few mediastinal reactive lymph nodes. Patient required NIV with low-flow oxygen therapy and CPAP."
          },
          {
            "number": "Figure 7d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-05//16745_7_4.png?itok=NfcPosES",
            "caption": "Patient 2 - CT scan during hospitalization \u2013 axial view: increased number and extension of parenchymal hyperdense areas, compatible with consolidations. Increased volume of mediastinal reactive lymph nodes (maximum diameter of 22 mm). Patient required NIV with low-flow oxygen therapy and CPAP."
          },
          {
            "number": "Figure 7e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-05//16745_7_5.PNG?itok=FehNEZl5",
            "caption": "Patient 2 - CT scan during hospitalization \u2013 coronal view: increased number and extension of parenchymal hyperdense areas, compatible with consolidations. Increased volume of mediastinal reactive lymph nodes (maximum diameter of 22 mm). Patient required NIV with low-flow oxygen therapy and CPAP."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/16745",
    "time": "08.05.2020"
  },
  "16747": {
    "case_id": 16747,
    "title": "COVID-19 Patient with olfactory alterations",
    "section": "Chest imaging",
    "age": "48",
    "gender": "male",
    "diagnosis": "COVID-19",
    "history": "48-year-old male patient with a five-day history of cough and fever. Past medical history was unremarkable. He also suffered from anosmia since three days. The patient was admitted to the hospital ward and discharged one week after admission with complete recovery.",
    "image_finding": "Chest X-ray: In the early phase, the patients demonstrated moderate clinical manifestations, where lesions were limited to single or multiple areas; and were distributed along the subpleural areas\nThese findings indicated the characteristics of the spread of the lesions along the airway, starting with invasion of the bronchioles and alveolar epithelium of the cortical lung tissues, and extending gradually from the periphery to the centre.",
    "discussion": "Background:\nCoronavirus is a large RNA virus family. Six subtypes have been identified [1]. SARS-CoV-2 is a new subtype whose genetic structure is 82% similar to SARS-CoV [2]. Basic reproduction number of COVID-19 was estimated to be 2.3 from reservoir to person and 3.58 from person to person which means that the expected number of secondary infections that result from introducing a single infected individual into an otherwise susceptible population was 3.58 [3]. The estimated reproduction numbers of severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS) ranged from 2 to 5 and from 2.7 to 3.9, respectively [3] The mortality rate is less than commonly ascribed to severe community-acquired pneumonia (12 \u201315%) but more than seasonal influenza (0.1%) [4]. \nClinical Perspective:\nA better understanding of the underlying pathobiology is required. Wan et al. reported that residue 394 (glutamine) in the SARS-CoV-2 receptor-binding domain, corresponding to residue 479 in SARS-CoV, can be recognized by the critical lysine 31 on the human angiotensin converting enzyme ACE2 receptor [5]. Further analysis even suggested that SARS-CoV-2 recognizes human ACE2 more efficiently than SARS-CoV increasing the ability of SARS-CoV-2 to transmit from person to person [5]. \nImaging Perspective:\nThe novel coronavirus is firstly causing interstitial damages and subsequently parenchymal changes. CT and plain chest radiography images could manifest different imaging features or patterns in COVID-19 patients with a different time course and disease severity [6, 7].\nIn the early phase, the patients demonstrated moderate clinical manifestations, where lesions like ground glass opacities were limited to single or multiple areas; and were distributed along the subpleural areas. These findings indicated the characteristics of the spread of the lesions along the airway, starting with invasion of the bronchioles and alveolar epithelium of the cortical lung tissues, and extending gradually from the periphery to the center.\nOutcome:\nOlfactory and taste disorders are well known to be related with a wide range of viral infections [8]. SARS-CoV has demonstrated in mice model a transneural penetration through the olfactory bulb [9]. Even our patient suffered from anosmia which has already been reported in COVID-19 [10]. Typical chest radiographs underlined the diagnosis of COVID-19, which was confirmed by RT-PCR.\nTake home message:\nAlthough chest radiograph is not very specific it is still the first imaging modality in COVID 19 patients. The present case demonstrated an unusual clinical manifestation with olfactory alterations. However multiple lung consolidations along the subpleural areas must be suspected for COVID 19.",
    "differential_diagnosis": "COVID-19, SARS, MERS, Adenovirus",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-05//16747_1_1.jpg?itok=_UEo8Cy0",
            "caption": "Chest X-ray: Peripheral ground glass opacities on both sides. Picture was taken five days after onset of symptoms"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-05//16747_2_1.jpg?itok=DTEBnpvS",
            "caption": "AP bedside chest X-ray: Three days later the patient deteriorated. Progressive opacities extending from the periphery to the center can be observed."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-05//16747_3_1.jpg?itok=MbIMP75s",
            "caption": "Chest X-ray: One week after the changes in chest radiography declined."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "Conventional radiography"
    ],
    "link": "https://www.eurorad.org/case/16747",
    "time": "08.05.2020"
  },
  "16750": {
    "case_id": 16750,
    "title": "Angiosarcoma Pericardium",
    "section": "Chest imaging",
    "age": "45",
    "gender": "male",
    "diagnosis": "Angiosarcoma Pericardium",
    "history": "A 45-year-old male with a history of chest pain, breathlessness since last three months gradually increasing. On and off low-grade fever which is increasing gradually. Mild loss of weight compared with last month. No other symptoms.",
    "image_finding": "Initially, a chest radiograph was done which was normal three months back. Later one month back the chest radiograph shows mild cardiomegaly. Patient was subsequently referred for further evaluation. CECT Chest was done which shows mild pericardial thickening with mild pericardial effusion.\nPatient was referred to PET-C T in the PUO Pyrexia of unknown Protocol.\nWhole-body PET-CT\u00a0 from the base of skull to mid-thigh shows diffuse irregular pericardial thickening with pericardial effusions. Small pericardial nodules were also noted within. This pericardial thickening and nodules show diffuse increased uptake along the pericardium. The pericardial fluid shows no uptake.\nThe SUV max values were 6-12 in different locations of the pleural thickening and nodules. Histopathological findings are suggestive of the Angiosarcoma Pericardium.",
    "discussion": "Primary malignant tumours of the pericardium are rare, and most primary malignant pericardial tumours are mesotheliomas. Secondary involvement of the pericardium is more common, and it is often caused by direct invasion of cardiac and lung neoplasms or by the metastatic spread. Angiosarcoma is the most frequent primary cardiac malignant tumour. However, primary pericardial angiosarcoma is extremely rare, and it has a poor prognosis.\nEnhanced CT scan delineate the outline and blood supply of the tumour and MRI has excellent diagnostic advantages regarding tumour delineation and clarification of the tumour location, its local spread, and the involvement of adjacent structures. However final diagnosis depends on biopsy.\nPET-CT is the important modality for the diagnosis and staging and restaging of the Sarcomas which will be helpful in prognosis.\nOn immunohistochemical analysis, the tumour is positive for CD31, CD34, and Factor VIII. In our case, it was positive for CD31, CD34, and SMA and negative for desmin [2]. Angiosarcoma grows rapidly with local invasion and distant metastasis. Constriction of the pericardium is caused by both the tumour itself and the hemorrhagic pericardial fluid. Tumour growth around the heart can also lead to constriction of the pericardium.\nThe prognosis of patients with angiosarcoma is extremely poor. The mean survival is 6-14 months, and few patients survive beyond 14 months [1]. This tumour responds poorly to chemotherapy and radiotherapy. Pericardiotomy, radiation therapy, and chemotherapy are associated with prolonged survival.",
    "differential_diagnosis": "Angiosarcoma, Pericardium, Tuberculosis, Metastasis, Myxoma, Lymphoma, Myxosarcoma, Rhabdomyosarcoma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-05//16750_1_1.jpg?itok=DSiwyPjn",
            "caption": "CT Whole Body showing diffuse irregular pericardial thickening with subtle small nodules."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-05//16750_2_1.jpg?itok=XRnwQSNK",
            "caption": "Images showing diffuse increased uptake in the pericardium with increased uptake of SUV Max ranging from 5.6 to 11.2. Moderate amount of the pericardial effusion noted. Rest of the body shows no distant metastases."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-05//16750_3_1.jpg?itok=tzcdaSgY",
            "caption": "Images showing diffuse increased uptake in the pericardium with increased uptake of SUV Max ranging from 5.6 to 11.2. Moderate amount of the pericardial effusion noted. Rest of the body shows no distant metastases."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Cardiovascular system"
    ],
    "imaging_technique": [
      "PET-CT"
    ],
    "link": "https://www.eurorad.org/case/16750",
    "time": "12.05.2020"
  },
  "16751": {
    "case_id": 16751,
    "title": "Incidental COVID-19",
    "section": "Chest imaging",
    "age": "62",
    "gender": "male",
    "diagnosis": "Asymptomatic COVID-19 infection.",
    "history": "A 62-year-old male patient with chemotherapy treatment under treatment with chemotherapy \u00a0due to a recently diagnosed rectum adenocarcinoma.\u00a0 \nHe arrived because of syncope and traumatism in the right hemithorax. The patient did not display any did not refer other symptoms. \nNew consolidations in the right hemithorax were evidenced found in chest radiography and asymptomatic COVID-19 was suggested and confirmed by polymerase chain reaction (PCR).",
    "image_finding": "Anteroposterior and oblique radiographs were performed to evaluate the ribs, which were normal. Incidentally, evidence of small opacities were found As an incidental finding small opacities were evidenced in the right lung base. A chest NECT was performed, due to a In suspicion of COVID-19 infection, a chest NECT was performed. \nOn CT, peripheral ground-glass opacities affecting all lobes of the right lung were confirmed, the same side where the patient had the traumatism without compatible symptoms of chest infection.",
    "discussion": "A global health emergency was declared in January 2020 by the World Health Organization (WHO), due to a \u00a0secondary to a coronavirus disease (COVID-19) [1- 5] caused by a severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) [1-4, 6] which may result in a life-threatening and rapidly progressive viral pneumonia (2). SARS-CoV-2 belongs to the family Coronaviridae [1, 2, 5] as well as the viruses that cause severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS) [1, 3, 5].\nThe infection began in China and rapidly spread worldwide [1, 2, 4- 6]. Rapid and accurate diagnosis is mandatory in order to prevent human-to-human transmission [1, 5, 6] as well as with the isolation of those patients infected patients [1, 6] coupled with a good patient management and for the best management for them [1]. Transmission can occur during the incubation period and in asymptomatic patients [5]. Children are 's population is less affected than adults and when it occurs, they present mild symptoms [1].\nAn alteration of the angiotensin-converting enzyme II inducing diffuse alveolar damage by the virus has been postulated [1]. It is usually presented with fever, dry cough, dyspnea, respiratory distress, and muscle pain. [3-5].\nReverse transcription-polymerase chain reaction (RT-PCR) [4, 6] or gene sequencing of the virus [6] of the nasopharyngeal aspiration are the standard diagnostic method [4, 6] although there are patients with false-negative results [1, 2, 4, 6], especially in early stages [1, 2]. Chest CT may be an important tool for prompt diagnoses and a follow-up of infected patients by SARS-CoV-2 [1-3, 5, 6]. Imaging findings can be seen before symptoms or positive laboratory test results [1].\n75% of imaging studies reveal bilateral involvement [5]. The most frequent imaging findings are ground-glass opacity and consolidation in peripheral [1- 4, 6] and posterior localization. These involve the involving lower and middle areas [1- 3], that increase in size and number as the disease progresses when disease progress with the affection of the upper areas of the lung [1, 2], which has been seen in 75% of patients [1]. Although less frequently, vascular enlargement, interlobular septal thickening, air bronchogram sign, air trapping, reversed halo sign, pulmonary nodules with halo sign [1, 2], crazy paving [2-4], bronchiectasias and pleural thickening [2] can also be seen.\u00a0 \nSome patients may develop irreversible injury of the lung parenchyma with fibrosis [1, 3]. \nIn summary, chest CT is a widely available and rapid diagnostic tool for COVID-19 useful in differentiating infected patients even before laboratory tests.\nAlthough chest CT is not specific for a diagnosis of COVID-19 pneumonia, it may be helpful in confirming typical findings in patients at risk for COVID infection with or without clinical symptoms in the absence of a positive PCR test. Furthermore, if typical findings are detected incidentally, as in our case, radiologists should alert referring physicians to the possibility of COVID-19 infection.",
    "differential_diagnosis": "Asymptomatic, COVID-19, infection., Adenovirus, chest, infection., H1N1, influenza., Atypical, pneumonia., Cytomegalovirus, pneumonia., Middle, east, respiratory, syndrome, coronavirus, (MERS-CoV).",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-05//16751_1_1.jpg?itok=k1gMTa1-",
            "caption": "Oblique chest radiography: small ground-glass opacities (circle) in the right lung base not visible on previous imaging studies."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-05//16751_2_1.jpg?itok=h-JFtQ0w",
            "caption": "axial NECT lung window: multiple ill-defined patchy ground-glass opacities with subtle thickened intralobular septum affecting the three lobes of the right lung with a peripheral distribution. Left lung was absolutely normal."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-05//16751_2_2.jpg?itok=lvbDZkL1",
            "caption": "axial NECT lung window: multiple ill-defined patchy ground-glass opacities with subtle thickened intralobular septum affecting the three lobes of the right lung with a peripheral distribution. Left lung was absolutely normal."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-05//16751_3_1.jpg?itok=hrhPzC8P",
            "caption": "coronal NECT lung window: multiple ill-defined patchy ground-glass opacities with a peripheral and diffuse distribution in the right lung. Left lung was absolutely normal"
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-05//16751_3_2.jpg?itok=_vAUR08V",
            "caption": "coronal NECT lung window: multiple ill-defined patchy ground-glass opacities with a peripheral and diffuse distribution in the right lung. Left lung was absolutely normal"
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-05//16751_3_3.jpg?itok=J1DVfC6R",
            "caption": "coronal NECT lung window: multiple ill-defined patchy ground-glass opacities with a peripheral and diffuse distribution in the right lung. Left lung was absolutely normal"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/16751",
    "time": "11.05.2020"
  },
  "16755": {
    "case_id": 16755,
    "title": "Unilateral crazy paving pattern in a healthy man with COVID-19 infection",
    "section": "Chest imaging",
    "age": "47",
    "gender": "male",
    "diagnosis": "COVID-19 pneumonia with crazy- paving pattern",
    "history": "A previously healthy 47 years old man presented to the emergency department with cough and high fever (38.5\u00b0C) for five days.\u00a0 At admission, oxygen saturation was normal (SpO2 99%) and laboratory tests showed leukopenia (3.99\u00d710^3/\u03bcL, normal range 4.0-11\u00d710^3/\u03bcL) and mild elevated c-reactive protein (20 mg/L, normal range <0.5 md/dl).",
    "image_finding": "Initially, bedside chest X-ray didn\u2019t show significative alterations and nasopharyngeal swab for COVID-19 was negative, therefore chest HRCT was performed due to the high clinical suspicion of SARS-CoV-2 infection. \nChest CT showed unilateral crazy paving pattern on the right lower lobe, consistent with interstitial pneumonia. COVID-19 was then confirmed through RT-PCR of bronchoalveolar lavage.\nThe first chest X-ray performed at bedside in the emergency room didn\u2019t demonstrate definitive alterations (Fig.1). Chest HRCT performed 6 hours later showed a wide area of crazy paving pattern in the posterior region of the lower right lobe (Fig.2); there were no parenchymal alteration on the left lung, bilateral lung effusion nor mediastinal nodal enlargement. The second chest X-ray performed 3 days later showed small bilateral basal consolidations (Fig.3).",
    "discussion": "Coronavirus disease 2019 (COVID-19) is a highly infectious respiratory syndrome caused by a novel coronavirus called SARS-CoV-2, that was first identified in Wuhan (China) in December 2019 [1]. The virus has spread rapidly worldwide causing thousands of deaths and on 11th March 2020, the World Health Organization confirmed COVID-19 as a pandemic. Actually a serious cluster of COVID-19 is reported in the North of Italy and in the country as the 27th March 80539 total cases with 8165 deaths were confirmed [2]. \nThe common symptoms of COVID-19 are fever, fatigue, dry cough and dyspnoea; lymphopenia and elevated PCR are typical findings at laboratory. It is reported that the average incubation period of the infection is 6.4 days [3]. The diagnosis is based on reverse transcription-polymerase chain reaction (RT-PCR) or gene sequencing of sputum, throat swab or lower respiratory tract secretions. It is emerging that chest CT, thanks to its high sensitivity (98%), could play a critical role in the diagnosis of \u00a0COVID-19 at the early stage of infection when chest X-ray is often negative or in patients with negative RT-PCR results but high clinical suspicion of infection [4].\nA Chinese retrospective study conducted on 21 patients with COVID-19 reported that on chest CT 71% of cases presented bilateral involvement, 57% ground-glass opacities, 33% rounded opacities, 33% peripheral distribution, 29% consolidation with ground-glass opacities and only 19% of the patients presented crazy-paving pattern [5].\nIn our case HRCT showed a unilateral crazy paving pattern with ground-glass opacity superimposed by interlobular and intralobular septal thickening, resembling irregular paving stones. It could be considered the result from the alveolar oedema and interstitial inflammatory of acute lung injury [4] and, although is less frequent than ground-glass opacities, it must be considered as suggestive for COVID-19, entering progressive or peak stage [6]. \u00a0\nThe patient was hospitalized for two weeks in our Hospital and then discharged for resolution of symptoms. \nChest HRCT, thanks to its high sensitivity, is a useful tool for COVID-19 diagnosis in patients with clinical suspicion of infection but with negative microbiological tests. Therefore, it is necessary to become familiar with the typical and atypical CT manifestations of COVID-19 and it is important to highlight that during this pandemic also unilateral consolidations must be considered with suspicion for Sars-Cov-2 infection.",
    "differential_diagnosis": "COVID-19, pneumonia, with, crazy-, paving, pattern, COVID-19, pneumonia, Bacterial, pneumonia, Acute, respiratory, distress, syndrome, (ARDS)",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-05//16755_1_1.jpg?itok=3edvlqQr",
            "caption": "Chest X-ray: the only antero-posterior view performed at bedside did not show obvious parenchymal consolidation or pleural effusion."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-05//16755_2_1.jpg?itok=nw7TleXV",
            "caption": "Chest HRCT in axial (a), sagittal (b) and coronal (c) views showed a wide area of crazy paving pattern in the posterior region of lower right lobe."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-05//16755_2_2.jpg?itok=A90QibAA",
            "caption": "Chest HRCT in axial (a), sagittal (b) and coronal (c) views showed a wide area of crazy paving pattern in the posterior region of lower right lobe."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-05//16755_2_3.jpg?itok=WEFMxuG_",
            "caption": "Chest HRCT in axial (a), sagittal (b) and coronal (c) views showed a wide area of crazy paving pattern in the posterior region of lower right lobe."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-05//16755_3_1.jpg?itok=II1RqPZK",
            "caption": "Chest X-ray performed 3 days later in antero-posterior view showed small bilateral basal consolidations."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/16755",
    "time": "28.05.2020"
  },
  "16765": {
    "case_id": 16765,
    "title": "Necrotising pneumoni",
    "section": "Chest imaging",
    "age": "3",
    "gender": "female",
    "diagnosis": "Necrotising pneumonia",
    "history": "A 3-year-old girl with no significant past medical history was brought to paediatric emergency in view of a 5-day history of fever, cough and lethargy. On examination she was haemodynamically stable and febrile, with decreased air entry in the left lower lung zone. Blood investigations revealed high inflammatory markers.",
    "image_finding": "Chest X-ray (CXR) showed a left pleural effusion with ipsilateral consolidation (Fig. 1). She was admitted for intravenous antibiotics, however, there was no improvement. A left-sided chest drain was inserted under ultrasound guidance and the patient initially improved, however subsequently deteriorated (Fig. 2). Computed tomography (CT) of the thorax was performed (Fig. 3a & b), which revealed complete consolidation of the left lower lobe with no aeration, multiple small pockets of gas and absent enhancement of a large portion of the involved consolidated parenchyma. The left lower lobe bronchus was patent. Findings were in keeping with necrotising pneumonia. A note was made of air within the pleural space surrounding the drain, together with a pocket of air in the left subpulmonic location (Fig. 4a & b). The antibiotic regime was adjusted based on these findings, and over time the patient\u2019s clinical and serological status improved significantly. She was fit for discharge and a repeat CXR one week later demonstrated radiographic improvement (Fig. 5).",
    "discussion": "Background\nNecrotising pneumonia is an uncommon, severe complication of community-acquired pneumonia. It was first described in the 1940s in adult patients, only being recently described in children with a reported increasing incidence. [1] The condition is often preceded by a viral infection and the major causative bacterial pathogens include pneumococci and Staphylococcus aureus. [2,3]\nPathologically, necrotising pneumonia is characterised by inflammatory changes with intrapulmonary vessel thrombosis and resultant necrosis of lung parenchyma. In addition, suppurative changes are seen, likely due to toxin-mediated cytokine activation and inflammatory response, leading to tissue destruction. [4]\nClinical Perspective \nMost affected children are young (<5 years of age) with no predisposing health condition. The clinical signs and symptoms are that of pneumonia, however, despite receiving appropriate antibiotic therapy, patients remain persistently ill with a worsening clinical and radiological picture. [4]\nImaging Perspective \nCT is the most sensitive imaging method for the demonstration of complications of pneumonia in children. It is also ideal for the detection of underlying congenital lung malformations. Necrotising pneumonia is diagnosed when a large proportion of consolidated lung appears hypodense and demonstrates decreased or absent enhancement following contrast administration. Associated necrotic cavities are characterised by parenchymal destruction with multiple fluids or air-filled thin-walled cavities with non-enhancing borders. In contrast, an abscess consists of a fluid or air-filled cavity with a well-defined enhancing wall. This distinction is important, as an intervention which may be indicated for abscesses would be detrimental in the case of necrotic pneumonia. Loculated areas of fluid or gas may be seen within the pleural cavity. Additional complications include parapneumonic effusions and empyema when there is an extension of necrotic regions to the pleura, together with bronchopleural fistulae. Rarely severe ischaemia due to vascular compromise results in gangrene. [5,6]\nOutcome \nManagement involves a multidisciplinary approach, with a prolonged course of intravenous antibiotics and ventilatory support forming the mainstay of treatment. Management of pleural complications (effusions, empyema, pyopneumothorax) is with chest-tube drainage with or without fibrinolytic use and rarely decortication. Surgical intervention is avoided due to the risk of bronchopleural fistulae. In rare cases, segmental/lobar resection or pneumonectomy may be required to deal with complications, which include tension pneumatocoeles, pulmonary gangrene involving more than half the affected lobe and massive haemoptysis. \nDespite the seriousness of this condition, it does not commonly result in mortality, provided there is timely diagnosis and appropriate management. Good clinical and radiological recovery can be expected within the first 4 months of diagnosis. [7,8]\n\u00a0\n\u00a0\nTake-Home Message / Teaching Points\n\nThe diagnosis of necrotising pneumonia should always be considered when dealing with protracted pneumonia in a previously healthy child, despite at least 72 hours of appropriate antibiotic therapy. \nCT is the mainstay for diagnosis and should not be delayed in such circumstances. \nDespite the short-term severe illness, long-term clinical outcomes are very favourable with minimal resultant morbidity.",
    "differential_diagnosis": "Necrotising, pneumonia, Lung, abscess, Secondarily, infected, congenital, lung, malformations, (CPAM,, bronchopulmonary, sequestration), Vasculitis, (ex:, granulomatosis, with, polyangiitis), Malignancy, (ex:, primary, germ, cell, tumour,, lymphoma), Traumatic, pseudocysts",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-06//16765_1_1.JPG?itok=01CixW4n",
            "caption": "CXR at presentation, demonstrating a left middle and lower zone consolidation, with an associated pleural effusion."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-06//16765_2_1.JPG?itok=PXHqX1aI",
            "caption": "CXR taken a few days following left chest drain insertion, after which the patient\u2019s clinical condition failed to improve. Note is made of persistent left lower zone consolidation and a left pleural effusion with areas of lucency suggestive of the presence of gas."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-06//16765_3_1.jpg?itok=cVdIm9T-",
            "caption": "Coronal contrast-enhanced CT of the chest in soft-tissue (A) and lung-window (B) setting. There is complete consolidation of the left lower lobe of lung with no aeration, multiple small pockets of gas (arrowheads) and absent enhancement of a large portion of the involved consolidated parenchyma (asterisk). There is gas within the pleural space surrounding the drain, together with a pocket of air in the left subpulmonic location (arrow)."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-06//16765_3_2.jpg?itok=kU5feWD1",
            "caption": "Coronal contrast-enhanced CT of the chest in soft-tissue (A) and lung-window (B) setting. There is complete consolidation of the left lower lobe of lung with no aeration, multiple small pockets of gas (arrowheads) and absent enhancement of a large portion of the involved consolidated parenchyma (asterisk). There is gas within the pleural space surrounding the drain, together with a pocket of air in the left subpulmonic location (arrow)."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-06//16765_4_1.jpg?itok=Nac18-i5",
            "caption": "Axial contrast-enhanced CT of the chest in soft-tissue (A) and lung-window (B) setting. Note is again made of left lower lobe consolidation with small pockets of gas (arrowheads) and absent enhancement of a large portion of the involved consolidated parenchyma (asterisk). There is gas within the pleural space surrounding the drain."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-06//16765_4_2.jpg?itok=omW09qnZ",
            "caption": "Axial contrast-enhanced CT of the chest in soft-tissue (A) and lung-window (B) setting. Note is again made of left lower lobe consolidation with small pockets of gas (arrowheads) and absent enhancement of a large portion of the involved consolidated parenchyma (asterisk). There is gas within the pleural space surrounding the drain."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-06//16765_5_1.JPG?itok=cAAuT-am",
            "caption": "CXR taken one week following discharge demonstrating resolved left lower pneumonia with residual post-inflammatory scarring."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Paediatric"
    ],
    "imaging_technique": [
      "CT",
      "Digital radiography"
    ],
    "link": "https://www.eurorad.org/case/16765",
    "time": "10.08.2020"
  },
  "16768": {
    "case_id": 16768,
    "title": "Benign metastasizing leiomyom",
    "section": "Chest imaging",
    "age": "58",
    "gender": "female",
    "diagnosis": "Benign metastasising leiomyoma to lung",
    "history": "A 58-year-old woman was referred to our institution for investigation of pulmonary nodules identified on external chest radiograph performed at the time of a road traffic accident.",
    "image_finding": "Repeated chest radiograph demonstrated unchanged multiple, bilateral pulmonary nodules, the largest in the right upper zone. A contrast-enhanced CT of the thorax, abdomen and pelvis was performed, which demonstrated multiple, bilateral, well-circumscribed, rounded pulmonary nodules, measuring up to 1.5 cm. A well-circumscribed, rounded, enhancing 2.3 cm mass was also noted in the posterior uterine myometrium. The patient underwent PET/CT, which demonstrated bilateral pulmonary nodules, at least one of which showed increased radiotracer uptake and an FDG-avid nodule in the posterior fundal myometrium.",
    "discussion": "The combination of CT TAP and PET/CT findings was suspicious for a primary endometrial tumour with haematogenous metastases to lung. A gynaecology opinion was recommended and the patient underwent hysteroscopy and curettage, which revealed multiple benign post-menopausal polyps only, with no evidence of hyperplasia, dysplasia or malignancy. Following multidisciplinary discussion, transbronchial biopsy of one of the pulmonary nodules was attempted but was non-diagnostic. Percutaneous CT-guided lung biopsy was subsequently performed, the histology of which revealed a bland smooth muscle tumour, suggestive of metastasising leiomyoma. The patient subsequently underwent total hysterectomy and bilateral salpingo-oophorectomy. The surgical specimen demonstrated multiple benign leiomyomata. No further intervention was required. Follow-up imaging demonstrates slow interval growth of the pulmonary lesions. The patient remains asymptomatic, 5 years later.\nBenign metastasising leiomyoma (BML) is a rare condition, with only approximately 214 published research articles relating to the subject. [1] It was first described by Steiner in 1939. [2] It refers to extra-uterine metastases of benign smooth muscle tumours. As in our case, the lungs are the most frequent site of metastases. [1] BML is most common in asymptomatic, perimenopausal women [1], like our patient. They usually have a history of uterine fibroids. Imaging typically demonstrates well-circumscribed, non-calcified, non-enhancing pulmonary nodule(s), ranging in size from a few millimetres to a few centimetres. Endobronchial and pleural sparing are typical. Rarely, miliary/cavitating nodules, cysts and interstitial disease have been described. [3] The accumulation of 18-FDG in pulmonary BML varies significantly, with tumours more likely to be non-avid than FDG-avid. [4] Histopathology confirms the presence of smooth muscle cells with low mitotic activity, limited vascularisation, no anaplasia/necrosis and positive immunohistochemical staining for smooth muscle markers, i.e. actin, desmin and hormonal receptors, i.e. oestrogen/progesterone. [5] Although hormone-dependent, BML has a favourable long-term prognosis. Targeted hormonal therapies and/or surgery can be used in disease management, with disease control or regression in 79% of patients treated with hormonal manipulation. [6]\nBML, although rare, should be considered in the differential diagnosis for women presenting with multiple pulmonary nodules, especially those with a history of uterine fibroids.",
    "differential_diagnosis": "Benign, metastasising, leiomyoma, to, lung, Malignant, pulmonary, metastases, vascular/collagen-vascular, disease, infectious/inflammatory, granulomata",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-06//16768_1_1.jpg?itok=ZYuj3TfJ",
            "caption": "PA chest radiograph demonstrates bilateral pulmonary nodules, largest in right upper zone."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-06//16768_2_1.jpg?itok=pt-4BAtt",
            "caption": "Axial slices from a contrast-enhanced CT thorax, abdomen, pelvis demonstrates multiple, bilateral, well-circumscribed, rounded pulmonary nodules (2A). The largest, in the right upper lobe, measures 1.5 cm (2B). There is a well-circumscribed, rounded, enhancing mass measuring 2.3 cm in the posterior uterine myometrium (2C)."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-06//16768_2_2.jpg?itok=INT_QG5x",
            "caption": "Axial slices from a contrast-enhanced CT thorax, abdomen, pelvis demonstrates multiple, bilateral, well-circumscribed, rounded pulmonary nodules (2A). The largest, in the right upper lobe, measures 1.5 cm (2B). There is a well-circumscribed, rounded, enhancing mass measuring 2.3 cm in the posterior uterine myometrium (2C)."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-06//16768_2_3.jpg?itok=eUZ1PMnJ",
            "caption": "Axial slices from a contrast-enhanced CT thorax, abdomen, pelvis demonstrates multiple, bilateral, well-circumscribed, rounded pulmonary nodules (2A). The largest, in the right upper lobe, measures 1.5 cm (2B). There is a well-circumscribed, rounded, enhancing mass measuring 2.3 cm in the posterior uterine myometrium (2C)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-06//16768_3_1.jpg?itok=suONCw5n",
            "caption": "Axial slices from fused PET/CT demonstrate increased radiotracer uptake within a right lower lobe pulmonary nodule (3A) and within the nodule in the posterior fundal myometrium (3B)."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-06//16768_3_2.jpg?itok=u2lIKYUQ",
            "caption": "Axial slices from fused PET/CT demonstrate increased radiotracer uptake within a right lower lobe pulmonary nodule (3A) and within the nodule in the posterior fundal myometrium (3B)."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-06//16768_4_1.jpg?itok=NFGWQXbr",
            "caption": "Percutaneous CT-guided lung biopsy of the largest right upper lobe nodule was performed. The procedure was complicated by a small right apical pneumothorax."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-06//16768_5_1.jpg?itok=josd__e8",
            "caption": "Follow-up CT 3 years later demonstrates slow interval growth of the pulmonary nodules \u2013 the right upper lobe nodule has increased in size from 1.5 to 1.8 cm."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Genital / Reproductive system female",
      "Lung"
    ],
    "imaging_technique": [
      "CT",
      "Digital radiography",
      "PET-CT"
    ],
    "link": "https://www.eurorad.org/case/16768",
    "time": "10.08.2020"
  },
  "16784": {
    "case_id": 16784,
    "title": "Pulmonary alveolar proteinosis",
    "section": "Chest imaging",
    "age": "48",
    "gender": "male",
    "diagnosis": "Autoimmune Pulmonary alveolar proteinosis",
    "history": "48-year-old male presents with a 6-week history of progressively worsening shortness of breath with associated cough and sputum production. Clinical examination noted finger clubbing. His history was notable for occupational exposure to hay and sawdust, and recreational pigeon keeping. Blood gases revealed a type 1 respiratory failure. The patient failed to respond to IV antibiotics and steroids and deteriorated requiring intubation and transfer to the intensive care unit. Bronchoscopy and whole lung lavage were negative for infection or malignancy and a diagnostic wedge excision biopsy was performed.",
    "image_finding": "Initial chest radiograph demonstrated diffuse bilateral consolidation/groundglass opacification with a lower lobe predominance. CT revealed diffuse bilateral groundglass opacification with subpleural sparing. There was associated smooth septal thickening resulting in a crazy paving appearance with innumerable small cystic spaces in the upper lobes. No associated pleural effusion. Repeat chest radiograph following steroid administration showed no improvement.",
    "discussion": "Histology confirmed protein alveolar proteinosis (PAP) and the patient was subsequently found to be positive for the Anti-GMCSF (granulocyte-macrophage colony-stimulating factor) antibody, consistent with primary autoimmune PAP. Treatment included multiple whole lung lavage and nebulised GM-CSF. The patient continues a low dose regimen of GM-CSF in the community and requires low dose oxygen on mobilisation.\nPAP is a rare disease characterised by accumulation of a surfactant like material composed of proteins and lipids in the alveoli due to abnormal clearance of surfactant by alveolar macrophages [1]. Incidence is estimated at less that one in one million [2]. PAP can be divided into primary PAP, either autoimmune or hereditary, secondary PAP, due to an underlying haematological malignancy or toxin exposure, or congenital PAP. Autoimmune PAP results from production of a GM-CSF antibody that prevents GM-CSF from stimulating the macrophages to clear the surfactant from the alveoli. Those with hereditary PAP have a genetic mutation that destroys the receptor for the GM-CSF on the macrophages [3,4]. In secondary PAP, an underlying disease or exposure to a toxin reduces the number and/or function of the macrophages [3,4]. \u00a0Congenital PAP accounts for less than 2% of cases [5] and is caused by the abnormal production of surfactant due to a genetic mutation.\nClinical presentation is most commonly with dyspnoea. Cough and a low grade fever may be present however some patients may be asymptomatic [6]. Cyanosis or clubbing is present in up to one third of patients and crackles on auscultation are not uncommon. Clinical examination can be normal [2]. Pulmonary function tests demonstrate a restrictive pattern [6].\nChest radiograph typically demonstrates diffuse and symmetrical alveolar opacities with relative sparing of the apices and costophrenic angles [1]. The pattern mimics acute interstitial oedema but pleural effusions and cardiomegaly are absent [2]. CT findings of PAP have clasically been described as crazy paving, a combination of groundglass opacification and septal thickening [7]. Consolidation, fibrosis and lymphadenopathy may also be present [7].\nDiagnosis is most commonly made using a combination of the CT findings and examination of the bronchoalveolar lavage fluid (BALF), specifically cytological examination and positive periodic acid-Schiff staining [2]. If the BALF is negative, as in our case, transbronchial or open lung biopsy may be performed [2].\nTreatment of PAP is by whole lung lavage with approximately fifteen litres of saline, each lung 24-48 hours apart [2]. 85% pf patients improve symptomatically, radiologically and functionally after whole lung lavage and one procedure is enough to treat approximately 50% of patients [7]. Recombinant GM-CSF, either subcutaneously or via nebuliser is used as maintenance in those with severe disease [8]. Outcomes in autoimmune PAP are unpredicatable and reported outcomes range from spontanous remission to death. Opportunistic infections, namely Aspergillus and Nocardia, can occur and pulmonary fibrosis has been reported in some patients [2].",
    "differential_diagnosis": "Autoimmune, Pulmonary, alveolar, proteinosis, Non-specific, interstitial, pneumonitis, Hypersensitivity, pneumonitis, Pneumocystis, jirovecii, pneumonia",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-06//16784_1_1.jpg?itok=TNM4LYcp",
            "caption": "Initial presenting chest radiograph demonstrates diffuse bilateral airspace opacification with a mid and lower zone distribution and sparing of the costophrenic angles."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-06//16784_2_1.png?itok=DAHEUcRq",
            "caption": "Axial and coronal CT images demonstrate diffuse bilateral groundglass opacification with septal thickening. Small cystic spaces were noted in the upper lobes."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-06//16784_3_1.jpg?itok=pSD6I60p",
            "caption": "Repeat chest radiograph following 3 whole lung lavage procedures and high dose nebulised GM-CSF shows significant improvement in the bilateral airspace opacification."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-06//16784_4_1.jpg?itok=hqvlC8l-",
            "caption": "Most recent chest radiograph on maintenance GM-CSF shows complete resolution of the findings."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/16784",
    "time": "15.06.2020"
  },
  "16787": {
    "case_id": 16787,
    "title": "Pericardial Hydatid Cyst",
    "section": "Chest imaging",
    "age": "69",
    "gender": "male",
    "diagnosis": "Hydatid cyst of pericardium",
    "history": "A 69-year-old male was admitted to our hospital with chest pain, fatigue and dry cough lasting for one month prior to admission. His medical history yielded no important clinical feature. Physical examination revealed normal respiratory and heart function. Chest X-ray demonstrated widening of the mediastinum with lobulated contours.",
    "image_finding": "Axial contrast-enhanced CT images (Fig 1 a,b) demonstrate a low-attenuated mass with multicystic appearance located in the left pericardial space. Axial chest CT image (Fig 2 a) reveals a low attenuated mass adjacent to ascending aorta. Axial chest CT image (Fig 2 b) at lower level shows a pseudoaneurysm arising from right lateral wall of the ascending aorta protruding into the neighbouring low attenuated cystic mass.",
    "discussion": "Hydatid cyst is a parasitic disease which occurs secondary to the development of the larval form of E. Granulosus. Cardiac involvement in hydatid disease is very uncommon and accounts for 0.5%-2% of all hydatisosis cases. Most frequently involved site in the heart is myocardium while pericardial involvement occurs in 2%-10% of cardiac echinococcosis [1, 2].\u00a0\u00a0\u00a0 Pericardial involvement of hydatid cyst may be caused by systemic circulation which results from fissuring of hydatid cyst from liver or lung, transdiaphragmatic dissemination or via lymphatic circulation [3]. \n\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Patients with pericardial hydatid cyst may remain asymptomatic until echinococcal cyst causes pressure effect on surrounding structures. Presenting symptoms of uncomplicated pericardial hydatid cyst include chest pain due to the stretch of pericardium and/or compression of coronary vessels, dyspnea, and palpitations [4]. \nAlthough pericardial hydatid cyst can be depicted by transthoracic echocardiography cross-sectional imaging studies like CT and/or MRI are usually necessary which demonstrate preoperative cardiac anatomy, the location and size, calcification of the cyst, and its adhesions and relationship to adjacent structures. CT is a better imaging technique in revealing is small calcifications which may be a helpful imaging finding in the diagnosis of a hydatid cyst. Relationship of hydatid cysts with adjacent structures can be depicted by MRI. Hydatid cysts present as a hypointense mass on T1- weighted images and hyperintense on T2-weighted images. A hypointense rim around the mass on T2-weighted images represents pericyst. Daughter cysts are characterized by cystic structures that are attached to the internal wall of the cyst with fluid signal intensity.\u00a0 \n\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Treatment of pericardial hydatid cyst can be accomplished with surgical excision of the cystic lesion. Medical treatment (e.g., albendazole and mebendazole) is complimentary for disseminated cases and for prophylaxis.",
    "differential_diagnosis": "Hydatid, cyst, of, pericardium, Differential, Diagnosis, List:, Congenital, pericardial, cysts, Pleuropericardial, cysts, Pericardial, hematomas, Myocardial, aneurysms,, Cystic, degenerating, tumors",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-06//16787_1_1.jpg?itok=QjMCnU5w",
            "caption": "Axial contrast-enhanced CT images (Fig 1 a,b) demonstrate a low-attenuated mass with multicystic appearance located in the left pericardial space."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-06//16787_1_2.jpg?itok=DGq38w4m",
            "caption": "Axial contrast-enhanced CT images (Fig 1 a,b) demonstrate a low-attenuated mass with multicystic appearance located in the left pericardial space."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-06//16787_2_1.jpg?itok=z2BbRCyL",
            "caption": "Axial chest CT image (Fig 2 a) reveals a low attenuated mass adjacent to ascending aorta. Axial chest CT image (Fig 2 b) at lower level shows a pseudoaneurysm arising from right lateral wall of the ascending aorta protruding into the neighbouring low attenuated cystic mass."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-06//16787_2_2.jpg?itok=29V_DXGl",
            "caption": "Axial chest CT image (Fig 2 a) reveals a low attenuated mass adjacent to ascending aorta. Axial chest CT image (Fig 2 b) at lower level shows a pseudoaneurysm arising from right lateral wall of the ascending aorta protruding into the neighbouring low attenuated cystic mass."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Cardiac",
      "Mediastinum"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/16787",
    "time": "15.06.2020"
  },
  "16797": {
    "case_id": 16797,
    "title": "Intralobar pulmonary sequestration",
    "section": "Chest imaging",
    "age": "39",
    "gender": "female",
    "diagnosis": "Intralobar pulmonary sequestration",
    "history": "A previously healthy 39-year-old female presenting with a 2-day history of epigastric pain, nausea, fever and mild cough.",
    "image_finding": "Chest radiograph on admission demonstrated a small left-sided pleural effusion associated with dense retrocardiac opacification (Fig. 1). No previous radiographs were available for comparison. Repeat radiograph 6 weeks following antibiotic treatment showed partial resolution of the findings with small residual retrocardiac opacity (Fig. 2). Recurrent symptoms a year later prompted a repeat chest radiograph which demonstrated increased opacification in retrocardiac region (Fig. 3). In view of this non-resolving retrocardiac opacity a contrast enhanced CT of the thorax was performed for further evaluation. This showed a diffuse mass lesion of heterogeneous attenuation within the medial basal segment of left lower lobe of lung. This consisted of areas of enhancing soft tissue attenuation, fluid filled cystic areas and multiple areas of punctate calcification. The mass lesion manifested a systemic arterial supply via a large calibre artery arising directly from the left side of the descending thoracic aorta (Fig. 4a, b, c).",
    "discussion": "Background:\nPulmonary sequestration is a rare congenital anomaly of the lower respiratory tract consisting of a segment of aberrant pulmonary tissue which lacks communication with the tracheobronchial tree and which receives its blood supply from branches of the systemic circulation [1]. The condition, also known as accessory lung, is classified anatomically into two distinct types: intralobar (75%) and extralobar sequestration (25%) [2]. In intralobar sequestration, the commoner of the two, the involved lung segment is contained within the same visceral pleural covering as the rest of the normal lung whilst extralobar sequestration is characterised by its own visceral pleura [3].\n\u00a0\nClinical perspective:\nThe age of presentation and the clinical manifestations are dependent on the type of sequestration. Intralobar sequestration typical presents in early adulthood with recurrent chest infections whilst the extralobar variant presents early on in life with symptoms of respiratory distress, chest infections and cyanosis [2].\n\u00a0\nImaging Perspective:\nA chest radiograph is usually performed as the first-line imaging modality in patients presenting with symptomatic pulmonary sequestration. Findings include focal opacities, consolidation, subsegmental atelectasis, cystic spaces, cavitation with or without air-fluid level and focal bronchiectasis.\u00a0 Pulmonary sequestration is most commonly seen in the left lower lobe [3,4]. Patients with non-resolving or recurrent changes should be assessed further by CT angiography which is considered to be the gold standard diagnostic modality [4]. CT reveals the underlying sequestered lung lesion and the anomalous systemic arterial supply, usually via a branch of the aorta, which is key to the diagnosis and differentiates sequestration from other differential diagnoses [5,6]. CT can also differentiate between intralobar and extralobar sequestration through identification of the venous drainage which occurs via the pulmonary veins in intralobar sequestration and via the systemic veins in the extralobar type [7].\n\u00a0\nOutcome:\nTreatment consists predominantly of surgical resection, even in the case of asymptomatic lesions, as these will invariably become infected if not removed. Whilst extralobar sequestrations can be removed by sparing normal lung parenchyma, intralobar sequestrations often require lobectomy. Surgical resection is best approached via open thoracotomy although video-assisted thoracoscopic surgery has been performed successfully. Preoperative coil embolisation has also been described [2,7].\n\u00a0\nTake Home Message / Teaching Points:\nThis case serves to highlight the importance of considering pulmonary sequestration as a potential diagnosis in young patients presenting with recurrent chest infections and to evaluate non-resolving chest radiograph changes via contrast enhanced CT of the thorax.",
    "differential_diagnosis": "Intralobar, pulmonary, sequestration, Extralobar, pulmonary, sequestration, Atypical, pneumonia, Pulmonary, abscess, Pulmonary, arteriovenous, malformation, Congenital, pulmonary, airway, malformation",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-06//16797_1_1.png?itok=ryHwBEzG",
            "caption": "Chest radiograph demonstrating airspace shadowing in the left lower lung zone associated with a small left-sided pleural effusion."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-06//16797_2_1.png?itok=vXmI5EOP",
            "caption": "Repeat chest radiograph 6 weeks following antibiotic treatment demonstrating partial resolution of the radiographic findings with a small residual opacity in the left retrocardiac region."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-06//16797_3_1.png?itok=zP46xRnF",
            "caption": "A repeat chest radiograph a year later due to recurrent symptoms demonstrates increased opacification in the retrocardiac region."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-06//16797_4_1.png?itok=lFg7jKsx",
            "caption": "Contrast-enhanced CT of the thorax demonstrating a mass lesion within the medial basal segment of left lower lobe of lung. This is of heterogeneous attenuation, consisting of areas of enhancing soft tissue attenuation, fluid filled cystic areas and multiple areas of punctate calcification."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-06//16797_4_2.png?itok=rq0HaPHk",
            "caption": "Contrast-enhanced CT of the thorax demonstrates systemic arterial supply via a large calibre artery arising directly from the left side of the descending thoracic aorta (red arrow)."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Mediastinum"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/16797",
    "time": "22.06.2020"
  },
  "16798": {
    "case_id": 16798,
    "title": "A round atelectasis developing a squamous lung cance",
    "section": "Chest imaging",
    "age": "79",
    "gender": "male",
    "diagnosis": "Lung cancer",
    "history": "An elderly gentleman of 79 years suffering from diabetes and COPD with asbestos exposure and smoking history, and previous malignant melanoma from which he had been declared healthy. He complains about weight loss and declining wellbeing. He had palpable cervical lymph nodes and pain in one rib dorsolateral on the right side.",
    "image_finding": "Figure 1 and 2. Chest X-Ray, AP and lateral\nA big rounded tumour in the right lower lobe with cavitation. Calcified pleural plaque bilaterally and findings of COPD.\nFigure 3 and 4. CT Chest with iv contrast\nSubpleural round tumour measuring 8 cm in diameter in the right lower lobe with well-defined borders and parts of low attenuation and cavitation in keeping with necrosis. Pleural involvement with a small amount of right-sided pleural effusion. Enlarged lymph nodes in the right hilum and mediastinum and metastasis with bone destruction in costa X on the right side. Bilateral calcified plaque with distribution suggesting asbestos exposure. Moderate emphysema.\nFigure 5 and 6.\nPapanicolaou staining of cytological material from endobronchial ultrasound-guided fine-needle aspiration showing keratinising squamous cell carcinoma.\nFigure 7, 8 and 9. CT Chest with iv contrast performed three years previously\nA round atelectasis in the right lower lobe where the tumour is present now. It is defined by its subpleural localisation adjacent to thickened pleura, wedge-shaped mass and curvilinear vessels and bronchi entering the mass (\u201ccomet sign\u201d).",
    "discussion": "Round atelectasis (RA) also known as folded lung, Blesovsky syndrome or atelectatic pseudotumour is a form of chronic pleuro-pulmonary disease. It emerges due to pleural disease with thickening, usually pleural fibrosis causing adhesions to the adjacent lung. The lung is trapped and over time gradually folded, probably facilitated by retraction of the pleura [1]. There are certain imaging findings such as subpleural location, pleural thickening of the adjacent pleura (88%), converging bronchovascular markings extending towards the hilum, associated ipsilateral pleural fluid (60%), and small calcifications (32%), more commonly men (88%) and most often found in the lower lobes [1,2]. In a series of 50 patients, the follow up stretching to 126 months 88% stayed stable or decreased in size (88%) [2]. If up filling the criteria the diagnosis of RA is straight forward. Sometimes there is a need for verification with a biopsy. On PET it shows increased uptake making it difficult to differ from malignancy.\nRA is commonly associated with asbestos-related pleural disease but has more often other causes such as infections, uremic or congestive heart disease pleuritic effusion and benign pleural exudates e.g. as in congestive heart disease (25% are exudate) or systemic diseases with serositis [3]. They can be associated with mesothelioma if asbestos-related. Lung cancer can also occur in RA although very rare since there are only two reported cases, one of them probably being coincidental [4]. It is unknown if RA itself is a risk factor for developing lung cancer or if it is coincidental. The coexistence is rare [5] and if present other risk factors such as smoking and asbestos exposure are more significant [6]. Given the rareness, RA as a risk factor itself is not likely. Nonetheless, the finding of a RA should always be put in a clinical context and preferably followed up. If any diagnostic doubt extensive investigation is mandatory. Regarding the timeline for the follow up, there are no recommendations.\nThis patient developed a squamous cell lung carcinoma in a RA. Unfortunately, he fell out from the follow up after the first chest CT and returned with advanced lung cancer and limited treatment options. He passed away within months of the diagnosis. This would be the third reported case with lung cancer in a RA.",
    "differential_diagnosis": "Lung, cancer, Metastasis, Organising, Pneumonia, Granulomatous, Polyangitis, Infection",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-06//16798_1_1.png?itok=LrFzr3h5",
            "caption": "A big rounded tumor in the right lower lobe with cavitation. Calcified pleural plaque bilaterally and findings of COPD."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-06//16798_2_1.png?itok=bei6eoF0",
            "caption": "A big rounded tumor in the right lower lobe with cavitation. Calcified pleural plaque bilaterally and findings of COPD."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-06//16798_3_1.png?itok=ABDowrdZ",
            "caption": "Subpleural round tumor measuring 8 cm in diameter in the right lower lobe with well-defined borders and parts of low attenuation and cavitation in keeping with necrosis. Pleural involvement with a small amount of right sided pleural effusion. Enlarged lymph nodes in the right hilum and mediastinum and a metastasis with bone destruction in costa X on the right side. Bilateral calcified plaque with distribution suggesting asbestos exposure. Moderate emphysema."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-06//16798_4_1.png?itok=vNk9kye6",
            "caption": "Subpleural round tumor measuring 8 cm in diameter in the right lower lobe with well-defined borders and parts of low attenuation and cavitation in keeping with necrosis. Pleural involvement with a small amount of right sided pleural effusion. Enlarged lymph nodes in the right hilum and mediastinum and a metastasis with bone destruction in costa X on the right side. Bilateral calcified plaque with distribution suggesting asbestos exposure. Moderate emphysema."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-06//16798_5_1.png?itok=Qj2KuPrP",
            "caption": "Papanicolaou staining of cytological material from endobronchial ultrasound-guided fine-needle aspiration showing keratinizing squamous cell carcinoma."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-06//16798_6_1.png?itok=9ewQz9Wk",
            "caption": "Papanicolaou staining of cytological material from endobronchial ultrasound-guided fine-needle aspiration showing keratinizing squamous cell carcinoma."
          }
        ]
      },
      {
        "number": "Figure 7",
        "subfigures": [
          {
            "number": "Figure 7",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-06//16798_7_1.png?itok=9KmXiPRv",
            "caption": "A round atelectasis in the right lower lobe where the tumor is present now. It is defined by its subpleural localization adjacent to thickened pleura, wedge-shaped mass and curvilinear vessels and bronchi entering the mass (\u201ccomet sign\u201d)."
          }
        ]
      },
      {
        "number": "Figure 8",
        "subfigures": [
          {
            "number": "Figure 8",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-06//16798_8_1.png?itok=L7Ry6Lhc",
            "caption": "A round atelectasis in the right lower lobe where the tumor is present now. It is defined by its subpleural localization adjacent to thickened pleura, wedge-shaped mass and curvilinear vessels and bronchi entering the mass (\u201ccomet sign\u201d)."
          }
        ]
      },
      {
        "number": "Figure 9",
        "subfigures": [
          {
            "number": "Figure 9",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-06//16798_9_1.png?itok=lm2yzpZF",
            "caption": "A round atelectasis in the right lower lobe where the tumor is present now. It is defined by its subpleural localization adjacent to thickened pleura, wedge-shaped mass and curvilinear vessels and bronchi entering the mass (\u201ccomet sign\u201d)."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Oncology",
      "Thorax"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/16798",
    "time": "22.06.2020"
  },
  "16805": {
    "case_id": 16805,
    "title": "The role of computed tomography and the assessment of lung involvement with 3D-pulmo software in COVID-19 pneumonia: a case report.",
    "section": "Chest imaging",
    "age": "76",
    "gender": "female",
    "diagnosis": "Coronavirus disease-19 (COVID-19)",
    "history": "A previously healthy 76-year-old woman with a history of five days of hyperpyrexia up to 40\u00b0 was admitted to the emergency department because of dyspnea. At admission, her SpO2 was 78%. Laboratory findings showed high CRP (195.25 mg/L, normal range 1-5 mg/L) and LDH (359 U/L, normal value < 248 U/L), white blood cell count was normal. Elevation of D-dimer (1596,17 \u03bcgr/L; < 500 \u03bcgr/L threshold to exclude venous thromboembolism) and IL-6 (130 pgr/mL, normal value < 5.9 pgr/mL) were found as well. She was negative for Legionella and Streptococcus pneumonia; she was tested and found positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Because of the rapid deterioration of the clinical condition, the patient required mechanical ventilation and was admitted to intensive care.",
    "image_finding": "A Computed Tomography (CT) examination was performed at admission, using a multi-detector CT scanner with 64 channels. The detailed parameters were: 120 kVp tube voltage; 100 mAs tube current; 1 mm slice thickness; 1 mm reconstruction interval; lung reconstruction algorithm. CT was acquired at full inspiration with the patient in the supine position and without contrast medium. The exam showed patchy bilateral ground-glass opacities (GGO) in the upper lobes mainly peripheral and associated with the thickness of interlobular and intralobular (\u201ccrazy paving\u201d pattern); perilesional vascular thickening was seen. In the lower lobes, CT showed more consolidated areas with air bronchogram. Bronchus architectural distortion, traction bronchiectasis, and fibrous stripes were also found. No signs of pleural effusion or mediastinal lymphadenopathy. Evaluation with 3D-Pulmo software showed a 50% involvement of the total parenchyma.",
    "discussion": "Coronavirus disease-19 (COVID-19) is a viral respiratory infection caused by SARS-CoV-2 [1]. The infection has airborne transmission via droplets. Symptoms include tiredness, fever, dry cough, and shortness of breath [2]. COVID-19 can range from asymptomatic to severe pneumonia leading to acute respiratory distress syndrome (ARDS) and death from respiratory failure [1]. \nDiagnosis is based on the combination of a history of exposure, clinical characteristics and RT-PCR (real-time polymerase chain reaction) assay from specimens obtained by oropharyngeal or nasopharyngeal swab, bronchoalveolar lavage, or tracheal aspirate, followed by imaging examination [3].\nChest X-Ray is not sensitive in the early stage; during the rapid progression, hazy increased opacities and consolidations may be present [3].\nCT has low specificity but high sensitivity in the detection of COVID-19. In the early stage, typical CT findings include multiple GGO, patchy consolidations, or crazy paving pattern. In the later phases of the disease, large consolidative opacities and contextual air bronchograms are present. Almost always, the CT manifestations are bilateral with involvement of more lobes (most frequently lower lobes), with predominantly peripheral distribution [4].\nArchitectural distortion, fibrous stripes, subpleural lines, vascular thickening, and reversed halo sign may be present. Mediastinal lymph-nodes enlargement and pleural effusion are rarely reported [5].\nDistribution of pulmonary lesions and lung involvement grading on admission could be assessed automatically by deep learning quantitative CT. The percentage of well-aerated parenchyma defined by software may stratify the severity of the infection and could be an important radiological predictor of the patient\u2019s outcome [6].\nPatients positive for COVID-19 are isolated and treated with the highest standard of care; however, at present, there are still no \"specific drugs\" available [7]. \nTeaching points\nCT imaging may be helpful in early detection of interstitial pneumonia in patients with high clinical suspicion for COVID-19 pneumonia and an initial negative or unknown RT-PCR. Furthermore, imaging may be helpful to assess the severity grade of lung\u2019s involvement to stratify the severity of the infection and to monitor its course.",
    "differential_diagnosis": "Coronavirus, disease-19, (COVID-19), Viral, Pneumonia, Atypical, Bacterial, Pneumonia, Cryptogenic, Organizing, Pneumonia, Interstitial, Lung, Disease",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-06//16805_1_1.png?itok=yOs01ibW",
            "caption": "Axial chest CT shows peripheral ground-glass opacities with thickness of interlobular and intra-lobular septa (\u201ccrazy paving\u201d pattern); perilesional vascular thickening (arrow) is observed."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-06//16805_2_1.png?itok=pImHnvv-",
            "caption": "(A) Axial chest CT shows bilateral ground glass-opacities with small peripheral consolidation with air-bronchogram sign (arrow in A). (B) Axial chest CT shows fibrous stripes (arrow in B)."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-06//16805_2_2.png?itok=o9kFFgIH",
            "caption": "(A) Axial chest CT shows bilateral ground glass-opacities with small peripheral consolidation with air-bronchogram sign (arrow in A). (B) Axial chest CT shows fibrous stripes (arrow in B)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-06//16805_3_1.png?itok=n-PBf3eE",
            "caption": "(A) Axial chest CT image shows patchy bilateral ground-glass opacities and some consolida-tions with air bronchogram in the right lower lobe. (B) Coronal chest CT image demonstrates bronchus architectural distortion with traction bronchiectasis (arrows in B)."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-06//16805_3_2.png?itok=gc9rfhtj",
            "caption": "(A) Axial chest CT image shows patchy bilateral ground-glass opacities and some consolida-tions with air bronchogram in the right lower lobe. (B) Coronal chest CT image demonstrates bronchus architectural distortion with traction bronchiectasis (arrows in B)."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-06//16805_4_1.png?itok=2tdLz2QW",
            "caption": "Reconstruction in 3D-Pulmo software depicts in blue well-ventilated lung parenchyma, in green areas of ground-glass opacities, and in orange areas of consolidations. Therefore, the color im-age highlights the distribution of pulmonary lesions, which is useful to determine the extension of lung involvement."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "CT",
      "CT-High Resolution"
    ],
    "link": "https://www.eurorad.org/case/16805",
    "time": "26.06.2020"
  },
  "16808": {
    "case_id": 16808,
    "title": "Miliary sarcoidosis",
    "section": "Chest imaging",
    "age": "41",
    "gender": "male",
    "diagnosis": "Miliary sarcoidosis",
    "history": "A 41-year-old patient presented with cough, dyspnoea and malaise.",
    "image_finding": "Patient was referred to our hospital from another local hospital where chest radiograph was performed and showed bilateral lung nodules and hilar lymphadenopathy. Subsequent CT scan revealed marked bilateral hilar and mediastinal lymphadenopathy, diffuse multiple fine pulmonary nodules and ground-glass opacities. Although these miliary opacities were diffuse, they demonstrated an upper and middle lung zone predominance. A bronchoscopic biopsy was performed and showed noncaseating granulomas with multinucleated giant cells suggestive of sarcoidosis.",
    "discussion": "Sarcoidosis is a multisystem granulomatous disease of unknown aetiology, characterized by the presence of noncaseating granulomas. These granulomas represent a chronic immunologic response resulting from a cell-mediated response to specific antigenic stimulation and are distributed primarily along the lymphatics in the peribronchovascular interstitial space, and to a lesser extent, in the subpleural interstitial space and interlobular septa [1].\n\u00a0\n50% of patients are asymptomatic. The most common clinical features at presentation are respiratory symptoms: dyspnea, dry cough and chest pain [4]. Nonspecific constitutional symptoms such as fever, malaise and weight loss may occur in about one-third of patients with sarcoidosis [4].\n\u00a0\nChest X-ray has been used as an initial investigation for the diagnosis, staging and follow-up of sarcoidosis. High-resolution CT provides more detailed information on both typical and atypical pulmonary manifestations of sarcoidosis. The typical findings include bilateral lymphadenopathy, perilymphatic nodules, interlobular septal thickening and perihilar opacities. These parenchymal abnormalities are mostly seen in the upper and middle lung fields. In contrast, miliary opacities are rare and present in less than 1% of cases [2]. Miliary pattern is seen as tiny innumerable nodules located in a random diffuse distribution instead of the classic perilymphatic location. Other atypical manifestations are masslike or alveolar opacities, honeycomb-like cysts, mosaic attenuation, tracheobronchial involvement and pleural disease [2]. The final diagnosis of sarcoidosis is made based on compatible\nclinical and radiologic findings, histologic demonstration of noncaseating granulomas and exclusion of other conditions which can mimic sarcoidosis. \nTreatment of sarcoidosis depends on symptoms and functional or imaging evidence of disease progression. The clinical course ranges from spontaneous resolvement in half of cases within 2 years [3] to chronic sarcoidosis. The main problems with chronic sarcoidosis are fibrosis, pulmonary hypertension and impaired quality of life.\nCorticosteroids are first-line drug choice followed by methotrexate. TNF alfa antagonists are used in refractory sarcoidosis which refers to patients progressing despite treatment [3].\nTo help reduce morbidity and mortality it is important to recognize both the typical and atypical radiologic patterns of the disease. When miliary pattern is seen, the differential diagnosis should include miliary tuberculosis, pneumoconiosis and metastatic lesions [2].\n\u00a0\nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Miliary, sarcoidosis, Miliary, tuberculosis, Pneumoconiosis, Metastatic, lesions",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-06//16808_1_1.jpg?itok=FrU-TXwT",
            "caption": "Mediastinal window axial scan showing bilateral hilar and mediastinal lymph node enlargement."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-06//16808_2_1.jpg?itok=WLMZboZx",
            "caption": "Mediastinal window axial scan showing mediastinal lymph node enlargement."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-06//16808_3_1.jpg?itok=8p7-9kB4",
            "caption": "Axial unenhanced high-resolution CT scan showed countless tiny micronodules and ground-glass opacities in a random distribution."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Thorax"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/16808",
    "time": "26.06.2020"
  },
  "16812": {
    "case_id": 16812,
    "title": "Adenocarcinoma in sit",
    "section": "Chest imaging",
    "age": "62",
    "gender": "female",
    "diagnosis": "Cryptogenic organizing pneumonia (COP)",
    "history": "62- years old female patient, has contact to animals in daily life, presented with progredient dyspnoea and cough with accompanying clear mucus for several weeks. She has no history of fever, pain or loss of weight. Smoking and C2-abusus were denied. The patient was initially treated with antibiotics due to suspected alveolitis but showed no signs of recovery.",
    "image_finding": "The chest x-ray (Fig. 1) shows a homogenous and compact opacity in the middle and right lower lobe. The computed tomography (Fig. 2) shows consolidations and extended ground-glass-opacity as well as interlobular septal thickening \u2013 the so called \u201ecrazy paving pattern\u201c - \u00a0in all lobes of the right lung and parts of the left lung. There are no signs of necrosis or infiltration. FDG-PET-CT (Fig. 3) with strong FDG-Uptake in the lower right lobe (SUV max 6,3), but no distant metastatic disease. The chest x-ray six weeks later (Fig. 4) and one month before transplantation shows a progredient opacity in the right lung and new opacities in the left lung.",
    "discussion": "The patient initially presented with cough and progredient dyspnoea. As the patient has contact to animals in daily life and the first Chest X-ray showed a homogeneous opacity of the right lower and middle lobe, alveolitis was considered as the most likely diagnosis.\u00a0 However, the antibiotic therapy was not successful. The symptoms of the patient even worsened in a month. \nCT scan showed a diffuse, bilateral crazy paving pattern which is a nonspecific sign and can be seen in several diseases. Therefore, it was inevitable to perform a bronchial lavage with biopsy to determine the final diagnosis.\nAs final diagnosis, the pathology found an adenocarcinoma in situ with a lepidic growth pattern: this G1 NSCLC does not show any invasive growth pattern. Tumour cells spread along the alveolar septa without infiltration or destruction [1]. Complications are severe hypoxia and diffusion restriction. Nevertheless, if complete resection of the tumour is achievable, the prognosis is considerably good [2]. Our case had an unusual, diffuse and bilateral tumour spread, so resection was impossible. The only chance for full recovery was lung transplantation [3]. According to staging, there was no evidence of extrapulmonary or nodal disease, so our patient was listed for transplantation, which was subsequently performed without any complications. Now, it is crucial to establish the best follow-up strategy to prevent recurrence of the tumour.\nIn conclusion: Adenocarcinoma in situ is a rare, but important differential diagnosis for the crazy paving pattern.",
    "differential_diagnosis": "Cryptogenic, organizing, pneumonia, (COP), Adenocarcinoma, in, situ, Acute, interstitial, pneumonitis, (AIP), Pulmonary, alveolar, proteinosis, (PAP), Goodpasture-, syndrome",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-06//16812_1_1.jpg?itok=x_lTukfg",
            "caption": "Chest X-ray in a frontal view and b lateral view showing mid lobe consolidation"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-06//16812_1_2.jpg?itok=i0zeLaxU",
            "caption": "Chest X-ray in a frontal view and b lateral view showing mid lobe consolidation"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-06//16812_2_1.jpg?itok=LM5cBy8D",
            "caption": "Computed tomography detecting a ground glass opacity with consolidation and b prominent mid lobe manifestation"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-06//16812_2_2.jpg?itok=BaBeEij3",
            "caption": "Computed tomography detecting a ground glass opacity with consolidation and b prominent mid lobe manifestation"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-06//16812_3_1.jpg?itok=UMgDnpm-",
            "caption": "Coronal PET-CT images with a bilateral manifestation and b extended FDG uptake of the right lower lung"
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-06//16812_3_2.jpg?itok=6K6m1tOL",
            "caption": "Coronal PET-CT images with a bilateral manifestation and b extended FDG uptake of the right lower lung"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-06//16812_4_1.jpg?itok=UrYbKlme",
            "caption": "Repeated x-ray of the chest after six weeks with progress of disease"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Thorax"
    ],
    "imaging_technique": [
      "CT",
      "PET-CT"
    ],
    "link": "https://www.eurorad.org/case/16812",
    "time": "29.06.2020"
  },
  "16815": {
    "case_id": 16815,
    "title": "Thickening of the wall of the right main bronchus in IBD",
    "section": "Chest imaging",
    "age": "59",
    "gender": "female",
    "diagnosis": "Thickening of the wall of the right main bronchus as manifestation of ulcerative colitis.",
    "history": "A 59-year-old woman with ulcerative colitis came to the emergency department for dyspnoea for 14 days with cough. Laboratory findings: increased inflammatory markers. \nDuring the last year the symptoms of inflammatory bowel disease worsened with diarrhoea 8 times per day with blood.",
    "image_finding": "Thickening of the right main bronchus with lymphadenopathy in the right hilum. Lamelar atelectasis in the right lower lobe.\nThere are now CT signs of pulmonary embolism.",
    "discussion": "Enlargement of the right main bronchus with lymphadenopathy in the right hilum is very suspected for tumour. Even if the patient is a non-smoker. \nPlease follow this structure for the discussion and select only the items that are relevant for the case: \nBackground: Thoracic manifestation of inflammatory bowel disease is rare of underdiagnosed (1), though airways manifestation is the most common (2). The pathophysiology of airways involvement is thought to be according to embryonic origin of the intestinal and respiratory system (2).\nClinical Perspective Nearly half of the patient with inflammatory bowel disease have respiratory symptoms like cough, dyspnea, wheezing (3). According to dyspnoea CT images are sometimes indicated to exclude pulmonary embolism\nImaging Perspective: Airways involvement include thickening of the bronchial wall, mucous plugs, bronchiectasis and signs of bronchiolitis (1).\nOutcome In the case of the thickening of the bronchial wall and hilum mass, tumour must be excluded. Of there are no malignant cells in bronchoalveolar lavage and transbronchial biopsy and the patient has clinical signs of active IBD, therapy of the IBD is indicated. After the therapy in remission of IBD the lung involvement is mostly resolved (3). \nTake-Home Message / Teaching Points If the patient has IDB always think about the possibility of thoracic involvement of IBD.",
    "differential_diagnosis": "Thickening, of, the, wall, of, the, right, main, bronchus, as, manifestation, of, ulcerative, colitis., Tumor, mass, in, the, right, pulmonary, hilum, Infection, \u2013, pulmonary,, bronchial, Metastasis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-06//16815_1_1.jpg?itok=SjaD6VOY",
            "caption": "CT of the chest, transversal scan. Thicknening of the right main bronchus wall. Lymphadenopathy in front of the carina."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-06//16815_2_1.jpg?itok=m1O8P3DA",
            "caption": "CT of the chest, transversal scan, mediastinal window. Thickening of the right main bronchus wall."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-06//16815_3_1.jpg?itok=g05Fs4nx",
            "caption": "CT of the chest, coronal scan, mediastinal window: Thickening of the right main bronchus wall with lymphadenopathy in the right hilum and in the subcarinal space."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-06//16815_4_1.jpg?itok=5AdeLNS-",
            "caption": "CT of the chest, transversal scan, lung window: lamellar atelectasis in the right lower lobe."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lymph nodes"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/16815",
    "time": "29.06.2020"
  },
  "16819": {
    "case_id": 16819,
    "title": "Pulmonary cavitating lesions",
    "section": "Chest imaging",
    "age": "63",
    "gender": "female",
    "diagnosis": "Cavitating rheumatoid nodules",
    "history": "Female patient with clinical presentation of headache, nausea, photophobia and vomiting, history of surgical interventions 4 months ago due to sphenoid mucopyocelle and severe Rheumatoid arthritis proven two years ago. Routine chest radiograph was done due to suspicion of bronchitis. Laboratory test results show inflammation /WBC 13\u00a0 10^9/l, CRP 91 mg/l, ESR 30 mm/h/.",
    "image_finding": "Fig. 1 Chest X-ray \nFig. 2 Axial CT through the upper chest\nFig. 3 Axial CT through the lower chest",
    "discussion": "Background: Rheumatoid arthritis /RA/ is an chronic autoimmune, inflammatory connective tissue disease, characterized by arthritis, but also may have extra-articular involvement (1). Rheumatoid nodules occur in one-third of the patients with seropositive disease, most often in subcutaneous tissue (2). However pulmonary rheumatoid nodules are quite rare. These nodules generally do not cause any clinical symptoms and so usually they are incidental findings. Drugs, such as methotrexate, anti-TNF agents and activity of the disease (high levels of ESR, CRP, WBC, RF) can cause the appearance of pulmonary nodules. Pathophysiologically rheumatoid nodules belong to Th1-mediated granulomas and are characterized with central fibrinoid necrosis, epithelioid cells around an outer zone with lymphocytes, plasma cells or fibroblasts. The central zone may become cavity due to the resolution of necrosis (3) as in the present case.\nClinical perspective: The patient is diagnosed with severe RA two years ago and treated with methotrexate and TNF blockers. Immunocompromised patients are at possible risk of all the above-mentioned conditions, however, most of them have clinical manifestations. In this case, there was no history of clinical symptoms from the respiratory system. The last chest X-ray performed 4 months ago was with normal finding \u2013 no evidence of pulmonary lesions.\nImaging perspective: Pulmonary X-ray was done on the day before the hospitalization due to suspicion of bronchitis revealed mix sized bilateral (cavitating) pulmonary lesions (Fig.1). The followed CT examination confirmed the presence of two cavitating nodular lesions, located bilateral, with irregular margins. There was no evidence of hilar enlargement, pleural effusion, enlarged lymph nodes or other disorders of the lung structure. Imaging methods alone are not sufficient for definitive diagnosis, therefore, suspicious lesions should be identified by histopathology (Fig. 2 and Fig.3). The diagnosis was made based on the clinical and imaging findings, histopathology results and the negative cultures.",
    "differential_diagnosis": "Mycotic, haematogenous, disseminated, infection., Chronic, cavitary, pulmonary, aspergillosis., Cavitating, rheumatoid, nodules, Cavitating, pulmonary, metastases, Cavitating, tuberculosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-06//16819_1_1.jpg?itok=dmO9uLMQ",
            "caption": "Chest X-ray"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-06//16819_2_1.jpg?itok=y9bm5FpX",
            "caption": "Axial CT through the upper chest"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-06//16819_3_1.jpg?itok=uJI2e5gi",
            "caption": "Axial CT through the lower chest"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Mediastinum"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/16819",
    "time": "29.06.2020"
  },
  "16824": {
    "case_id": 16824,
    "title": "Quantitative longitudinal imaging findings of a severe unilateral COVID-19 associated with other types of pneumoni",
    "section": "Chest imaging",
    "age": "44",
    "gender": "male",
    "diagnosis": "COVID-19 pneumonia",
    "history": "A 44-year-old male patient with a history of indirect contact with Wuhan people in China\uff0cpresented with 4 days fever, cough, sputum, and shortness of breath, his axillary temperature was fluctuated from 37.5 to 40\u2103, and then he was admitted to our hospital on day 5. Laboratory studies showed decreased white blood cell counts (2.25*109/L), decreased neutrophil counts (1.70*109/L), decreased lymphocyte counts (0.37*109/L), and increased C-reaction protein (CRP, 65.58 mg/L).",
    "image_finding": "The chest CT examinations on day 5 and day 7 showed that the infected lesion on right lung mainly presented as mixed ground glass opacity and consolidation with fine reticulation (Fig. 1a), thickened vessels (Fig. 1b) within the lesion. The third chest CT examination on day 10 showed that the old lesion progressed, and a new lesion appeared on the right lower lobe of the ipsilateral lung. The bronchial wall within the lesions was thickened (Fig. 1c), and air bronchogram and serrated margin can be observed in a curved planar reconstruction image (Fig. 1d). The progress of the infected unilateral lesions and pulmonary involvement was demonstrated in Figure 2. Comparing with quantitative measurement results on day 5, the lesions\u2019 volume and lesions\u2019 volume change on day 10 increased by 357% and 18.8%, respectively (Figure 3).",
    "discussion": "Background \nA novel coronavirus, which can be transmitted from person to person, is mainly manifested by novel coronavirus pneumonia (NCP). The virus was named as severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2) [1], and the caused disease was designated as coronavirus disease 2019 (COVID-19) [2] by World Health Organization in February 2020. The disease is highly contagious with a basic infectivity of 2.2 person-times [3]. \nClinical Perspective \nThe typical clinical manifestations of COVID-19 include fever, cough and myalgia [4], severe patients may develop dyspnoea, lymphopenia and/or hypoxemia several days later and progress rapidly to acute respiratory distress syndrome. According to the Diagnosis and Treatment Protocol for Novel Coronavirus Pneumonia (Trail Version 7) released by the Chinese government in March 2020 [5], one of the diagnostic criteria for COVID-19 is to test real-time fluorescent RT-PCR for new coronavirus nucleic acid for suspected patients. In early stage with mild NCP symptoms, chest CT can be an important complement to negative RT-PCR because of its high sensitivity (97%) for diagnosis of COVID-19 [6], while CT is not specific for COVID-19, confirmation by RT-PCR testing is still required. \nImaging Perspective\nAll the COVID-19 patients had abnormalities in chest CT images, and the typical imaging findings include unilateral or bilateral ground-glass opacities (GGO), consolidation, mixed GGO and consolidation, bronchial wall thickening, and vascular enlargement [7]. NCP should be distinguished from other known viral pneumonia and mycoplasma pneumoniae infections. However, the patient we introduced in this study also presented as mycoplasma pneumonia, gram-positive bacterium positive (++) and gram-negative bacterium (+) according to laboratory studies, clinical symptoms, serological test and CT imaging findings, thus result in a unilateral consolidation as the primary imaging manifestation and progressed within ipsilateral lung. \nOutcome \nThe patient was transferred to the isolation ward for the novel coronavirus quarantine, and the nasopharyngeal swab test was positive which confirmed the infection of SARS-CoV-2. Quantitative CT analysis can give objective and direct results on the extent of disease progression in the course of disease diagnosis and treatment, and it is very important to guide clinical medication. After supportive treatment with ceftriaxone and moxifloxacin for antibacterial treatment, and recombinant human interferon(\u03b11b), ganciclovir and lopinavir/ritonavir for antiviral treatment, the patient recovered gradually, his final chest CT examination revealed lesion absorption and fibrosis, then the patient was discharged from hospital.\nTake-Home Message/Teaching points\nThe severe COVID-19 patient presented some Atypical imaging manifestations. Only unilateral lung was infected throughout the course, and the lung parenchyma and bronchus were affected simultaneously due to the mixed infection. Quantitative dynamic CT images of the chest can longitudinally monitor the disease progress of COVID-19 patient.\nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "COVID-19, pneumonia, Adenovirus, pneumonia, SARS, Syncytial, virus, pneumonia, Influenza, virus, pneumonia",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-06/1a.JPG?itok=m8291Haq",
            "caption": "The Typical imaging findings of the lesions. (a) red arrow shows mixed ground glass opacity lesion with reticulation, which is caused by interstitial thickening in the lobules. (b) red arrow shows the thickening of the vessels in the lesion, which is caused by inflammatory stimulation, increased vascular permeability and telangiectasia. (c) red arrow shows the thickened bronchial wall in the posterior segment of the right upper lobe. (d) red arrow shows air bronchogram and serrated margin in bronchial wall in a curved planar reconstruction image."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-06/1b.jpg?itok=Y7hpBE-Y",
            "caption": "The Typical imaging findings of the lesions. (a) red arrow shows mixed ground glass opacity lesion with reticulation, which is caused by interstitial thickening in the lobules. (b) red arrow shows the thickening of the vessels in the lesion, which is caused by inflammatory stimulation, increased vascular permeability and telangiectasia. (c) red arrow shows the thickened bronchial wall in the posterior segment of the right upper lobe. (d) red arrow shows air bronchogram and serrated margin in bronchial wall in a curved planar reconstruction image."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-06/1c.jpg?itok=NKZccQAO",
            "caption": "The Typical imaging findings of the lesions. (a) red arrow shows mixed ground glass opacity lesion with reticulation, which is caused by interstitial thickening in the lobules. (b) red arrow shows the thickening of the vessels in the lesion, which is caused by inflammatory stimulation, increased vascular permeability and telangiectasia. (c) red arrow shows the thickened bronchial wall in the posterior segment of the right upper lobe. (d) red arrow shows air bronchogram and serrated margin in bronchial wall in a curved planar reconstruction image."
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-06/1d.jpg?itok=DKbyMGRZ",
            "caption": "The Typical imaging findings of the lesions. (a) red arrow shows mixed ground glass opacity lesion with reticulation, which is caused by interstitial thickening in the lobules. (b) red arrow shows the thickening of the vessels in the lesion, which is caused by inflammatory stimulation, increased vascular permeability and telangiectasia. (c) red arrow shows the thickened bronchial wall in the posterior segment of the right upper lobe. (d) red arrow shows air bronchogram and serrated margin in bronchial wall in a curved planar reconstruction image."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07/2a.png?itok=TmWT6QnA",
            "caption": "The progress of the infected lesions and pulmonary involvement. (a)-(c) and (d)-(f) represents the 3D volume in anterior-posterior position and corresponding axial images of the patient\u2019s chest CT on day 5, day 7 and day 10, respectively. The dark red in (a)-(c) indicates lesion 1, and the dark blue in (c) indicates lesion 2"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07/2b.png?itok=szX9Mp0U",
            "caption": "The progress of the infected lesions and pulmonary involvement. (a)-(c) and (d)-(f) represents the 3D volume in anterior-posterior position and corresponding axial images of the patient\u2019s chest CT on day 5, day 7 and day 10, respectively. The dark red in (a)-(c) indicates lesion 1, and the dark blue in (c) indicates lesion 2."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07/2c.png?itok=LgU6-vlJ",
            "caption": "The progress of the infected lesions and pulmonary involvement. (a)-(c) and (d)-(f) represents the 3D volume in anterior-posterior position and corresponding axial images of the patient\u2019s chest CT on day 5, day 7 and day 10, respectively. The dark red in (a)-(c) indicates lesion 1, and the dark blue in (c) indicates lesion 2."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07/2d.png?itok=NtiAJo3d",
            "caption": "The progress of the infected lesions and pulmonary involvement. (a)-(c) and (d)-(f) represents the 3D volume in anterior-posterior position and corresponding axial images of the patient\u2019s chest CT on day 5, day 7 and day 10, respectively. The dark red in (a)-(c) indicates lesion 1, and the dark blue in (c) indicates lesion 2."
          },
          {
            "number": "Figure 2e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07/2e.png?itok=dpyZOfca",
            "caption": "The progress of the infected lesions and pulmonary involvement. (a)-(c) and (d)-(f) represents the 3D volume in anterior-posterior position and corresponding axial images of the patient\u2019s chest CT on day 5, day 7 and day 10, respectively. The dark red in (a)-(c) indicates lesion 1, and the dark blue in (c) indicates lesion 2."
          },
          {
            "number": "Figure 2f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07/2f.png?itok=KPAlgJnj",
            "caption": "The progress of the infected lesions and pulmonary involvement. (a)-(c) and (d)-(f) represents the 3D volume in anterior-posterior position and corresponding axial images of the patient\u2019s chest CT on day 5, day 7 and day 10, respectively. The dark red in (a)-(c) indicates lesion 1, and the dark blue in (c) indicates lesion 2."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07/table_1.png?itok=cAtEbTTC",
            "caption": "Comparing with quantitative measurement results on day 5, the lesions\u2019 volume and lesions\u2019 volume change on day 10 increased by 357% and 18.8%, respectively."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Breast",
      "Lung"
    ],
    "imaging_technique": [
      "CT-High Resolution",
      "CT-Quantitative"
    ],
    "link": "https://www.eurorad.org/case/16824",
    "time": "29.06.2020"
  },
  "16832": {
    "case_id": 16832,
    "title": "COVID-19 progressive stage imaging findings in a patient with initially negative RT-PCR",
    "section": "Chest imaging",
    "age": "57",
    "gender": "male",
    "diagnosis": "COVID-19 pneumonia (progressive stage)",
    "history": "A 57-year-old male patient with history of recent travel presented to the emergency department with dry cough, fever and increasing shortness of breath for 2 weeks. Laboratory analysis revealed elevated c-reactive protein (7.71mg/dL), LDH (892U/L), CK (1215U/L) and slighty elevated d-dimers (0.32 ug/ml). RT-PCR testing was initially negative for COVID-19.",
    "image_finding": "On admission, the chest radiography revealed mild bilateral patchy areas of ill-defined lung opacities with peripheral and lower zone distribution (Fig.1). Due to progressive respiratory deterioration, a pulmonary embolism (PE) was suspected by the physicians. Accordingly, a chest contrast-enhanced computed tomography (CT) was requested which was negative for a PE but revealed bilateral multifocal and predominantly peripheral ground-glass opacities with superimposed interlobular septal thickening and visible intralobular lines (\u201ccrazy-paving\u201d pattern) together with some discrete consolidative opacities with evidence of air bronchogram in the affected lung areas (Fig. 2). In the lower left lobe, a central ground-glass opacity surrounded by a denser consolidation of crescentic shape was also noticed which was interpreted as an emerging atoll sign (Fig.3). About 25-50% of lung parenchyma was affected bilaterally with slight posteroinferior predominance. Increased size lymph nodes, pleural or pericardial effusion were not found.",
    "discussion": "Background \nThe Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV- 2), is a novel zoonotic pathogen that first appeared among several pneumonia cases in Wuhan (China) during December 2019 and rapidly spread worldwide[1]. In February 2020, the World Health Organization named the disease \u201cCOVID-19\u201d and by March it was declared a global pandemic[2]. \nClinical Perspective \nCOVID-19 varies from asymptomatic or paucisymptomatic to severe forms of pneumonia[2]. The most frequent symptoms are fever, dry cough and dyspnea[2]. Although laboratory-based performance of RT-PCR test demonstrates high sensitivity and specificity, in clinical practice its sensitivity can be reduced with incorrect specimen collection or low viral load[3,4]. Initially, false-negative RT-PCR tests can occur in patients with CT findings of COVID-19 who later test positive[4]. \nImaging Perspective \nChest CT has a high positive rate and clinical symptoms are closely related to imaging findings allowing severity and progression assessment[4,5]. CT is more sensitive for early disease than chest x-ray, better for differential diagnosis, and can evaluate pulmonary thromboembolism (if contrast-enhanced CT is performed)[3]. Early-stage COVID-19 manifest as patchy ground-glass opacities (GGOs) with vascular dilation mainly in subpleural or peribronchovascular regions of one or both lungs, with posterior lower lobes predominance[4,5]. Progressive stage is revealed by increasing GGOs and involvement of multiple lobes, development of crazy pattern, and some GGOs converting into consolidations with air bronchograms[4,5]. Patients with nodular opacities on initial CT show an increase in number, size, or fusion of these [6]. Advanced/peak stage presents with diffuse distribution, mostly consolidations, and increasing reticular opacities[4,5]. Indeed, the imaging findings correlate with the histologic pattern of an acute fibrinous and organizing pneumonia[7]. In some cases, the atoll sign may occur during the progressive stage (consolidation developing around GGO) or during the absorption phase of the disease (lesion absorption leaving a decreased intensity in the center)[8]. Pleural effusions and hilar/mediastinal lymphadenopathies are rare[8].\nFour categories have been proposed with standardized reporting of CT imaging features (typical, undeterminate, atypical for COVID-19 and negative for pneumonia) which can provide guidance and confidence to radiologists reducing variability of reporting as well as increased clarity to physicians for management decision[9].\nOutcome \nIn our case, the chest CT findings were structurally reported and categorized as \u201ctypical appearance of COVID-19 pneumonia\u201d. This prompted a second RT-PCR testing for COVID-19 which confirmed the infection. \nTake-Home Message / Teaching Points \n\u00a0\n\nRadiologists must be familiar with the COVID-19 imaging findings according to its different stages.\nStandardized reporting with the use of probability categories are helpful to guide physicians.",
    "differential_diagnosis": "COVID-19, pneumonia, (progressive, stage), Viral, pneumonia, (Influenza,, parainfluenza,, adenovirus,, CMV,, RSV,, MERS-coronav\u00edrus,, SARS-CoV), Bacterial, pneumonia, (such, as, streptococci,, mycoplasma,, and, chlamydia), Organizing, pneumonia, Acute, eosinophilic, pneumonia",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-06//16832_1_1.jpg?itok=u0S6j2XI",
            "caption": "Chest radiography reveals mild bilateral patchy areas of ill-defined lung opacities with peripheral and lower zone distribution"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-06//16832_2_1.jpg?itok=9iwMcMHF",
            "caption": "Chest CT revealing bilateral multifocal and predominantly peripheral ground-glass opacities with superimposed interlobular septal thickening and visible intralobular lines (\u201ccrazy-paving\u201d pattern) together with some discrete consolidative opacities with evidence of air bronchogram in the affected lung areas. The affected areas of lung have predominantly posterior lower lobe distribution."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-06//16832_3_1.jpg?itok=xWMhQwuz",
            "caption": "Chest CT revealing an emerging atoll sign in the left lower lobe appearing as a central ground-glass opacity (green asterisk) surrounded by denser consolidation of crescentic shape (blue arrows)"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/16832",
    "time": "30.06.2020"
  },
  "16841": {
    "case_id": 16841,
    "title": "COVID-19 pneumonia and CT signs of peripheral lung microinfarctions: a possible correlation? Two clinical cases",
    "section": "Chest imaging",
    "age": "25",
    "gender": "male",
    "diagnosis": "COVID-19 Pneumonia",
    "history": "Case 1: a 25 years old male nurse referred to Vigevano emergency department with fever and cough. No laboratory tests available.\nCase 2: a 58 years old male, husband of a nurse, presented to Sanremo emergency department with fever and cough. Laboratory tests: neutrophilia and lymphopenia, increase of LDH levels.",
    "image_finding": "Case 1\n29/03/2020 Chest radiography AP view:\nTwo ill-defined parenchymal opacities in the left medium-lower lung. No pleural effusion.\n29/03/2020 Chest CT\nFurther evaluation of the left lung findings is obtained with an unenhanced chest CT.\nIn both lungs are noticeable several subpleural consolidations and ground glass opacities (GGO), mainly with rounded shape and some with triangular shape or with Hampton hump sign, most of which show bubbly appeareance. No pleural effusion.\nCase 2\n27/03/2020 non-contrast Chest CT: multiple ground glass opacities, some of which surrounded with denser consolidations (reverse halo sign), in relationship with centrolobular structures, mainly peripheral, mostly with rounded or elongated shape. No pleural effusion. Dilatation of main pulmonary artery (41 mm).\nDue to clinical worsening, an X-ray was performed before intensive care admission\n30/03/2020 Chest radiography AP view: bilateral consolidations, mainly peripheral and in lower lung zones, also in right perihilar zone. No pleural effusion. Further X-rays performed in the following days showed progressive improvement of lung transparency, with only remaining of thin atelectatic streaks in the left basal zone.",
    "discussion": "On 11th march 2020 the World Health Organization declared a pandemic state for COVID-19 that caused, as to 19 april 2020, 152,551 deaths in 2,241,359 confirmed cases worldwide [1]. Symptoms are aspecific, mostly flu-like, but in some more severe cases the disease may be fatal [2, 3].\nSince the earliest autopsies, it was reported that exitus was caused by multiorgan failure, with predominant lung involvement characterized by infarctions and haemorrhages in peripheral small vessels [4 - 6].\n\u00a0\nTo confirm the importance of coagulation alterations in patients with COVID-19 it has been shown that the outcome is directly related to the values of D-Dimer [7] and the use of anticoagulant therapy is important in the management of patients [8 - 10]\n\nBecause of the low sensitivity of X-ray examinations [11], CT scans are increasingly requested to better evaluate critical patients and to help differential diagnosis,\u00a0 with heterogeneous findings [12, 13]\n\nAlthough cases of pulmonary thromboembolism in COVID-19 patients have been described in literature [14], chest CT is usually performed without contrast medium if there are no specific clinical suspicions, in concerning to organizational / management problems and because of the main peripheral involvement of the alterations.\n\u00a0\n\u00a0Rounded lung opacities in COVID-19 is a known expression of the disease both in pure GGO presentation [15]\u00a0\u00a0\u00a0 and in partially-solid or solid consolidations [16],\u00a0 but its real prevalence has not yet been proven.\n.\nIn both our cases Real-Time \u2013 Polymerase Chain Reaction (RT-PCR) obtained from oropharyngeal swab specimens was performed, resulting positive for COVID-19. Both their CT scans showed peripheral GGO and consolidations, associated with some signs usually found in pulmonary peripheral infarction [17 - 20]: reverse halo sign, subpleural triangular shape consolidations, Hampton hump, bubbly consolidations; this evidence seem to validate the histopathological findings seen about peripheral thromboembolic disease.\n\nTake-Home Message: also without contrast medium, numerous signs in non-contrast chest CT of COVID-19 pneumonia suggest\u00a0 a correlation between pulmonary changes highlighted in histopathological tests and characterized by infarctions and haemorrhages in small peripheral vessels.\n\u00a0Further studies should be needed to confirm the correlation between COVID-19 pneumonia and CT signs of pulmonary infarctions, especially to better understand the patients\u2019 outcome.\n\u00a0\nWritten informed consent for publication has been obtained for both patients.",
    "differential_diagnosis": "COVID-19, Pneumonia, Other, viral, pneumonia, with, peripheral, pulmonary, infarction, Tromboembolic, pulmonary, infarction, Aspergillosis, Septic, embolism, Malignancy",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07/fig._1_0.jpg?itok=LuAxcKtl",
            "caption": "Case 1 \u2013  Chest X-Ray: two ill-defined parenchymal opacities in the left medium-lower lung. No pleural effusion."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07/fig._2_0.jpg?itok=rOFIracf",
            "caption": "Case 1 \u2013  Chest CT, axial plane: triangular shape peripheral consolidation in the left lower lung lobe."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07/fig._3_0.jpg?itok=GIytCpJe",
            "caption": "Case 1 \u2013  Chest CT, axial plane: consolidation in the right lower lung lobe with Humpton hump sign."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07/fig._4_0.jpg?itok=V1GKwTfZ",
            "caption": "Case 1 \u2013  Chest CT, axial plane: bilateral peripheral consolidations with  bubbly appearance."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07/fig._5_0.jpg?itok=cGgV2ClA",
            "caption": "Case 1 \u2013  Chest CT, coronal reconstruction: peripheral posterior consolidations."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07/fig._6.jpg?itok=koTIY0Ql",
            "caption": "Case 1 \u2013  Chest CT, sagittal reconstruction: consolidation in the posterior segment of the right lung."
          }
        ]
      },
      {
        "number": "Figure 7",
        "subfigures": [
          {
            "number": "Figure 7",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07/fig._7.jpg?itok=acKJn0oi",
            "caption": "Case 1 \u2013  Chest CT, sagittal reconstruction:  multiple consolidations in the left lung"
          }
        ]
      },
      {
        "number": "Figure 8",
        "subfigures": [
          {
            "number": "Figure 8",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07/fig._8.jpg?itok=KrubTru5",
            "caption": "Case 2 \u2013  Chest CT, axial plane: multiple bilateral ground glass opacities."
          }
        ]
      },
      {
        "number": "Figure 9",
        "subfigures": [
          {
            "number": "Figure 9",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07/fig._9.jpg?itok=_8__w9-3",
            "caption": "Case 2 \u2013  Chest CT, axial plane: peripheral bilateral ground glass opacities, also with reverse halo sign."
          }
        ]
      },
      {
        "number": "Figure 10",
        "subfigures": [
          {
            "number": "Figure 10",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07/fig._10.jpg?itok=XLHP6xBt",
            "caption": "Case 2 \u2013  Chest CT, axial plane (mediastinum window): dilatation of main pulmonary artery up to 41 mm."
          }
        ]
      },
      {
        "number": "Figure 11",
        "subfigures": [
          {
            "number": "Figure 11",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07/fig._11.jpg?itok=n2u80lsz",
            "caption": "Case 2 \u2013  Chest CT, coronal reconstruction: peripheral bilateral ground glass opacities, also with reverse halo sign."
          }
        ]
      },
      {
        "number": "Figure 12",
        "subfigures": [
          {
            "number": "Figure 12",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07/fig._12.jpg?itok=85hHqmbu",
            "caption": "Case 2 \u2013  Chest CT, sagittal reconstruction: multiple ground glass opacities in the right lung, the one in the superior segment of the lower lobe with reverse halo sign."
          }
        ]
      },
      {
        "number": "Figure 13",
        "subfigures": [
          {
            "number": "Figure 13",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07/fig._13.jpg?itok=P2Z2KIQM",
            "caption": "Case 2 \u2013  Chest X-Ray before intensive care admission: bilateral consolidations, mainly peripheral and in lower lung zones, also in right perihilar zone. No pleural effusion."
          }
        ]
      },
      {
        "number": "Figure 14",
        "subfigures": [
          {
            "number": "Figure 14",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07/fig._14_0.jpg?itok=Dq-AtTn2",
            "caption": "Case 2 \u2013  Chest X-Ray during hospitalization: improvement of lung transparency"
          }
        ]
      },
      {
        "number": "Figure 15",
        "subfigures": [
          {
            "number": "Figure 15",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07/fig._15_0.jpg?itok=WXFy2fAC",
            "caption": "Case 2 \u2013  Chest X-Ray before hospital discharge: remaining of thin atelectatic streaks in the left basal zone."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/16841",
    "time": "01.07.2020"
  },
  "16844": {
    "case_id": 16844,
    "title": "Pneumothorax and pneumomediastinum: a rare complication in the evolution of COVID-19 pneumonia.",
    "section": "Chest imaging",
    "age": "74",
    "gender": "male",
    "diagnosis": "Pneumothorax and pneumomediastinum in a patient with COVID-19 pneumonia.",
    "history": "74-year-old-man with a dry cough, dyspnea, fever, risk factors for poor evolution (hypertension, diabetes) and data of severity (oxygen saturation of 89, tachypnea) was hospitalized. Reverse transcription-polymerase chain reaction for COVID-19 was positive. Eighteen days after admission he suffered a sudden clinical worsening with pain in the right hemithorax.",
    "image_finding": "Chest x-ray performed at admission showed low-attenuated peripheral opacities in the right lung (figure 1). During hospitalization the patient remained afebrile and eupneic with progressive improvement and normalization of respiratory work. Intubation was not required at any point of its hospitalization. Eighteen days after admission he suffered a sudden clinical worsening with onset of stabbing pain in the right hemithorax and crackles in the middle and lower fields of the right lung. A portable chest x-ray was performed (figure 2) showing worsening of the opacities of the right lung. Blood test depicted a significant increase in D-dimer values, thus pulmonary angio-CT was requested on suspicion of pulmonary thromboembolism (figure 3). Pulmonary thromboembolism was not found, but CT showed right pneumothorax and pneumomediastinum as complications of COVID-19 (figure 4).",
    "discussion": "Coronavirus disease 2019 (COVID-19) is a highly infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) [1]. Chest imaging tests are not indicated in patients with mild symptoms without risk factors for poor evolution. However, they are indicated in those patients with suspected COVID-19 pneumonia with moderate-severe clinical features and a high pretest probability of disease (combination of age > 65 years and presence of comorbidities as chronic respiratory disease, cardiovascular disease, diabetes, hypertension, immune-compromise) [2]. It should also be considered that chest CT is important in the follow-up for guiding management in patients with COVID-19 pneumonia and worsening of the respiratory status [2]. \nAmong imaging tests, CT pulmonary angiography allows confirming acute pulmonary thromboembolism, as it has been documented its high prevalence in patients with COVID-19 (23%, [95%CI, 15-33%] [3], but also helps recognizing other complications described in these patients, such as pneumothorax or pneumomediastinum [4]. Pneumothorax is an uncommon finding in COVID-19 patients, with a frequency of a 1% in a recent published single-center study [5]. Pneumomediastinum is an extremely rare complication in these patients, according to our knowledge there has been only one published case [6].",
    "differential_diagnosis": "Pneumothorax, and, pneumomediastinum, in, a, patient, with, COVID-19, pneumonia., Normal, evolution, of, COVID-19, pneumonia., Pulmonary, thromboembolism., Acute, respiratory, distress, syndrome, (ARDS)., Bacterial, pneumonia",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16844_1_1.jpg?itok=nclMzCCd",
            "caption": "chest x-ray at admission showing patchy ground-glass opacities with peripheral distribution in right lung (arrows)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16844_2_1.jpg?itok=WmfJ3Xbh",
            "caption": "chest x-ray 18 days after admission showing radiological worsening, with dense peripheral opacities and lose of volume in the right lung."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16844_3_1.jpg?itok=q38lxdTE",
            "caption": "CT pulmonary angiography. (A) Axial imagen and (B) coronal plane with maximum intensity projection (MIP) reconstruction obtained on day 18 after onset of the disease. No pulmonary thromboembolism was identified."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16844_3_2.jpg?itok=ZWeVjISQ",
            "caption": "CT pulmonary angiography. (A) Axial imagen and (B) coronal plane with maximum intensity projection (MIP) reconstruction obtained on day 18 after onset of the disease. No pulmonary thromboembolism was identified."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16844_4_1.jpg?itok=UG_fhd5b",
            "caption": "CT pulmonary angiography. Axial image (A) and thoracic midline sagittal reconstruction (B) with lung window setting obtained on day 18 after onset of the disease. Bilateral areas of peripheral crazy paving and ground-glass opacities due to COVID pneumonia were depicted (black frames). Right pneumothorax (arrowheads) and pneumomediastinum mainly in prevascular space (black arrows) were also seen."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16844_4_2.jpg?itok=uyPqzCOe",
            "caption": "CT pulmonary angiography. Axial image (A) and thoracic midline sagittal reconstruction (B) with lung window setting obtained on day 18 after onset of the disease. Bilateral areas of peripheral crazy paving and ground-glass opacities due to COVID pneumonia were depicted (black frames). Right pneumothorax (arrowheads) and pneumomediastinum mainly in prevascular space (black arrows) were also seen."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/16844",
    "time": "02.07.2020"
  },
  "16856": {
    "case_id": 16856,
    "title": "Multiple arterial emboli and Covid-19",
    "section": "Chest imaging",
    "age": "50",
    "gender": "male",
    "diagnosis": "COVID-19 severe pneumonia with multiple arterial emboli",
    "history": "A 50-year-old male, without any significant prior medical history, who had been admitted to hospital for bilateral viral pneumonia by COVID-19 (RT-PCR +) for two weeks. He started with sudden coldness and absence of distal pulses in the right leg. In addition, the patient had a confusional syndrome.",
    "image_finding": "Chest-abdomen-pelvis CT with intravenous contrast in arterial phase and CT-angiography of both lower limbs were done. Scan revealed extensive bilateral lung involvement in the form of ground-glass opacities with inter- and intralobular septal thickening (\u201ccrazy paving pattern\u201d), in a predominantly subpleural location. No pleural effusion was found. (Fig 1 A-B)\nIn the vascular study, a sub-occlusive embolus was observed in the distal aorta without extension to the iliac arteries (Fig 2). In the right lower limb, there was occlusion of the hypogastric artery (Fig 3), occlusion of muscular branches of the deep femoral artery (Fig 4) and occlusion of the distal popliteal artery with involvement of the origin of the anterior tibial artery and the tibioperoneal trunk, with distal repermeabilisation of the infrapopliteal arteries (Fig 5). In the left lower limb, all the arteries were patent.\nNon-enhanced cranial CT showed established ischemic stroke in the territory of the left PICA (Fig 6).",
    "discussion": "Background \nCOVID-19 (coronavirus disease 2019) is a new infectious disease caused by the new emerging virus SARS-CoV-2. The first cases were described in Wuhan (China) in December 2019 and the pathogen was identified in late January 2020 in the same city [1].\n\u00a0\nClinical Perspective \nThe clinical spectrum varies from being asymptomatic to severe respiratory failure that can cause death. The most frequent symptoms are persistent fever, dry cough, fatigue, myalgias and dyspnea [1].\nInfections produce endothelial cell dysfunction resulting in excess generation of thrombin and fibrinolysis shutdown, resulting in a state of hypercoagulability in infected patients. In addition, the hypoxemia that occurs in severe pneumonia can stimulate thrombosis not only with increased blood viscosity but also a hypoxia-inducible transcription factor-dependent signalling pathway [2].\nPlatelet levels in COVID-19 patients were found to be significantly higher than in patients with non-COVID infections in one study [2].\nHowever, severe cases of COVID-19 are frequently complicated by coagulopathy [2]. More and more cases of patients with viral COVID-19 pneumonia that are complicated by venous thrombosis of the lower limbs and /or acute pulmonary thromboembolism are being published [2]. Angio-CT of the pulmonary arteries is fundamental for the diagnosis.\nThis hypercoagulable state also favours these patients to be prone to acute lower limb ischemia, coronary artery disease or ischemic strokes [2, 3, 4]. Acute arterial embolism of the lower limbs produces a sudden onset of pain, paleness, coldness and absence of distal pulses [5]. \nImaging Perspective \nThe most common radiological findings of COVID-19 in the lung parenchyma are patchy ground-glass opacities (GGO) and patchy consolidation which were mainly distributed in the middle and peripheral zone of the lung [1].\nCT angiography is essential to study acute ischemia of the lower limbs to assess the permeability of vascular structures and provide a vascular map to the vascular surgeon that is useful in performing embolectomy. The diagnostic image is the absence of contrast filling of the arteries [5].\n\u00a0\nOutcome \nThe diagnosis of acute lower limb ischemia is essential as it requires urgent treatment by embolectomy [5].\n\u00a0\nTake-Home Message / Teaching Points \nPatients with severe COVID-19 infection may be complicated with coronary artery disease, pulmonary embolism, arterial embolism of the lower limbs and even at the cerebral level.",
    "differential_diagnosis": "COVID-19, severe, pneumonia, with, multiple, arterial, emboli, Arterial, Emboli, Arterial, Thrombosis, COVID-19, Cryptogenic, organizing, pneumonia",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16856_1_1.png?itok=rQTnaP97",
            "caption": "A) Coronal MPR with lung window. B) Axial CT with lung window. Extensive bilateral lung involvement in the form of ground-glass opacities (blue circle) with inter- and intra-lobular septal thickening (green circle) (\u201ccrazy pazing pattern\u201d), mainly located in a subpleural location."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16856_1_2.png?itok=yqvzDCcL",
            "caption": "A) Coronal MPR with lung window. B) Axial CT with lung window. Extensive bilateral lung involvement in the form of ground-glass opacities (blue circle) with inter- and intra-lobular septal thickening (green circle) (\u201ccrazy pazing pattern\u201d), mainly located in a subpleural location."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16856_2_1.png?itok=ks9CAkLz",
            "caption": "Coronal MPR of the CT-angiography showing sub-occlusive embolus in distal aorta without extension to the iliac arteries (blue circle)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16856_3_1.png?itok=tiwhYEu9",
            "caption": "Sagittal MPR of the CT-angiography showing occlusion of the right hypogastric artery (orange arrow) and adequate opacification of the external iliac artery (green arrow)."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16856_4_1.png?itok=ObWJBuju",
            "caption": "Coronal MPR of the CT-angiography showing occlusion of muscular branches of the right deep femoral artery (blue circle) comparing to the normal branches of the left deep femoral artery (green circle)."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16856_5_1.png?itok=xzi51X7b",
            "caption": "A) Sagittal MPR of the right leg. B) Coronal MPR of the CT-angiography showing occlusion of the right distal popliteal artery with involvement of the origin of the anterior tibial artery and the tibioperoneal trunk (blue arrow), with distal repermeabilization of the infrapopliteal arteries (green arrow)."
          },
          {
            "number": "Figure 5b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16856_5_2.png?itok=EbRgsUXr",
            "caption": "A) Sagittal MPR of the right leg. B) Coronal MPR of the CT-angiography showing occlusion of the right distal popliteal artery with involvement of the origin of the anterior tibial artery and the tibioperoneal trunk (blue arrow), with distal repermeabilization of the infrapopliteal arteries (green arrow)."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16856_6_1.png?itok=CsJm8gZq",
            "caption": "Non-enhanced cranial CT showing established ischemic stroke in the territory of the left PICA (blue circle)."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Arteries / Aorta",
      "Thorax"
    ],
    "imaging_technique": [
      "CT-Angiography"
    ],
    "link": "https://www.eurorad.org/case/16856",
    "time": "03.07.2020"
  },
  "16858": {
    "case_id": 16858,
    "title": "COVID-19 Coinfection with Mycoplasma Pneumoniae",
    "section": "Chest imaging",
    "age": "50",
    "gender": "male",
    "diagnosis": "Coronavirus disease-19 (COVID-19) coinfection with mycoplasma pneumoniae",
    "history": "A 50-year-old male with recent positive coronavirus disease-19 RT-PCR and obesity (BMI 31.7) presented with dyspnea, myalgias, nausea and persistent dry cough. Laboratory studies were remarkable for lymphopenia (0.6\u00d7103/\u00b5L), elevated c-reactive protein, ferritin, procalcitonin, interleukin-6, and d-dimer. A respiratory antigen panel was obtained and was positive for Mycoplasma IgM antibodies.",
    "image_finding": "AP chest x-ray on admission demonstrated multifocal bilateral, peripheral-predominant patchy solid and ground-glass opacities, compatible with atypical viral pneumonia (Fig. 1).\nNon-contrast CT chest on admission demonstrated multifocal bilateral, peripheral-predominant patchy ground-glass and consolidative opacities. Mild traction bronchiectasis was noted. There were subpleural and intraparenchymal cystic changes incidentally noted in the bilateral lower lobes and lingula. Scattered mildly prominent mediastinal lymph nodes, including one 1.1 cm right paratracheal lymph node, were noted (Figs. 2a-e). \nAP chest x-ray on day two of admission demonstrated increased bilateral patchy peripheral-predominant, likely associated with a multifocal infectious process such as viral pneumonia. Bilateral low lung volumes were noted (Fig. 3).",
    "discussion": "Background \nCoronavirus disease-19 (COVID-19), a novel viral pandemic, has rapidly increased in incidence and can present with a wide range of symptoms and disease severity [1]. Morbidity and mortality have been shown to be associated with multiple comorbidities, including obesity [2].\nClinical Perspective \nThere is limited literature on patients with COVID-19 who are coinfected with other respiratory pathogens, including mycoplasma pneumonia [3]. Chest computed tomography (CT) and serial chest x-rays can aid in the diagnosis and monitoring of COVID-19 progression. Imaging characteristics for COVID-19 tend to follow a common trend, with an early stage, progressive stage, peak stage, and absorption stage. The greatest severity is seen around ten days after the initial onset of symptoms [4].\nImaging Perspective \nOn chest CT, bilateral peripheral ground-glass opacities with absence of lymphadenopathy, pleural effusions, pulmonary nodules, and lung cavitations are characteristic findings in patients with COVID-19 [5-7]. Of note, significant overlap exists between imaging characteristics of COVID-19 and other respiratory pathogens. Furthermore, it is still relatively unclear how coinfection with mycoplasma pneumoniae or other respiratory pathogens may affect imaging [8]. However, the presence of lymphadenopathy, pleural effusion, or pulmonary nodules may suggest the presence of bacterial coinfection [9]. Common findings in patients with mycoplasma pneumoniae infection include bronchial wall thickening, centrilobular nodules, ground-glass attenuation, and air-space consolidation on chest CT [10,11].\nOutcome \nOn day two of admission, the patient was transferred to the ICU for worsening hypoxic respiratory failure and increased oxygen requirement. He was found to have positive IgM antibodies for mycoplasma and was started on doxycycline for possible coinfection. His symptoms gradually improved, and oxygen was weaned. He did not require intubation or ventilatory support. \nTake-Home Message / Teaching Points \nCOVID-19 has several imaging findings that are dependent upon the time course of symptoms. Many imaging findings overlap between COVID-19 and other respiratory infections. Mediastinal lymphadenopathy may be suggestive of bacterial coinfection. Radiologists and clinicians must consider the possibility of respiratory coinfection when treating patients with COVID-19.",
    "differential_diagnosis": "Coronavirus, disease-19, (COVID-19), coinfection, with, mycoplasma, pneumoniae, Coronavirus, disease-19, (COVID-19), Multifocal, bacterial, pneumonia, Viral, pneumonia, Acute, Respiratory, Distress, Syndrome, (ARDS), Cryptogenic, organizing, pneumonia",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16858_1_1.png?itok=Iqg0moKp",
            "caption": "Portable, semi-upright AP chest x-ray on admission demonstrated multifocal bilateral, peripheral-predominant patchy solid and ground-glass opacities, compatible with atypical viral pneumonia."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16858_2_1.png?itok=__9bftiU",
            "caption": "Non-contrast CT chest on admission demonstrated multifocal bilateral, peripheral-predominant patchy ground-glass and consolidative opacities. Mild traction bronchiectasis was noted. There were subpleural and intraparenchymal cystic changes noted in the bilateral lower lobes and lingula. Scattered mildly prominent mediastinal lymph nodes, including one 1.1 cm right paratracheal lymph node, were noted."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16858_2_2.png?itok=gHYEYWGA",
            "caption": "Non-contrast CT chest on admission demonstrated multifocal bilateral, peripheral-predominant patchy ground-glass and consolidative opacities. Mild traction bronchiectasis was noted. There were subpleural and intraparenchymal cystic changes noted in the bilateral lower lobes and lingula. Scattered mildly prominent mediastinal lymph nodes, including one 1.1 cm right paratracheal lymph node, were noted."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16858_2_3.png?itok=TE4ed4RS",
            "caption": "Non-contrast CT chest on admission demonstrated multifocal bilateral, peripheral-predominant patchy ground-glass and consolidative opacities. Mild traction bronchiectasis was noted. There were subpleural and intraparenchymal cystic changes noted in the bilateral lower lobes and lingula. Scattered mildly prominent mediastinal lymph nodes, including one 1.1 cm right paratracheal lymph node, were noted."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16858_2_4.png?itok=pNaxQifK",
            "caption": "Non-contrast CT chest on admission demonstrated multifocal bilateral, peripheral-predominant patchy ground-glass and consolidative opacities. Mild traction bronchiectasis was noted. There were subpleural and intraparenchymal cystic changes noted in the bilateral lower lobes and lingula. Scattered mildly prominent mediastinal lymph nodes, including one 1.1 cm right paratracheal lymph node, were noted."
          },
          {
            "number": "Figure 2e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16858_2_5.png?itok=7KxH5Mol",
            "caption": "Non-contrast CT chest on admission demonstrated multifocal bilateral, peripheral-predominant patchy ground-glass and consolidative opacities. Mild traction bronchiectasis was noted. There were subpleural and intraparenchymal cystic changes noted in the bilateral lower lobes and lingula. Scattered mildly prominent mediastinal lymph nodes, including one 1.1 cm right paratracheal lymph node, were noted."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16858_3_1.png?itok=ptTaFHT6",
            "caption": "Portable, semi-upright AP chest x-ray on day two of admission demonstrated increased bilateral patchy peripheral-predominant, likely associated with a multifocal infectious process such as viral pneumonia. Bilateral low lung volumes were noted."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Respiratory system"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/16858",
    "time": "08.07.2020"
  },
  "16865": {
    "case_id": 16865,
    "title": "COVID-19 halo sign",
    "section": "Chest imaging",
    "age": "25",
    "gender": "male",
    "diagnosis": "The RT-PCR confirmed SARS-CoV-2 infection.",
    "history": "A 25 year-old male resident presented with a 72 h history of fever up to 38 \u00baC, odynophagia, myalgia and general malaise. Laboratory studies only showed increased C-reactive protein (23 mg/L, normal range 0-5 mg/L). D-dimer was 0,23 \u03bcg / ml which is normal.\nA chest X-ray was performed due to a suspicion of a COVID-19 infection.",
    "image_finding": "A consolidation in the posterior region of the left lower lobe was seen in an anteroposterior and lateral chest radiographs. In a chest non-enhanced CT a consolidation surrounded by ground glass opacities consistent with halo sign and air bronchogram inside was confirmed in the apical segment of the left lower lobe.",
    "discussion": "The World Health Organization (WHO) declared a pandemic caused by a new coronavirus [1], the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), in January 2020 [2, 3]. Six types of coronavirus have been described that cause human infection [1], especially severe respiratory disease [2]. It should be noted those responsible for causing severe acute respiratory disease (SARS) and the Middle East respiratory syndrome (MERS), both considered zoonotic infections [2] which share 85% of homology with SARS-CoV-2 [4].\nThe disease caused by SARS-CoV-2 is named coronavirus disease 2019 (COVID-19) [2-4], life-threatening pneumonia [3] and it is spread by human contact [1, 2, 4] and respiratory droplets [4]. Fever, dry cough, fatigue, and respiratory distress are the main symptoms [1, 4]. \u00a0\nTransmission can occur during the incubation period or in asymptomatic stages [1].\nReverse transcription-polymerase chain reaction (RT-PCR) [3] is the gold standard diagnostic tool [3, 4] although some patients reveal false-negative results [2, 3] due to its high specificity and low sensitivity [4], especially in early stages [3] which may be a problem for early diagnosing and isolation measures [2].\nImaging techniques, especially chest X-ray and chest CT, have become important diagnostic and management tools in patients with suspected infection because they can be positive even before symptoms or positive laboratory test results [2, 3] with a higher sensitivity (98%) than RT-PCR (78%) [4]. Moreover, due to its wide availability [2], imaging has proven to be essential in the evaluation of the severity and progression of the disease [1].\nGround glass opacifications (GGO) and consolidations [2, 3, 5] with bilateral, up to 75% of cases [1], and multifocal affectation [2-4] in the peripheral [2-4] and posterior [3] regions and involvement in the lower lobes [2, 3] are the most frequent signs seen on chest CT scan. Vascular enlargement, septal thickening, air bronchogram sign, air trapping, crazy paving pattern, halo sign and reversed halo sign can be also seen although less frequently [2-4].\nAs pulmonary involvement progresses, seen in 75% of patients, coalescence of the infiltrates and involvement of the upper pulmonary lobes are observed [2] with an increase in number, size, and density of the consolidations [3, 4]. \nThe patient was discharged\u00a0and made a full recovery at home with minor\u00a0symptoms. Control RT-PCR 4 weeks after the initial diagnosis was negative.",
    "differential_diagnosis": "The, RT-PCR, confirmed, SARS-CoV-2, infection., Hemorrhagic, nodules., Angioinvasive, fungal, infections., SARS., MERS., Cryptogenic, organizing, pneumonia.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16865_1_1.jpg?itok=mVwI54dG",
            "caption": "PA (a) and lateral (b) chest radiograph evidenced a consolidation (arrow) in the posterior region of the left lower lobe."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16865_1_2.jpg?itok=Q705b4Rn",
            "caption": "PA (a) and lateral (b) chest radiograph evidenced a consolidation (arrow) in the posterior region of the left lower lobe."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16865_2_1.jpg?itok=q3y1S7KF",
            "caption": ":  Axial chest CT scan (lung window) showing a consolidation in the apical segment of the left lower lobe surrounded by ground-glass opacity. Air bronchogram sign is seen inside de consolidation."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16865_2_2.jpg?itok=mBz0DJZL",
            "caption": ":  Axial chest CT scan (lung window) showing a consolidation in the apical segment of the left lower lobe surrounded by ground-glass opacity. Air bronchogram sign is seen inside de consolidation."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16865_3_1.jpg?itok=oPdRUYHQ",
            "caption": "Coronal (a) and sagittal (b) CT reconstruction: halo sign in the posterior and apical area of the lower left lobe."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16865_3_2.jpg?itok=smtChx8T",
            "caption": "Coronal (a) and sagittal (b) CT reconstruction: halo sign in the posterior and apical area of the lower left lobe."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/16865",
    "time": "09.07.2020"
  },
  "16866": {
    "case_id": 16866,
    "title": "Pulmonary embolism in patient with COVID-19 infection",
    "section": "Chest imaging",
    "age": "47",
    "gender": "female",
    "diagnosis": "Pulmonary Embolism in COVID pneumonia patient",
    "history": "A 74-year-old woman with an episode of 3 days of shortness of breath, asthenia and low-grade fever.\u00a0 She was tested for COVID in the second day with negative result. Chest X-rays and a CT-pulmonary angiogram were performed during her hospital admittance.",
    "image_finding": "In the first chest X-ray performed (Figure 1), we can see the characteristic bilateral peripheral infiltrates of this infection, bilateral alveolar pulmonary consolidation in right mid-and lower zones and in the left lower region.\nThe patient was admitted to the hospital and remained stable, with antiretroviral and steroid treatment. But the D-dimer figures were on the rise, up to 18032 ng/mL (normal: \u00a3500 ng/mL), so a CT-pulmonary angiogram was performed to rule out concomitant pulmonary embolism.\nIn the CT images, we have widespread bilateral ground-glass opacities with a posterior predominance. (Figures 2 and 3) \nThe suspected pulmonary embolism was demonstrated as well; emboli occupied the left inferior artery as well as branches of the right superior lobar pulmonary arteries. (Figure 4 and 5).\nHeparin at anticoagulant dose was administered and the patient remains stable 10 days after admittance, with improvement of the shortness breath and disappearance of the fever.\nRT-PCR became positive after five days of symptoms. She was discharged after 15 days of admittance to follow isolation at home.",
    "discussion": "Late 2019, a new virus which got named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), caused in Wuhan China, multiple cases of severe pneumonia and several deaths. Since then, the virus has become pandemic in most countries, especially Italy and Spain. \nThe most common clinical features of the disease are fever and respiratory symptoms. The most common laboratory finding is lymphopenia.[1]. However, in almost 10% of cases, generally with older people or with comorbidities, it can evolve into respiratory failure for diffuse alveolar damage, multiorgan failure, shock and death. As the disease is easily spread and numerous people get infected, ICUs face great challenges as the number of new patients can exceed the maximum capacity.\nAt the moment the mortality rate is estimated to be around 3%. [2] \nRT-PCR is typically used to diagnose a\u00a0COVID-19 infection. Sensitivity ranges from 60% up to 97% in the known literature [3]. In the cases, where the characteristic clinical presentation characteristic and the pandemic scenario we have in Spain, make it a probable case, where imaging can be of assistance.\nImaging can help also in the event of complications.\nChest CT studies can show at early stage (1-5 days) ground-glass opacity and consolidation in the basal and peripheral of bilateral lungs, evolving into crazy paving and consolidation peaking around 9\u201313 days.\nPulmonary embolism as a complication of the COVID infection is being reported [4]. The mechanism for pulmonary embolism remains unknown and is under study and may be different as to the thrombi originated in the lower extremities. But it can be a cause for additional shortness of breath in these patients that can impair the course of the infection. Other thrombotic complications have been reported such as strokes and visceral infarction.\n\u00a0Chest CT plays an important role in the diagnosis, especially when RT-PCR is not yet positive, follow-up and complication monitoring of this new type of viral pneumonia.\nWritten patient consent for this case was waived by the Editorial Board. Patient data may have been modified to ensure patient anonymity.",
    "differential_diagnosis": "Pulmonary, Embolism, in, COVID, pneumonia, patient, Coronavirus, disease, 2019, pneumonia, (COVID-19), Bacterial, pneumonia, Non-specific, interstitial, pneumonia, Viral, pneumonia, Hypersensitivity, pneumonitis, (HSP)",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16866_1_1.jpg?itok=Gyvvmv68",
            "caption": "Portable chest X ray performed at the emergency department that shows peripheral infiltrates located in the right superior region and left parahiliar area, findings very suggestive of COVID-19 pneumonia."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16866_2_1.JPG?itok=k9xvxzlG",
            "caption": "Coronal reconstruction of the CT pulmonary angiography performed, in lung window, that shows a lobar consolidation in the right upper lobe (red arrow) and other ground glass opacities in the left upper lobe and right lung base (blue arrows)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16866_3_1.JPG?itok=hB_K3Z2k",
            "caption": "Coronal reconstruction of the CT pulmonary angiography performed, that shows a ground glass consolidation in the right upper lobe (red arrow)."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16866_4_1.JPG?itok=ONPduIMn",
            "caption": "Axial image of the CT pulmonary angiography, which exhibits filling defects in segmental and subsegmental branches of the lower lobe and right upper lobe pulmonary arteries (green arrows), associated with peripheral consolidation, related to COVID-19 pneumonia known."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16866_5_1.JPG?itok=6nVuZJeT",
            "caption": "Coronal thick maximum intensity projection of CT pulmonary angiography demonstrating filling defects in the left lower lobe (white arrows) and in segmentary braches of the right upper lobe pulmonary arteries (green arrows)."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/16866",
    "time": "10.07.2020"
  },
  "16882": {
    "case_id": 16882,
    "title": "Severe dysphagia caused by oesophgeal leiomyoma. Radiological findings",
    "section": "Chest imaging",
    "age": "45",
    "gender": "female",
    "diagnosis": "Benign leiomyoma of the oesophageal wall.",
    "history": "A 45-year old woman, with apparent healthy status, manifested retrosternal pain and a progressively worsening solid and liquid dysphagia with weight loss in the last weeks. Laboratory tests were normal. Esophagram with oral water-soluble contrast medium was first performed after followed by contrast-enhanced Computed Tomography (CECT) study.",
    "image_finding": "Esophagram with oral water-soluble contrast medium showed a filling defect in the middle part of the oesophagus without any signs of mucosal abnormality as an extrinsic compression (figure 1). The CECT scan showed an intraluminal oesophagal soft-tissue mass (3,5x3x6 cm) of uniform density, that could not clearly be distinguished from the oesophagal wall (figure 2.a). The lesion didn\u2019t have any calcifications and showed homogeneous contrast enhancement. Oesophageal wall resulted mildly compressed by it, but there were no signs of invasion into adjacent tissue (figure 2. b,c). There were no pathological lymph nodes in the mediastinum. The lesion was resected operatively and histological analysis confirmed diagnosis of oesophageal leiomyoma.",
    "discussion": "Oesophageal leiomyoma is the most common benign tumour of the oesophagus. It usually originates in the middle or distal part of the organ\u2019s wall from mesenchymal tissue (smooth muscle cells) and its size doesn\u2019t usually overcome 5 cm [1]. It is more frequently diagnosed in males than in females [2].\nIts diagnosis is often accidental, due to the lack or inconsistency of symptoms (3). When increasing in size (i.e. > 1000 gr), it is defined \u201cgiant leiomyoma\u201d, which is more likely associated to gastrointestinal symptoms, such as retrosternal pain, dysphagia, regurgitation, hypertension, bleeding and weight loss [2, 4]. It could be associated with Alport syndrome, in the form of a diffuse oesophageal leiomyomatosis [2]. \nThe diagnosis is based on imaging techniques and biopsy. X-ray oesophageal transit study is usually the first investigation to be executed: it demonstrates a smooth filling defect in the lumen without any signs of mucosal abnormality and it appears to be helpful in differentiating benign from malignant tumours. CECT scan is particularly useful in diagnosing larger tumours, especially those localized in the distal oesophageal wall; it is also useful in determining the extension of the lesion and eventual lymphadenopathies. At CECT exam, leiomyomas appear as homogeneous, regular-shaped lesions indivisible from the oesophageal wall, with coarse calcification and moderate contrast enhancement. Conversely, endoscopy helps to detect superficial lesions, showing submucosal movable masses that don\u2019t infiltrate the mucosa; however, endoscopy has limits in identifying the origination and growth direction of the tumour. Endoscopic Ultrasonography (EUS) has demonstrated good sensitivity in detecting the origin, nature and development of these lesions. On EUS, oesophageal leiomyoma appears as a homogenous, hypoechoic lesion surrounded by a hyperechoic region [2, 3, 5]. \nThere are actually two different possibilities of treating an oesophageal leiomyoma, depending on the size and location of the lesion: endoscopic resection and surgery. Endoscopy is preferred for more superficial tumours, especially those arising from muscularis mucosa, and has better prognoses and less adverse effects (such as haemorrhage) then surgical treatment. Surgery, mainly in the form of thoracotomy, is preferred for more profound tumours or giant lesions [2,4].\nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Benign, leiomyoma, of, the, oesophageal, wall., Squamous, esophageal, carcinoma, Adenomatous, oesophagal, carcinoma, Leiomyosarcoma, of, the, oesophagus, Achalasia",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16882_1_1.jpg?itok=63AQyaSQ",
            "caption": "X-ray esophageal transit with water-oral contrast media shows a delayed transit with endoluminal stasis (arrowheads) and a filling defect in the mid third of the oesophagus (arrow) without any signs of mucosal abnormality"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16882_2_1.JPG?itok=_90Zz8G8",
            "caption": "Contrast-enhanced Computed Tomography, axial plane, shows a large solid lesion extending longitudinally in the middle part of the mediastinum (arrow)."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16882_2_2.JPG?itok=ufbPwg01",
            "caption": "Contrast-enhanced Computed Tomography, sagittal plane, shows the same lesion which enhances homogeneously (arrow)."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16882_2_3.JPG?itok=TN1ppO2Z",
            "caption": "Contrast-enhanced Computed Tomography, coronal plane, shows regular margins and non-infiltrating features (arrow)."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Gastrointestinal tract",
      "Mediastinum"
    ],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/16882",
    "time": "14.07.2020"
  },
  "16883": {
    "case_id": 16883,
    "title": "COVID-19 infection with new onset atrial fibrillation",
    "section": "Chest imaging",
    "age": "71",
    "gender": "male",
    "diagnosis": "Coronavirus disease-19 (COVID-19)",
    "history": "A 71-year-old male with no known past medical history presented to the emergency department with fever (39.1\u00b0C), cough, shortness of breath, and myalgias for one week. Laboratory studies were remarkable for lymphopenia (0.4\u00b4103/mL, normal range 0.9\u00b4103/mL \u2013 3.3\u00b4103/mL), elevated c-reactive protein, elevated ferritin, elevated interleukin-6, elevated d-dimer, and elevated procalcitonin.",
    "image_finding": "AP chest x-ray on admission demonstrated bilateral perihilar and peribronchial thickening with perihilar opacities (Fig. 1).\n\nNon-contrast chest CT on admission demonstrated multiple patchy, peripheral-predominant ground-glass and consolidative opacities. A \u201ccrazy-paving\u201d appearance associated with interlobular septal thickening was noted. There was no significant intrathoracic or axillary lymphadenopathy (Figs. 2a-d).",
    "discussion": "Background\nCoronavirus disease-19 is a novel viral pandemic that primarily affects the lungs, causing respiratory symptoms including dry cough and shortness of breath [1]. However, recently there has been an increasing number of cardiac complications reported in patients with COVID-19 infection [2, 3]. The mechanism of myocardial injury in these patients is hypothesized to be the onset of cytokine storm in response to infection [4\u20136]. In addition, hydroxychloroquine, an antimalarial drug used to treat some severe cases of COVID-19, has been shown to increase atrioventricular depolarization length, potentially leading to drug-induced atrial and ventricular arrhythmias [7\u20139].\nClinical Perspective\nTypical COVID-19 symptoms include fever, dry cough, myalgia, and lymphopenia [10]. Recent cases suggest that myocardial disease and injury may be a consequence of a COVID-19 induced cytokine storm [11, 12]. Elevated ferritin levels are associated with cytokine storm onset, which may predict myocardial damage related to severe inflammatory responses [13].\nImaging Perspective\nCharacteristic computed tomography (CT) findings for COVID-19 become more apparent as the disease progresses and may include multilobar ground-glass opacities and a crazy-paving pattern [14, 15]. CT may be more sensitive than chest x-ray for detection of classic COVID-19 findings, including ground-glass opacities [14\u201316]. \nOutcome\nCOVID-19 RT-PCR returned positive. On day two of admission, the patient was started on hydroxychloroquine. On day six of admission, he developed new-onset atrial fibrillation with rapid ventricular rate, requiring initiation of a beta-blocker for rate control. \nTeaching Points\nPotential cardiac complications should be monitored in patients with COVID-19 infection. Hydroxychloroquine has been associated with arrhythmias and should be administered with caution.",
    "differential_diagnosis": "Coronavirus, disease-19, (COVID-19), Influenza, pneumonia, Multifocal, bacterial, pneumonia, Cryptogenic, Organizing, Pneumonia, Acute, Respiratory, Distress, Syndrome, (ARDS)",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16883_1_1.png?itok=8sFEMWl-",
            "caption": "Portable semi-upright AP chest x-ray on admission demonstrated bilateral perihilar and peribronchial thickening with perihilar opacities."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16883_2_1.png?itok=7O1z7cKH",
            "caption": "Non-contrast chest CT on admission demonstrated multiple patchy, peripheral-predominant ground-glass and consolidative opacities. A \u201ccrazy-paving\u201d appearance associated with interlobular septal thickening was noted. There was no significant intrathoracic or axillary lymphadenopathy."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16883_2_2.png?itok=lNICMXsJ",
            "caption": "Non-contrast chest CT on admission demonstrated multiple patchy, peripheral-predominant ground-glass and consolidative opacities. A \u201ccrazy-paving\u201d appearance associated with interlobular septal thickening was noted. There was no significant intrathoracic or axillary lymphadenopathy."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16883_2_3.png?itok=JY36jWuO",
            "caption": "Non-contrast chest CT on admission demonstrated multiple patchy, peripheral-predominant ground-glass and consolidative opacities. A \u201ccrazy-paving\u201d appearance associated with interlobular septal thickening was noted. There was no significant intrathoracic or axillary lymphadenopathy."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16883_2_4.png?itok=ZugWuHw4",
            "caption": "Non-contrast chest CT on admission demonstrated multiple patchy, peripheral-predominant ground-glass and consolidative opacities. A \u201ccrazy-paving\u201d appearance associated with interlobular septal thickening was noted. There was no significant intrathoracic or axillary lymphadenopathy."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Respiratory system"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/16883",
    "time": "14.07.2020"
  },
  "16884": {
    "case_id": 16884,
    "title": "18-F FDG PET-CT appearances in COVID-19 patients: A Case Series",
    "section": "Chest imaging",
    "age": "59",
    "gender": "female",
    "diagnosis": "COVID-19 pneumonia.",
    "history": "We describe the 18-F FDG PET-CT appearances of COVID-19 in three outpatients. \nCase 1: 59-year-old female with background lymphoma, presenting with shortness of breath \nCase 2: 63-year-old male investigated for collapse\nCase 3: 83-year-old female admitted with weight loss and raised C-Reactive Protein (CRP)",
    "image_finding": "All three patients underwent an 18-Fluorine fluorodeoxyglucose positron emission tomography-computed tomography (18-F FDG PET-CT) study, with unenhanced free-breathing CT for attenuation correction. \nIn case 1, the PET-CT was performed 1 week after the patient\u2019s acute presentation and revealed diffuse peripheral consolidation of basal predominance, which was intensely FDG-avid (SUVMax 7.6), no nodal enlargement and a complete metabolic response to lymphoma. \nIn case 2, the PET-CT was performed 2 weeks after the acute admission. Avid lymph nodes above and below the diaphragm in keeping with subsequently biopsy-proven lymphoma. In addition, moderate\u00a0tracer uptake demonstrated in subpleural areas of ground-glass opacification (SUV max 3.7) \nIn case 3, the PET-CT was performed 5 weeks after acute admission to investigate possible vasculitis in a patient with eosinophilia and a splenic infarct. The scan demonstrated a photopaenic splenic infarct and non-FDG avid bilateral pleural effusions with no characteristic COVID-19 chest appearances.",
    "discussion": "Background:\nThe coronavirus (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has a propensity for causing a potentially fatal pneumonia[1]. The infection fatality rate is estimated between 0.7% and 6.4%[2] with poorer outcomes identified for those with co-morbidities[3].\nThe use of imaging in diagnosis, particularly CT, has demonstrated increased sensitivity than RT-PCR testing[4]. The most common CT appearances of COVID-19 pneumonia are bilateral and subpleural areas of ground-glass opacification, lower lobe consolidation[5] and occasionally crazy-paving appearances[1]. However, these appearances are non-specific and encountered in other viral pneumonias such as influenza, SARS and MERS.\nThe emerging evidence is that microvascular thrombi are strongly associated with COVID-19 infection and contribute to the high D-dimer levels commonly seen in the typical blood changes. Correlating the CT findings with blood abnormalities of lymphopaenia, a raised CRP and raised D-dimer[6] is important in raising the possibility of COVID-19 infection.\nClinical perspective:\nIn case 1, the patient was admitted one week after the PET CT with shortness of breath. During the admission, she had a lymphopaenia of 0.8, a CRP of 187 and a\u00a0D-dimer of 2892. Given the typical imaging and blood findings, she was treated clinically for COVID pneumonia despite a negative swab.\nIn case 2, PET CT was performed 3 days after the patient was discharged and 13 days after the positive swab. During admission, CRP was 174 and D-dimer was 1328.\nIn case 3, the PET CT was performed 34 days after the positive swab. At the time of the swab, the CRP was 286 and a lymphopaenia of 0.16.\nImaging perspective:\nIn both cases 1 and 2, the typical CT appearances of COVID-19 pneumonia are demonstrated with concomitant increased FDG-avidity. The addition of functional imaging allows us to interpret whether there is an active glycolytic process within ground glass lung infiltrates.\nPatients with COVID-19 may be investigated for co-existent pathology as thromboembolic complications are being reported in multiple organs. In case 3, The PET was of value in excluding vasculitis\u00a0or any residual COVID-19 related inflammation but it showed a splenic infarct, a possible late COVID-19 complication.\u00a0\nOutcome:\nAll 3 patients in our series have been discharged home.\nTake-home message:\nDuring the pandemic and recovery phase, PET-CT imaging continues for non-COVID indications. It is important for the radiologist to recognise the variable whole body findings on metabolic imaging.",
    "differential_diagnosis": "COVID-19, pneumonia., Viral, pneumonia, (influenza,, MERS,, SARS)., Atypical, bacterial, infection, (mycoplasma)., Idiopathic, organising, pneumonia., Chronic, eosinophilic, pneumonia., Drug-induced, injury.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16884_1_1.jpg?itok=khWOtPeK",
            "caption": "Maximum intensity projection (MIP) image demonstrating significant peripheral lung uptake"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16884_1_2.jpg?itok=p5uEW0nS",
            "caption": "Fused PET-CT image on lung windows demonstrating avidity within the peripheral and basal consolidation"
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16884_1_3.jpg?itok=FJVDwauT",
            "caption": "CT image on lung windows demonstrating peripheral and basal consolidation"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16884_2_1.jpg?itok=IWrnL_ed",
            "caption": "Maximum intensity projection (MIP) image demonstrating significant uptake in lymph nodes above and below the diaphragm, and moderate lung uptake"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16884_2_2.jpg?itok=EpZHUV_W",
            "caption": "Fused PET-CT image on lung windows demonstrating moderate tracer uptake in subpleural areas of ground glass opacification. Avid right axillary nodal mass is in keeping with lymphoma"
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16884_2_3.jpg?itok=afOdRPqE",
            "caption": "CT image on lung windows demonstrating subpleural areas of ground glass opacification and a right axillary nodal mass"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16884_3_1.jpg?itok=XmkEf7qm",
            "caption": "Maximum intensity projection (MIP) image demonstrating thyroid and low grade bowel uptake with no lung uptake"
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16884_3_2.jpg?itok=wDGEgXAF",
            "caption": "Fused PET-CT image on soft tissue windows demonstrating a photopaenic focus in the spleen in keeping with a splenic infarct"
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16884_3_3.jpg?itok=0HlwaYo8",
            "caption": "Contrast enhanced CT image on soft tissue windows demonstrating a wedge shaped splenic infarct"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Hybrid Imaging",
      "Respiratory system"
    ],
    "imaging_technique": [
      "PET",
      "PET-CT"
    ],
    "link": "https://www.eurorad.org/case/16884",
    "time": "14.07.2020"
  },
  "16885": {
    "case_id": 16885,
    "title": "COVID-19. Imaging features of a fatal case.",
    "section": "Chest imaging",
    "age": "81",
    "gender": "male",
    "diagnosis": "COVID-19 Pneumonia",
    "history": "An 81-year-old male arrived at the emergency because of ten days dry cough and fever treated by Acetaminophen.\u00a0 His body temperature was 38.2\u00b0C and SpO2 was 89% on FiO2 21%. Lymphocytopenia (0.76x 103/ul; normal range 1.5-3.0 ), neutrophilia (10.85 x10/ul; normal range 3.0-5.8), increased of PCR (236.5mg/l; normal range 0-5), and increased D-dimer concentration 22.27mg/l (normal range 0-0.5), Fibrinogen (596mg/dl normal range 180-400) and LDH (807U/L normal range 125-220) was detected. Based on the COVID-19 outbreak, a nasopharyngeal swab was performed, with a positive result for SARS-CoV-2 on real-time reverse transcriptase-polymerase chain reaction assay.\u00a0 The diagnosis of viral pneumonia based on nucleic acid test results was available one day after CT and only supportive therapies had been applied before.\nDespite antiviral treatments, antibiotics, hydroxychloroquine, thromboprophylaxis with enoxaparin and non-invasive ventilation, clinical conditions did not improve and laboratory parameters remained constantly altered (on the sixth-day lymphocytes were 0.72x 103/ul, neutrophiles 13.25x10/ul, PCR 183mg/l, LDH 520 U/L.\nThe patient died after ten days, due to acute respiratory failure in multi-organ failure, two days after follow-up TC.\nThis case highlights that early aggressive treatment could change the prognosis of these patients because when the patient was admitted he already had an advanced stage of the disease.",
    "image_finding": "Unenhanced chest CT showed at the admission bilaterally evidence of widespread thickening of the pulmonary interstices, more marked in the lower lobes, especially in the posterior segments and in the posterior segments and in the concomitance of the pleural sheets. There is moderate concomitant segmental thickening of the pleural leaflets in contiguity with the parenchymal opacities.\nOn the seventh-day unenhanced chest CT showed widespread thickening of the lung interstices, with the presence of ground-glass areas, involving larger areas of parenchyma and engaging all the lung lobes. Onset of widespread areas of parenchymal consolidation, wider at the lower lobes, with prevailing posterior arrangement, in contiguousness of the pleura could be also seen.",
    "discussion": "The ongoing pandemic of Coronavirus disease 2019 (COVID-19) is severely challenging healthcare systems all around the world, with the need to provide intensive care to a previously inconceivable number of patients (Wu Z, 2020). When SARS-CoV-2 infects a person, the lesions are not limited to the lungs. The virus causes viraemia after entering the body and the main clinical manifestations are fever, pharyngalgia, fatigue, diarrhoea and other non-specific symptoms. The incubation takes 1-14 days. Peripheral blood leucocytes are normal or slightly lower at this phase. Then the viruses spread through the bloodstream and mainly in the lungs, gastrointestinal tract, heart. This phase occurs around 7-14 after the onset of the symptoms when the virus starts a second attack, which is also the main cause of the aggravation of symptoms. As this time, pulmonary lesions become worse, and chest CT scans show imaging changes consistent with COVID-19. At this stage, the peripheral blood lymphocytes decrease significantly, and inflammatory factors in peripheral blood are increased. Patients at this phase will begin to develop the hypercoagulable state and D-Dimer increases from mild to significant, with prolonged prothrombin time (PT) and gradual decrease of fibrinogen and platelet (Taisheng Li, 2020). \nImaging features: COVID-19 imaging mainly has subpleural distribution and is confined to the middle and lower zones on the initial chest CT. Follow up CT shows that, as the disease advances, consolidates and pervades the lungs. Also, the upper lobes are affected (Yan L. 2020)\n\u00a0Unenhanced chest CT shows bilateral disease in 89.3% with a ground-glass pattern in 53.8% and ground glass with consolidation in 46.2% (JWu et al 2020); interlobular septal thickening in 75% (Song F et al 2020); air bronchogram in 80%\u00a0(Song F, 2020). An increased lung involvement score is a powerful prognostic indicator\u00a0(Ran Yang, 2020).\nThoracic lymphadenopathy is generally absent and pleural effusion is extremely rare. (Bernheim A et al 2020)",
    "differential_diagnosis": "COVID-19, Pneumonia",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16885_1_1.png?itok=4ih2Kl4y",
            "caption": "Basal ground-glass areas with prevalent subpleural distribution"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16885_2_1.png?itok=nvIfzMoI",
            "caption": "basal More marked interstitial thickening in the lower lobes in the posterior segments. Segmental thickening of the pleural sheets and notes of vascular enlargement."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16885_3_1.png?itok=m45QyajM",
            "caption": "follow up Areas of parenchymal consolidation and ground glass with a predominantly subpleural disposition"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16885_4_1.png?itok=096tZcwD",
            "caption": "follow up Areas of parenchymal consolidation and widespread pleural thickening"
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16885_5_1.png?itok=jREofRHK",
            "caption": "-"
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16885_6_1.png?itok=Bn0pvEH1",
            "caption": "-"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT",
      "CT-High Resolution"
    ],
    "link": "https://www.eurorad.org/case/16885",
    "time": "15.07.2020"
  },
  "16886": {
    "case_id": 16886,
    "title": "Paraganglioma of the medium mediastinum (chemodectoma)",
    "section": "Chest imaging",
    "age": "33",
    "gender": "male",
    "diagnosis": "Paraganglioma of the aortopulmonary window (Chemodectoma)",
    "history": "A 33-year-old man was admitted to our radiology department with dyspnea and chest pain for 4 weeks. No fever nor haemoptysis were revealed. There were no symptoms suggesting increased catecholamine secretion. Serum biochemistry showed no pathological findings. Urine biochemistry depicted normal vanillylmandelic acid levels.",
    "image_finding": "Chest X-Ray (PA & lateral) depicted the presence of a left-sided mediastinal mass, probably located in the aortopulmonary window. There were no pleural effusion or pulmonary abnormalities.\nCT scan with and without IVC was performed to confirm the findings and rule out other diagnosis.\nThere were no pathological findings in both lungs. \nIn basal CT scan, a 10 cm round-shaped lesion located in the aortopulmonary window was observed. It presented well-defined borders. \nAfter IVC administration; lesion revealed heterogeneous peripheral avid enhancement, due to high vascularization. Centre of the lesion was hypodense, and didn\u2019t show enhancement, suggesting central necrosis. Thus, lesion displayed through contact with thymus gland, aorta and pulmonary artery. \nPartial resection of the lesion was performed by medium sternotomy. Infiltration of the pericardium, adventitia of aorta and pulmonary arteries and phrenic and recurrent nerves was confirmed.",
    "discussion": "Paraganglioma is a rare tumour of the mediastinum (0.3% of all tumours)1-3. It has a mild female predominance, and the average age at time of diagnosis is 49. It arises from the paraganglia cells placed in the lymphatic ganglia of the autonomic system; which are located in the adrenal medulla, chemoreceptors, vagal body and plexus 1-3. Most of paragangliomas are located in the region of the cardiac plexus (middle mediastinum) or along the aortic sympathetic chain in the costovertebral sulcus (posterior mediastinum). Those located in the posterior mediastinum are easier to resect1. Histologically, they can be indistinguishable from a pheochromocytoma. They display zellballen pattern positive for chromogranin A and vascular stroma of sustentaculum cells (S100 +). It may be difficult to differentiate benign from malign tumours by pathologist 5, 6. Multiple associations have been described; such as Von Hippel Lindau Syndrome, Von Recklinghausen fibromatosis, Carney Triad and MEN I.\nParagangliomas are asymptomatic or display symptoms related to invasion of local structures or hormonal activity 1-3. Non-adrenal paragangliomas are rarely functioning4. IVC CT scan is the most accurate imaging technique for the diagnosis.\nCT findings include an hypervascular mediastinal mass, fed by dilated arteries; which shows heterogeneous and avid enhancement after IVC administration. Vascular invasion signs may be present. Feeding arteries generally arise from the internal mammary artery. On MRI, paraganglioma displays mild hyperintensity to adjacent muscle on T1WI, high hyperintensity on T2WI and avid enhancement with contrast. Phrenic, recurrent and vague nerves may be englobed by the lesion. Selective DSA can demonstrate vascular supply, enabling surgical planning. Definite diagnosis can be made by CT scan. Biopsy is unnecessary.\nParaganglioma poses a surgical challenge due to its proximity to essential structures and high vascularization. Complete resection is very difficult. Surgical technique includes previous embolization of feeding arteries, medium sternotomy, partial resection and cardiopulmonary bypass. Alpha and Beta-blockers administration before surgery are necessary if functioning symptoms are present. Radiation and chemotherapy are ineffective. Adjacent structures invasion and active bleeding deteriorate the prognosis.\nMediastinal paragangliomas are rare and arise from the paraganglia cells of the autonomic nervous system. They are either asymptomatic or display invasion of adjacent structures or hormonal activity. Definite diagnosis can be made by CT scan. Biopsy is unnecessary. Complete resection is very difficult and radiation and chemotherapy are ineffective. \u00a0Surgery is the therapy of choice, striving whenever possible for complete resection.",
    "differential_diagnosis": "Paraganglioma, of, the, aortopulmonary, window, (Chemodectoma), Castleman, disease, Mediastinum, haemangioma, Intrathoracic, goitre",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16886_1_1.JPG?itok=JBae7nHo",
            "caption": "Chest X-Ray (PA & Lateral):  A medium mediastinum mass was visualized. No additional findings were observed."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16886_2_1.JPG?itok=jwpxlfEC",
            "caption": "Basal CT (axial projection): a 10 cm round-shaped lesion located in the aortopulmonary window was observed."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16886_3_1.JPG?itok=geOx5mRb",
            "caption": "IVC CT (axial projection): lesion revealed heterogeneous peripheral avid enhancement, due to high vascularization. Centre of the lesion was hypodense, and didn\u2019t show enhancement, suggesting central necrosis."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16886_4_1.JPG?itok=5s3amkDx",
            "caption": "IVC CT (coronal and sagittal projections): lesion displayed through contact with thymus gland, aorta and pulmonary artery."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Cardiovascular system"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/16886",
    "time": "16.07.2020"
  },
  "16891": {
    "case_id": 16891,
    "title": "Non invasive mechanical ventilation as a rare cause of pulmonary barotrauma in course of COVID 19.",
    "section": "Chest imaging",
    "age": "59",
    "gender": "male",
    "diagnosis": "Pulmonary barotrauma.",
    "history": "A 59-year-old patient with no co-morbidities was admitted to hospital with a two weeks history of fever, cough and dyspnoea. A chest x ray documented bilateral subpleural infiltrates consistent with pneumonia. Arterial blood gas test was compatible with mild ARDS. A RT-PCR from a nasopharyngeal swab confirmed a SARS-CoV-2 infection.",
    "image_finding": "During hospitalization three chest CTs were performed. The first CT at day 10 showed\u00a0 pneumomediastinum with air decompressing along cervical fascial planes into subcutaneous tissue (Fig 1a). Air (Fig 1b, arrow) consistent with pulmonary interstitial emphysema (PIE) was seen along with peribronchovascular bundles. No pneumothorax was present. Diffuse ground-glass opacities (GGO) were present bilaterally in all lobes (Fig 1c) with areas of \u201ccrazy paving\u201d increased density and consolidations with a prevalent subpleural distribution. A score of lung parenchymal involvement was estimated visually from 50 to 75%.\nThe second CT at day 19 showed the same range of parenchymal involvement, characterized by irregular bands of dense consolidation (Fig 2). Pneumomediastinum had dramatically reduced; no more soft tissue emphysema and PIE were seen.\nA contrast CT scan at day 30 ruled out pulmonary embolism. Parenchymal changes were still present with GGO and areas of irregular, mild consolidation (Fig 3). No more signs of barotrauma were present.",
    "discussion": "The clinical spectrum of SARS-CoV-2 pneumonia ranges from mild to critically ill cases and morbidity and mortality is largely due to acute respiratory distress syndrome (ARDS); as described in early reports from Wuhan about 30 % of patients with COVID-19 required mechanical ventilation [1].\nMechanical positive pressure ventilation is the most common treatment for acute respiratory failure (ARF); it can be delivered through a noninvasive (nasal or face mask, nasal plugs), or an invasive interface (endotracheal tube, tracheostomy). \nPulmonary barotrauma is defined as the presence of extra alveolar air due to lung injury. Barotrauma can be a complication of mechanical ventilation, either invasive (IV) or non-invasive (NIV), and may be associated with increased morbidity and mortality [2]. Mechanical ventilation may determine alveolar rupture, which results in air leakage into extra-alveolar interstitium. Interstitial air may dissect along perivascular sheaths towards pleural space, mediastinum and skin leading to pulmonary interstitial emphysema (PIE), pneumothorax, pneumomediastinum and subcutaneous emphysema [3]. The incidence of barotrauma depends on the underlying lung pathology; recent papers report an incidence of 10% averaged between different populations [4]. Keeping pressures and volumes low is considered a lung-protective ventilation procedure. Pressures related to NIV are lower compared with IV, thus barotrauma is reported to be rare in the former group. NIV is the initial approach in patients with signs of mild ARF [5-7].\nLung barotrauma is a clinical diagnosis; imaging is crucial as regards diagnosis, follow-up and treatment planning. \nChest x-ray is the first line exam to identify signs of barotrauma, specifically pneumothorax; CT can precisely characterize all manifestations of lung injury and is usually performed as a second line exam [6].\nWe report the benign course of a 59 years patient with a SARS-CoV-2 pneumonia-causing mild ARDS, who underwent NIV mechanical ventilation. A first CT scan was requested after ten days because of clinical worsening ; lung infiltrates involved more than 50% of lung parenchyma and some manifestations of lung barotrauma were noted. Pneumonia was treated with antiviral agents, while the non-life-threatening manifestations of barotrauma were monitored radiographically. After nine days another CT scan was performed in order to monitor antiviral therapy; a last CT scan was done at day 30 from admission because of chest pain. The clinical situation gradually improved with normalization of the arterial blood gas values; reduction of lung parenchymal consolidations and self-limitation of the manifestations of barotrauma were progressively demonstrated. The patient was discharged and sent to rehabilitation after 38 days of hospitalization.",
    "differential_diagnosis": "Pulmonary, barotrauma., Spontaneous, pneumomediastinum, Oesophagal, perforation, Traumatic, lung, injury",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16891_1_1.jpg?itok=xIX7hCIl",
            "caption": "Axial chest CT at day 10 from admission shows evidence of pneumomediastinum with great amount of air decompressing along cervical fascial planes into subcutaneous tissue."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16891_1_2.jpg?itok=Iy5nkbiH",
            "caption": "Axial CT (detail) with evidence of air consistent with pulmonary interstitial emphysema (PIE) along  peribronchovascular bundles adjacent to mediastinum."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16891_1_3.jpg?itok=qSyOckTo",
            "caption": "Axial CT demonstrates diffuse ground glass opacities (GGO) extended bilaterally in all lobes with concomitant areas of \u201ccrazy paving\u201d increased density and signs of consolidation; areas of consolidation had a prevalent posterior subpleural distribution."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16891_2_1.jpg?itok=7nWH-8Ar",
            "caption": "Axial CT at day 19 with evidence of areas of altered density , mainly consolidative,  with irregular bands of dense parenchyma consistent with a later stage of disease."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16891_3_1.jpg?itok=d1hOh2st",
            "caption": "Axial chest CT at day 30, in lung window setting, with evidence of decreased areas of parenchymal altered densities, consistent with benign course of disease."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/16891",
    "time": "16.07.2020"
  },
  "16892": {
    "case_id": 16892,
    "title": "COVID-19 infection with isolated gastrointestinal symptoms",
    "section": "Chest imaging",
    "age": "47",
    "gender": "male",
    "diagnosis": "Coronavirus disease-19 (COVID-19)",
    "history": "A previously healthy 47-year-old male presented with a 1-week history of fever, vomiting, nausea, and epigastric pain. Laboratory studies were notable for lymphopenia (0.8\u00d7103/\u00b5L, normal range 0.9\u00d7103/\u00b5L \u2013 3.3\u00d7103/\u00b5L). Vitals signs were remarkable only for low-grade fever (37.9\u00b0C). He reported no respiratory complaints or known sick contacts.",
    "image_finding": "CT of the abdomen and pelvis was performed with intravenous contrast and demonstrated patchy, peripheral-predominant ground glass opacities at the bilateral lung bases. A subsequent AP chest x-ray demonstrated diffuse peri-bronchial thickening and faint nodular opacities without focal consolidation.",
    "discussion": "Background \nCoronavirus disease-19 (COVID-19) is a novel viral pandemic that primarily affects the respiratory tract and classically produces symptoms of fever, dry cough, and shortness of breath [1]. The virus invades cells by binding to the angiotensin-converting enzyme 2 (ACE2) receptor [2, 3]. High expression of this receptor is found in the lungs, heart, and intestines, which may facilitate the entry of the virus into these areas and multisystem symptoms [4 \u2013 6].\nClinical Perspective \nPatients with COVID-19 typically present with fever, dry cough, and dyspnea. There is increased recognition that gastrointestinal symptoms, including nausea, vomiting, and abdominal pain, maybe presenting features [7, 8]. In some cases, gastrointestinal symptoms may appear without respiratory symptoms during initial stages of infection [9 \u2013 11]. It is important that clinicians maintain a high index of suspicion for COVID-19 when encountering patients with gastrointestinal symptoms. \nImaging Perspective \nChest radiographs may be normal in the early stages of COVID-19 infection, and CT may be positive even prior to symptom development [12]. Common CT findings include bilateral, peripheral-predominant ground-glass opacities and interlobar septal thickening [13]. CT imaging may detect a \u201ccrazy paving\u201d pattern later in the disease course, which has been reported in patients presenting with atypical symptoms [14, 15]. Clinicians and radiologists must maintain a low threshold of suspicion to detect atypical presentations of COVID-19.\nOutcome\nBased on imaging findings, a test for COVID-19 nucleic acid from nasopharyngeal swab was ordered and returned positive. The patient remained stable in the emergency department and was discharged with instructions to self-quarantine and strict return precautions.\nTake-Home Message / Teaching Points \nRadiologists and other providers should be aware of both classic and atypical imaging characteristics of COVID-19 infection, including peripheral ground-glass opacities, crazy paving, and interlobular septal thickening. Gastrointestinal symptoms may be isolated, early, or predominant manifestation of COVID-19 infection. A high clinical suspicion for COVID-19 infection is required to accurately diagnose atypical COVID-19 presentations.",
    "differential_diagnosis": "Coronavirus, disease-19, (COVID-19), Gastroenteritis, Appendicitis, Acute, Cholecystitis, Diverticulitis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16892_1_1.png?itok=ggOQtVn3",
            "caption": "Contrast enhanced CT abdomen and pelvis in lung window demonstrates patchy, peripheral-predominant ground glass opacities at the bilateral lung bases (arrows)."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16892_1_2.png?itok=ecERt6VG",
            "caption": "Contrast enhanced CT abdomen and pelvis in lung window demonstrates patchy, peripheral-predominant ground glass opacities at the bilateral lung bases (arrows)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16892_2_1.png?itok=bVs0yI9B",
            "caption": "Portable AP chest x-ray demonstrates diffuse peri-bronchial thickening and faint nodular opacities without focal consolidation."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Respiratory system",
      "Thorax"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/16892",
    "time": "17.07.2020"
  },
  "16895": {
    "case_id": 16895,
    "title": "COVID-19 patient with a remarkable increase in D-Dimer values and suspicion of pulmonary embolism",
    "section": "Chest imaging",
    "age": "65",
    "gender": "male",
    "diagnosis": "Pulmonary Embolism in a COVID-19 patient",
    "history": "A 65-year-old male patient with a past medical history of hypertension and dyslipidemia presented to the emergency department with a 5-day history of cough and fever, associated with dyspnoea in the last 48 hours. Initial laboratory tests showed a normal white cell count, elevated C-reactive protein (118 mg/L, normal range 0-5 mg/L), elevated D-dimer (1,0 mcg/ml, normal range 0-0,5 mcg/ml), elevated interleukin-6 (76,6 pg/ml, normal range < 3,4 pg/ml) and elevated ferritin (1639 ng/ml, normal range 22-322 ng/ml). The day after admission the patient developed acute respiratory distress, was emergently intubated and transferred to the ICU.",
    "image_finding": "Chest X-ray at admission showed a patchy airspace opacities in both basal and central pulmonary areas (Fig 1).\nFollow-up\nChest X-ray controls showed no worsening, but D-dimer continued to rise until reaching a peak of 23,4 mcg/L (normal range 0-0,05 mcg/ml) on 18th day of hospitalization without clinical suspicion of deep venous thrombosis in lower limbs. ICU physicians requested a chest CT scan to rule out Pulmonary Embolism (PE). \nA chest CT scan with contrast (pulmonary angiogram) was performed on 19th day of hospitalization and showed a filling defect in segmental arteries of both inferior lobes and the beginning of the superior left lobe artery. The filling defect was central and non-occlusive in almost all arteries, and only the anterior segmental artery of the left lower lobe was totally occupied (occlusive emboli) (Fig 2). No cardiac compromise was described. \nIn the lung window were observed patchy and peripheral areas of ground-glass opacities in pulmonary parenchyma of all pulmonary lobes with a focal consolidative process in the inferior right lobe and a crazy-paving appearance in the middle right lobe associated (Fig 3-5). Findings were compatible with moderate COVID-19 involvement [1].",
    "discussion": "Background\n\u00a0\nThe coronavirus disease 2019 (COVID-19) its caused by a new coronavirus named SARS-CoV-2, that belongs to the coronaviruses family, a broad family of RNA viruses that are capable of mutation and recombination, and can lead to a respiratory infection and severe complications, probably due to the hyperinflammatory syndrome [2,3,4]\n\u00a0\nClinical Perspective\n\u00a0\nCOVID-19 has been recently associated with an increased risk for venous thromboembolism, probably due to the proinflammatory and hypercoagulable state evidenced by the increase in values in C-reactive protein, D-Dimer, Ferritin and interleukin levels. Most of the current publications relate a value of D-Dimer > 1 mcg/L with increased mortality [4, 5, 6]. In a retrospective study in China find that patients with COVID-19 and PE had a median D-dimer of 11,07 mcg/ml. Therefore, a remarkable increase of D-Dimer values should lead to suspicion of a thrombotic event such as PE. [7]\n\u00a0\nImaging Perspective\n\u00a0\nChest CT scan with contrast (pulmonary angiogram) could be useful in patients with COVID-19 and clinical/analytic suspicion of PE. First, it allows to rule out PE, and secondly, it allows to evaluate the pulmonary parenchyma involvement. In 10 patients with COVID-19 and PE described in a retrospective study, the lesions were only found in the small branches of each lobe artery [7, 8]. \nOutcome \nThe patient was treated with hydroxychloroquine and Ritonavir/Lopinavir since admission and required corticosteroids and a single dose of Tocilizumab at the ICU because of clinical worsening. Bemiparin was initiated as a prophylactic measure in the ICU, and after PE was diagnosed, Enoxaparin at full dose was initiated (8000 IU every 12 hours) and the D-Dimer values gradually descended in the following days (last value 4 mcg/mL). The patient recovered and was discharged home 30 days after hospital admission, full-dose Enoxaparin was maintained.\nTake-Home Message / Teaching Points \nElevated D-Dimer values in COVID-19 patients has been related to high risk of death and probably a risk of thrombotic events (venous and arterial), despite thromboprophylaxis since up to 31% of ICU patients can develop a thrombotic complication [4,5,6]. However, high values of D-dimer may be due to other conditions as sepsis, acute myocardial infarction, advanced age or immobilization. \n\u00a0\nThus, when to consider a D-dimer value remarkable increased remains a reasonable question. In 138 patients with COVID-19 analyzed in Wuhan showed that ICU patients had a median value of D-dimer of 0,4 mcg/L and non-UCI patients had 0,1 mcg/L. Other study made in France about the relationship between D-dimer levels and PE in patients with COVID-19 showed that a D-dimer value >2,6 mcg/mL had a sensitivity of 100% and a specificity of 67% for PE on CT scan. [9,10]\n\u00a0\nTherefore, suspicion of PE should be considered when D-dimer values abnormally increases in the analytical monitoring above the median values in a patient with COVID-19, and it\u2019s important to rule out it with a chest CT scan with contrast (pulmonary angiogram) because of an accurate diagnosis influence the treatment and probably the clinical outcome. [7,8,10] \n\u00a0\nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Pulmonary, Embolism, in, a, COVID-19, patient, COVID-19, pneumonia, Pulmonary, Embolism, Viral, pneumonia, other, than, COVID-19, Multifocal, bacterial, pneumonia, Acute, respiratory, distress, syndrome, (ARDS)",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16895_1_1.jpg?itok=e2pBuGba",
            "caption": "Chest X-ray showing patchy airspace opacities in both basal and central pulmonary areas"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16895_2_1.jpg?itok=kLEgUS3J",
            "caption": "Chest CT scan with contrast showing a central filling defect (non-occlusive emboli) in segmental arteries of right lower lobe (arrow), and a complete filling defect (occlusive emboli) in anterior segmental artery of the left lower lobe (arrowhead). Axial (a) and coronal (b) sections."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16895_2_2.jpg?itok=BwtC0m-y",
            "caption": "Chest CT scan with contrast showing a central filling defect (non-occlusive emboli) in segmental arteries of right lower lobe (arrow), and a complete filling defect (occlusive emboli) in anterior segmental artery of the left lower lobe (arrowhead). Axial (a) and coronal (b) sections."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16895_3_1.jpg?itok=FlytIvyf",
            "caption": "Coronal section of chest CT scan showing patchy and peripheral areas of ground-glass opacities in parenchyma of all pulmonary lobes."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16895_4_1.jpg?itok=7C_jjJC7",
            "caption": "Axial sections of Chest CT scan showing a crazy-paving appearance in the middle right lobe (arrow) (a) and a small consolidation in the inferior right lobe (arrow)"
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16895_4_2.jpg?itok=rVnxO2UD",
            "caption": "Axial sections of Chest CT scan showing a crazy-paving appearance in the middle right lobe (arrow) (a) and a small consolidation in the inferior right lobe (arrow)"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Pulmonary vessels",
      "Thorax"
    ],
    "imaging_technique": [
      "Infection"
    ],
    "link": "https://www.eurorad.org/case/16895",
    "time": "21.07.2020"
  },
  "16903": {
    "case_id": 16903,
    "title": "COVID-19 presenting with a small ground-glass opacity in the upper lobe of the lung",
    "section": "Chest imaging",
    "age": "19",
    "gender": "male",
    "diagnosis": "COVID -19 pneumonia",
    "history": "A 19-year-old male presented to our hospital with fever and cough. No history of traveling or other comorbidity. The Chest X-Ray was unremarkable (Fig.1), but, on his chest CT, a small single ground-glass opacity in the left upper lobe of the lung was observed (Figs. 2a, 2b, 2c). His real-time PCR was positive for COVID-19.",
    "image_finding": "In the left upper lobe of the lung, a small area of ground-glass opacity was observed, however, both lungs aeration and vascularization were within normal limits. Pleura and interlobar fissures were normal.",
    "discussion": "Background\nThe initial cases of pneumonia of unknown aetiology first identified on Dec 31, 2019, by the Health Commission of Hubei province of China. [1]. On February 11, 2020, the World Health Organization named this disease as Corona Virus 2019 (COVID-19) [2]. The virus is also called as SARS-Cov2, which is a class of enveloped, positive-sense, single-strand RNA viruses that can cause respiratory, enteric, hepatic, and neurologic diseases [3]. It is mainly transmitted through nosocomial transmission, respiratory droplets, and contact [4]. Studies support the COVID-19 S-protein interaction with human ACE2 receptors in the pathogenesis of COVID -19, leading to cellular entry [5].\nClinical Perspective \nThe common symptoms of disease are fever, cough, myalgia, fatigue, and dyspnoea [6]. Although the real-time reverse-transcription-polymerase chain reaction (RT-PCR) is the standard of diagnosis, imaging can play a useful complementary role in determination and management of COVID-19 pneumonia [7].\nImaging Perspective \nBilateral multifocal ground-glass opacities (GGO) in the lower lobes are the most common initial findings on CT [8]. Pleural thickening, bronchiectasis, and septal thickening are less common imaging manifestations and mainly seen in the later stages [9]. The PCR is the reference standard for the diagnosis of COVID-19 but, in some cases of the early stages of diseases, it may have a false-negative result [10]. Thus, in patients with typical clinical features, chest CT may play a useful complementary role in the integrated diagnosis of disease even when the PCR result is negative [11].\nOutcome\nCOVID-19 pneumonia has nonspecific and diverse CT imaging findings but, GGO is the most typical feature. [12]. In patients with typical clinical features and high suspension, chest CT may play a useful complementary role in disease diagnosis and management, especially where the PCR access is difficult [7, 11]. \n\u00a0\nTake-Home Message \nAlthough the COVID-19 pneumonia often manifests as multifocal GGO with peripheral distribution in the lower lobes it can be presented as a single GGO in the upper lobe.",
    "differential_diagnosis": "COVID, -19, pneumonia, Viral, pneumonia, due, to, other, viruses, Atypical, bacterial, pneumonia, Solitary, pulmonary, nodule, Interstitial, lung, disease, Pulmonary, oedema",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16903_1_1.jpg?itok=gKRSbFeV",
            "caption": "Chest X-Ray; Apparently Normal Chest X-Ray Study"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16903_2_1.jpg?itok=qC6BGBEk",
            "caption": "Axial Chest CT Image; the image shows a small Single Ground Glass Opacity in the left upper lobe of the lung."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16903_2_2.jpg?itok=zKE-6CEK",
            "caption": "Coronal Chest CT Image; The image shows a small Single Ground Glass Opacity in the left upper lobe of the lung."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16903_2_3.jpg?itok=D_XhtENA",
            "caption": "Sagittal Chest CT Image; The image shows a small Single Ground Glass Opacity in the left upper lobe of the lung."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "CT-High Resolution"
    ],
    "link": "https://www.eurorad.org/case/16903",
    "time": "22.07.2020"
  },
  "16907": {
    "case_id": 16907,
    "title": "A case of lower extremity deep venous thrombosis with acute pulmonary embolism and resultant pulmonary infarction",
    "section": "Chest imaging",
    "age": "74",
    "gender": "male",
    "diagnosis": "Deep venous thrombosis with acute pulmonary embolism and pulmonary infarction",
    "history": "A 74-year-old elderly male was brought to the emergency department with history of acute onset right-sided chest pain and mild fever. He had a history of on and off shortness of breath since last six months. No past medical history of diabetes or hypertension was noted.",
    "image_finding": "Since the patient presented with acute onset of right-sided chest pain, initial evaluation was carried out with a chest X-ray. Chest X-ray showed a thin-walled cavitary lesion in the right mid zone (Fig 1). Bilateral pleural effusion was noted. Based on the chest x-ray findings, patient was evaluated in the line of infective pathology and contrast CT chest was done (that is why we do not have the pulmonary angiography images in this case). To our surprise, contrast CT showed hypodense filling defect in the right descending pulmonary artery (Fig 4, Fig 5) and segmental arteries (Fig 6) suggestive of pulmonary thromboembolism. Cavitating, wedge-shaped peripheral based consolidation suggestive of pulmonary infarction was also noted (Fig 2, Fig 3).\u00a0 Doppler study of bilateral lower limbs revealed deep venous thrombosis of the left lower limb extending to the infra-renal inferior vena cava (Fig 7, 8, 9).",
    "discussion": "Background and clinical perspective: Pulmonary thrombo-embolism refers to the occlusion of the pulmonary arterial system by a thrombus or an embolus. It usually occurs following deep venous thrombosis of the lower limbs. A number of factors can lead to the increased risk of pulmonary thrombo-embolism such as prolonged immobilization, trauma, pregnancy, malignancy, hypercoagulable states (protein C and S deficiency) and oestrogen replacement therapy. Pulmonary infarction occurs only in a minority of patients with pulmonary embolism (10 to 15% of cases) [1]. \nImaging Perspective: CT pulmonary angiography is the gold standard imaging modality for the evaluation of patients with pulmonary thromboembolism [2].\u00a0 However, in cases of any suspected pulmonary pathologies, chest X-ray is usually the initial investigation carried out. Typical chest radiographic findings in cases of pulmonary thromboembolism with pulmonary infarction include enlarged central pulmonary artery with regional oligaemia and wedge-shaped juxtapleural opacification (Hampton's Hump). CT angiography shows non enhancing hypodense filling defect within the pulmonary arteries (suggestive of pulmonary thromboembolism) with peripheral wedge-shaped pulmonary consolidations (suggestive of pulmonary infarction). Cavitation may be seen in septic embolism and in cases of infection of a bland infarct (cavitatory pulmonary infarction) as in our case. In CT angiography, acute pulmonary embolism is noted as a hypodense filling defect surrounded by the contrast (Polo mint sign) and it makes an acute angle with the vessel wall [3]. Chronic pulmonary embolism, on the other hand, presents as asymmetric wall thickening of the vessel with the hypodensity making an obtuse angle with the vessel wall [4]. Nuclear study in the form of ventilation/perfusion scan can also be done in patients with suspected pulmonary embolism. Ventilation-perfusion study shows areas of ventilation-perfusion mismatches [5]. A study showing two or more unmatched segmental perfusion defects is considered to be a high probability study. Doppler study of lower limbs should be carried out in all patients with pulmonary embolism so as to rule out the deep venous thrombosis of the lower extremities as the potential cause of pulmonary thromboembolism.\nTreatment and outcome: In all patients with pulmonary thromboembolism, with or without pulmonary infarction, the initial treatment is the cardiopulmonary support. In those patients with no risk of active bleeding, anticoagulation should be started. In cases of patients with massive emboli, thrombolysis can be undertaken. Pulmonary artery embolectomy with placement of vena cava filters can help in preventing further episodes of pulmonary thromboembolism.\n\u00a0\nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Deep, venous, thrombosis, with, acute, pulmonary, embolism, and, pulmonary, infarction, Bronchogenic, carcinoma, Pulmonary, tuberculosis, Granulomatosis, with, polyangiitis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16907_1_1.png?itok=g-wp8kMz",
            "caption": "Chest X-ray PA view showing thin walled cavitary lesion in the right mid zone (white arrow) with adjacent airspace opacity. No air fluid level is seen."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16907_2_1.jpg?itok=q5nS1vXp",
            "caption": "CT chest lung window axial view showing peripheral based wedge shaped consolidation with cavitary changes in superior segment of right lower lobe (yellow arrow)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16907_3_1.jpg?itok=CO86HEGZ",
            "caption": "CT chest lung window sagittal view showing peripheral based wedge shaped consolidation in superior segment of right lower lobe with cavitary changes (red circle)."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16907_4_1.jpg?itok=pm5c0dVj",
            "caption": "Contrast enhanced CT chest coronal view showing hypodense filling defect in the descending branch of right pulmonary artery (white arrow) suggestive of pulmonary thromboembolism."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16907_5_1.jpg?itok=CzZGHIVy",
            "caption": "Contrast enhanced CT chest sagittal view showing hypodense filling defect in the right descending pulmonary artery (yellow arrow); the filling defect makes acute angle with the arterial wall suggestive of acute thrombo-embolism (red arrow)."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16907_6_1.jpg?itok=Emu3xUgW",
            "caption": "Contrast enhanced CT chest axial view showing embolism in segmental branch of right descending pulmonary artery (yellow arrow). Adjacent pulmonary infarction is also noted (blue arrow)."
          }
        ]
      },
      {
        "number": "Figure 7",
        "subfigures": [
          {
            "number": "Figure 7",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16907_7_1.jpg?itok=Y3lMEd0T",
            "caption": "Ultrasonogram B-Mode image showing hypoechoic thrombus in left common femoral vein (red arrows)."
          }
        ]
      },
      {
        "number": "Figure 8",
        "subfigures": [
          {
            "number": "Figure 8",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16907_8_1.jpg?itok=OduL2Cqc",
            "caption": "Ultrasonogram Colour Doppler Image showing no flow in the left common femoral vein (yellow arrows)."
          }
        ]
      },
      {
        "number": "Figure 9",
        "subfigures": [
          {
            "number": "Figure 9",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-07//16907_9_1.jpg?itok=WDJ5fqje",
            "caption": "Ultrasonogram B-mode image showing hypoechoic content in the inferior vena cava suggestive of IVC thrombosis (red arrows)."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Emergency",
      "Lung",
      "Vascular"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/16907",
    "time": "24.07.2020"
  },
  "16951": {
    "case_id": 16951,
    "title": "Ruptured pulmonary arteriovenous malformation",
    "section": "Chest imaging",
    "age": "36",
    "gender": "male",
    "diagnosis": "Ruptured pulmonary arteriovenous malformation left lower lobe with hemothorax",
    "history": "36-year-old male patient with no previous comorbidities presented with 2-week history of left-sided chest pain.",
    "image_finding": "Plain radiograph revealed left pleural effusion with an added radioopacity in the left lower zone. Plain and contrast-enhanced CT thorax revealed an abnormal tortuous vascular structure in the left posterior basal segment with more than one feeding artery from left branch of pulmonary artery and multiple draining veins to left inferior pulmonary vein. Hemothorax was noted on the left with evidence of contrast leak.",
    "discussion": "Pulmonary arteriovenous malformations are rare low resistance, high flow abnormal vascular structures that connect a pulmonary artery to a pulmonary vein bypassing the normal capillary bed and resulting in an intrapulmonary right to left shunt\u00a0[1]. Pulmonary AVMs are divided into simple and complex lesions. Complex AVMs account for approximately 20% of pulmonary AVMs.[2] Simple pulmonary AVMs are lesions defined as comprising of a single feeding artery connected through a bulbous aneurysmal non-septated communication with one or more draining veins. Complex AVMs are defined as lesions supplied by 2 or more feeding arteries connected via a septated aneurysmal sac to 2 or more draining veins\u00a0[1]. Diffuse pulmonary AVMs involve every segmental or subsegmental type of arteries of atleast one lung lobe and are extensive\u00a0[3]. \nThe incidence of pulmonary AVMs is 2 \u2013 3 per 100000 population. The condition remains under-recognized until 2nd decade of life\u00a0[1]. These patients maybe asymptomatic but may also present with features of hypoxia, fatigue, dyspnea and cyanosis. Right to let shunting can result in pulmonary embolism and may cause stroke or brain abscess. Less common but life-threatening complications include hemoptysis and hemothorax\u00a0[4]. 50 \u2013 80% of pulmonary AVMs occur in patients with hereditary telangiectasia[5]. Rupture of AVMs can be seen in hereditary telangiectasia and pregnancy from hormonal changes.\nPulmonary AVM is characterised by abnormal vascular structures that connect the feeding artery and draining veins. They appear on radiographs\u00a0 as rounded well defined nodular lesions of varying size with dilated draining vessels and branching feeding vessels. On pulmonary arterial phase intense enhancement with demonstration of feeding and draining vessels is seen. Uncommonly non enhancing peripheral hypodense nodule is seen in thrombosed AVM\u00a0[1]. \nOur patient presented with ruptured pulmonary AVM and was managed surgically by segmentectomy of the involved segment. Patient is stable and symptom-free at present. Hemothorax and hemoptysis, though life threatening are rare complications\u00a0[4]. \nMassive hemoptysis and hemothorax have been reported with fatal outcomes but hemothorax that is not life-threatening as in this case has been very rarely described in literature[6].",
    "differential_diagnosis": "Ruptured, pulmonary, arteriovenous, malformation, left, lower, lobe, with, hemothorax, Pulmonary, aneurysm, Pulmonary, varix, Calcified, granuloma, Bronchocoele",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-08//16951_1_1.jpeg?itok=5cbzvylU",
            "caption": ""
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-08//16951_2_1.jpg?itok=TIr0ROJ1",
            "caption": ""
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-08//16951_3_1.jpg?itok=5A_zmH0f",
            "caption": ""
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-08//16951_4_1.jpg?itok=g0UwCQez",
            "caption": ""
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-08//16951_5_1.jpg?itok=9ttUr0Xt",
            "caption": ""
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-08//16951_6_1.jpg?itok=4i6fyGBI",
            "caption": ""
          }
        ]
      },
      {
        "number": "Figure 7",
        "subfigures": [
          {
            "number": "Figure 7",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-08//16951_7_1.jpg?itok=fvSdPji9",
            "caption": ""
          }
        ]
      },
      {
        "number": "Figure 8",
        "subfigures": [
          {
            "number": "Figure 8",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-08//16951_8_1.jpg?itok=n3an2A7T",
            "caption": ""
          }
        ]
      },
      {
        "number": "Figure 9",
        "subfigures": [
          {
            "number": "Figure 9",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-08//16951_9_1.jpg?itok=s_yRxVth",
            "caption": ""
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/16951",
    "time": "06.08.2020"
  },
  "16953": {
    "case_id": 16953,
    "title": "Delayed symptomatic cavity formation in COVID-19 pneumoni",
    "section": "Chest imaging",
    "age": "20",
    "gender": "male",
    "diagnosis": "Post COVID-19 pneumatoceles",
    "history": "A 20-year-old male with a history of asthma presented with cough and fever. He was diagnosed with COVID-19 pneumonia (positive throat PCR swab) and pulmonary emboli. He was treated with Apixaban, Piperacillin-Tazobactam and Continuous Positive Airway Pressure (CPAP). He represented one month later with pleuritic chest pain and exertional breathlessness.",
    "image_finding": "His initial Chest X-ray (CXR) showed bilateral lower zone consolidation (Figure 1). A CT Pulmonary Angiogram (CTPA) revealed features of severe COVID-19 pneumonia; multifocal ground-glass opacities, dense consolidation in the right middle lobe and lingula, small bilateral subsegmental pulmonary emboli and a small left pleural effusion (Figure 2a). There was no dilatation of the peripheral vessels travelling towards or within the areas of ground glass shadowing [1].\u00a0 \nThe CTPA on readmission showed resolution of pulmonary emboli and left pleural effusion. New multiple, bilateral, peripheral, thick smooth walled cavities were present (Figure 2b and c). The largest cavity, in the right lower lobe, measured 11cm and contained an air-fluid level (Figure 3). A new small right pleural effusion and moderately enlarged mediastinal lymph nodes (>1cm) were present, which is suggestive of severe COVID-19 infection [2, 3] or superadded infection.",
    "discussion": "Background:\nDelayed cavitation has been rarely described as a pulmonary manifestation of COVID-19 [4-7]. \nTypical acute features of COVID-19 pneumonia include ground-glass opacities, interstitial thickening with \u2018crazy-paving\u2019, \u2018halo and reverse-halo signs\u2019 and consolidation with air bronchograms [8]. \nClinical Perspective:\nAtypical features of COVID-19 raise concern for other infection or additional diagnoses [9,10]. Bacterial and Fungal infection should be excluded, as well as cavity-forming organisms [4]. Fungal (Beta-D Glucan and Aspergillus serology), atypical bacterial and vasculitic screens were negative in our patient.\nThere is no consensus on how post COVID-19 cavities should be managed with very few reports of such a complication. Of these, most have been managed conservatively with only one case reporting excision of infected pneumatoceles [4]. \nImaging Perspective:\nVery large post COVID-19 cavities have not been previously reported such as in our case.\nMechanical ventilation, ischaemic parenchymal damage [7] and post-consolidation alveolar walls disruption with pneumatocele formation [8] were proposed as mechanisms for cystic lesions and pneumothorax.\nPneumatoceles are thin-walled parenchymal cysts that can complicate severe pneumonia. Histology of pneumatoceles shows inflammation and necrosis of airway walls with formation of direct communication between the bronchovascular interstitium and the pulmonary parenchyma [11]. Interval imaging can differentiate pneumatoceles from lung abscess, due to their characteristics of rapid change in appearance, size and location [12]. Pneumatoceles resolve spontaneously.\nHigh incidence of pulmonary emboli (PE), up to 30%, has been reported in patients with COVID-19 [13].\u00a0 A COVID-19 PE phenotype is suggested, as clots commonly occur in peripheral vessels, possibly due to thromboembolic disease and in situ immunothrombosis [14]. Cavitation, due to aseptic liquefaction or secondary infection [15], can complicate pulmonary infarction in 2.7-7% of cases [16] and was reported during the 2003 SARS pandemic [17].\nThe largest cavity in our patient, contained an air-fluid level which raised the suspicion of a \u00a0broncho-pleural fistula; a communication between the pleural space and the bronchial tree. \u00a0A definite airway - cavity communication was not identified after careful review of CT reconstructions in all planes, however this does not necessarily rule out a broncho-pleural fistula \nOutcome:\nPercutaneous drainage of the largest, fluid-filled cavity was considered, but not performed on MDT (Multi-Disciplinary Team) consensus, as the patient\u2019s modest symptoms did not warrant the risk of introducing pleural infection and creating a bronchopleural fistula.\u00a0 \nThe patient was treated conservatively and monitored with serial CXRs for six weeks (Figures 4 and 5). These showed reduction in size of the cavities with resolution of the air-fluid level.\nTeaching points:\n\nDelayed cavitation is a rare, symptomatic feature of Covid-19 pneumonia.\nExclusion of additional pathologies and close clinic-radiological cooperation should guide treatment.\nIn well individuals, post Covid-19 cavitation may be successfully managed conservatively. \u00a0\nLymphadenopathy may be a predictor of worse outcome in severe COVID-19 pneumonia \n\nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Post, COVID-19, pneumatoceles, Pneumatoceles, Secondary, infection, leading, to, lung, abscess, formation, Cavitating, pulmonary, infarcts, due, to, COVID-19, related, thrombo-embolic, disease, or, micro-thrombotic, process, Bronchopleural, fistula",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-08//16953_1_1.jpg?itok=Md7ScgQw",
            "caption": "The initial AP CXR shows patchy, bilateral consolidation in a lower zone distribution."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-08//16953_2_1.jpg?itok=4NtgbCJ3",
            "caption": "The first CTPA shows diffuse ground glass change. No peripheral dilated vessel could be identified."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-08//16953_2_2.jpg?itok=vFD6IFgk",
            "caption": "The second CTPA shows multiple, predominantly smooth and thick-walled cavities. The largest cavity has a slightly irregular wall and an air-fluid level is seen within."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-08//16953_2_3.jpg?itok=uBnUdzvF",
            "caption": "The second CTPA shows multiple, predominantly smooth and thick-walled cavities. The largest cavity has a slightly irregular wall and an air-fluid level is seen within."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-08//16953_3_1.jpg?itok=N5UPbQZ2",
            "caption": "The PA CXR shows the right mid zone cavity with a clear air-fluid level. Other small cavities are seen bilaterally. There is patchy opacification within both lower zones."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-08//16953_4_1.jpg?itok=2QoDSGLi",
            "caption": "On this three week follow up PA CXR, there has been a reduction in the size of the cavities, particularly the right mid zone cavity, with minimal fluid present in the dependent portion of the cavity. There is significant improvement in the consolidative shadowing in the periphery of both lungs."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-08//16953_5_1.jpg?itok=n60eXy6E",
            "caption": "At six weeks, there is further reduction in the size of the cavities with new atelectatic scarring in the right mid zone."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Respiratory system"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/16953",
    "time": "06.08.2020"
  },
  "16954": {
    "case_id": 16954,
    "title": "Iodine quantification to assess inflammation in patients with COVID-19",
    "section": "Chest imaging",
    "age": "75",
    "gender": "male",
    "diagnosis": "Inflammatory acute lung injury secondary to COVID-19 pneumonia",
    "history": "75-year-old man with prior history of hypertension, coronary and chronic obstructive pulmonary disease was admitted for sudden onset of dyspnea. Laboratory examinations showed lymphopenia, increased C-reactive protein, D-dimer and troponin T levels. Pulmonary CT angiography to rule out pulmonary embolism was performed, after findings; COVID-19 was confirmed with RT-PCR test.",
    "image_finding": "A dual-energy CT (DECT) pulmonary angiography ruled out pulmonary embolism (PE) and showed bilateral, diffuse ground glass opacities (GGO), lacking a specific distribution (Fig. 1, A-B). Visual inspection of the iodine maps (Syngo.via, Siemens Healthineers, Forchheim, Germany) revealed higher iodine content within the GGO (Fig. 1, C-D). Quantitative analysis of the iodine concentration demonstrated average iodine concentrations (IC) of 3.1 mg/ml in the GGO and 0.3 mg/ml in the non-affected lung parenchyma, respectively (Fig. 1, E-F). This finding allowed to consider an acute inflammatory lung injury likely secondary to an atypical infection. Even if indeterminate in appearance [1], COVID-19 was suggested, which was later confirmed with PCR test.",
    "discussion": "The novel Severe Acute Respiratory Syndrome-Coronavirus (SARS-CoV-2) outbreak that emerged in Wuhan (China) in December 2019 is the responsible of the most important viral infection in the last 100 years. In March 2020, the World Health Organization (WHO) declared the infection as Pandemic and COVID-19 (Coronavirus Disease 2019) as the official acronym to refer to the disease caused by the viral infection.\nClinically, COVID-19-infected pneumonia is characterised by fever, fatigue, dry cough and dyspnea. Chest CT is of great value in the diagnosis and prognosis of COVID-19. The pattern of bilateral and predominantly peripheral ground glass and consolidative pulmonary opacities is emerging as a CT hallmark of COVID-19 pneumonia [1,2]. However, some CT imaging findings in COVID-19 may not be specific or may even overlap with other entities, such as cardiogenic pulmonary oedema. \nIn our patient, the acute clinical presentation raised the clinical suspicion of PE or congestive heart failure. For this purpose, a dual-energy CT pulmonary angiography was performed. The exam ruled out PE but showed diffuse bilateral GGO involvement. Quantitative determination of the IC within the affected lung allowed to establish the inflammatory nature of lung involvement. In our case, the IC was higher in the affected lung areas (3.1 mg/ml) with respect to the normal parenchyma (0.3 mg/ml). This increase in IC within the areas of GGO probably reflects the increased blood flow due to the high permeability of the capillary wall in the acutely inflamed tissue (inflammation and reactive hyperemia). This observation has been previously described in the context of acute interstitial lung disease (AILD) [3]. In a cohort of patients undergoing dual-energy CT to exclude PE, Takeuchi et al. were able to differentiate AILD from cardiogenic pulmonary oedema based on the IC. Similar to our case, these authors observed significantly higher IC values within the affected areas in patients with AILD than in patients with cardiogenic pulmonary edema [3]. In the latter, the IC tends to be homogeneously increased within the entire lung parenchyma. It is reasonable to think AILD and acute inflammatory changes due to infection very likely share a common mechanism and physiopathology originated by a pulmonary insult that produces marked hyperemia and inflammatory cascade.\nIn challenging cases, when alternate diagnoses are suspected, patients with COVID-19 may benefit from a dual-energy CT pulmonary angiogram. In addition to confirming or ruling out pulmonary embolism, the quantification of the iodine content within the affected lung helps to establish the inflammatory nature of the radiological findings and to differentiate them from other entities, such as cardiogenic pulmonary oedema.",
    "differential_diagnosis": "Inflammatory, acute, lung, injury, secondary, to, COVID-19, pneumonia, Cardiogenic, pulmonary, oedema, Non-specific, interstitial, pneumonia, ., Atypical, lung, infections, (Influenza,, Mycoplasma\u2026)",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-08//16954_1_1.JPG?itok=_G3BjH9T",
            "caption": "Severe presentation of COVID-19 pneumonia on chest CT. Coronal (A) and transverse (B) images reveal bilateral, multifocal, and diffuse ground glass opacities (GGOs), lacking a specific distribution."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-08//16954_2_1.JPG?itok=c9CLmu7q",
            "caption": "A. Coronal reconstructions. A. Lung window. B. Color-coded image. C. Quantitative iodine maps. Bilateral GGOs are observed, especially in lower lobes. B. Color-coded (B) and quantitative iodine maps (C) show higher iodine content within the affected areas (2.5 to 3.1 mg/ml and 0.3 to 0.5 mg/ml in the GGO areas and in the non-affected lung, respectively)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-08//16954_3_1.JPG?itok=XK0TKF-2",
            "caption": "A. Axial reconstructions.  A. Lung window. B. Color-coded image. C. Quantitative iodine maps. Bilateral GGOs are observed. B. Color-coded (B) and quantitative iodine maps (C) show higher iodine content within the affected areas (3.1 mg/ml and 0.3 mg/ml in the GGO areas and in the non-affected lung, respectively)."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "CT-Quantitative"
    ],
    "link": "https://www.eurorad.org/case/16954",
    "time": "06.08.2020"
  },
  "16972": {
    "case_id": 16972,
    "title": "Reverse halo sign: Atypical chest CT findings in COVID-19 pneumoni",
    "section": "Chest imaging",
    "age": "45",
    "gender": "male",
    "diagnosis": "Coronavirus-19 infection (Covid-19)",
    "history": "A 45-year-old male presented with low-grade fever (38.5C) and mild discomfort in chest since 3 days. He denied having cough or any other symptoms. On enquiry, he also gave history of loss of smell and taste since 5days. His laboratory investigations revealed slightly increased C-reactive protein (CRP- 6.5 mg/L; normal range <5.0 mg/L). he was hospitalised for further management.",
    "image_finding": "High resolution non contrast CT scan of chest revealed multiple focal areas of subpleural and bronchogenic opacities and ground-glass attenuation in both lungs, predominantly involving peripheral basal segments of bilateral lower lobes. Few opacities showed central ground glass attenuation surrounded by mildly dense opacity giving appearance of REVERSE HALO in right lower lobe.",
    "discussion": "1. Background \nA recent outbreak of Coronavirus disease-19 (COVID-19) had started in the Wuhan city of China\u2019s Hubei province [1]. In short span of time it has spread to multiple countries all over the world with increased mortality.\u00a0 The World Health organisation (WHO) declared it as a global health emergency on January 30, 2020 and then classified it as a pandemic on March 11, 2020 [2].\nOn Jan 7, 2020, a novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2; previously known as 2019-nCoV), was identified as the causative organism which is the seventh known coronavirus to infect humans [1] with previous two remarkable outbreaks of severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS).\n2. Clinical Perspective \nMajority of the symptomatic patients present with lower respiratory tract infections [2,3]. Few patients also show gastrointestinal symptoms prior to respiratory symptoms. Symptoms are variable from mild to severe forms with fatality rate being 3% [2].\n3. Imaging Perspective \nReal-time polymerase chain reaction (RT-PCR) is the current standard diagnostic method used to diagnose COVID19 infection with sensitivity as low as 60-71% for detecting SARS-CoV-2 attributed to the low viral load present in test samples [4].\nChest CT shows approximately 56-98% sensitivity for COVID-19 even in the initial course of the disease and can be useful in correcting false negatives acquired from RT-PCR [4,5] and for the initial screening in individuals who are suspected to be have the virus [6].\nThe pattern of ground-glass and patchy consolidations with bilateral and peripheral lung distribution is considered to be the hallmark of COVID-19 infection [7].\u00a0 These may be associated with smooth septal thickening (\u201ccrazy\u201d paving pattern). These further progress into fibrosis or healing in chronic stage. The reverse halo sign typically occurs later in the course of disease suggesting that this CT finding correlates with the underlying pathophysiology of the disease process as it organises [2]. Such findings indicate that organising pneumonia is one of the mechanisms of lung injury [8]. \n4. Outcome \nCT plays a vital role in this COVID-19 pandemic presently due to its easy availability and diagnostic value. It helps in early diagnosis and prognosis of the disease based on typical and atypical imaging patterns. \n5. Take Home Message / Teaching Points \nThe atypical findings like reverse halo sign correlates with natural history of disease and its pathophysiology so these also need to be carefully evaluated besides the typical imaging features.",
    "differential_diagnosis": "Coronavirus-19, infection, (Covid-19), Organising, pneumonia, Aspiration, pneumonia, Granulomatous, diseases",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-08//16972_1_1.jpg?itok=tfqZs_2S",
            "caption": "Figure1-5 Axial plain CT chest images show small focal areas of subpleural and bronchocentric opacities and ground glass attenuation in both lungs, predominantly involving peripheral basal segments of bilateral lower lobes. Few of these show reverse halo sign (Figure 1-2)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-08//16972_2_1.jpg?itok=IiKG2YXp",
            "caption": "Figure1-5 Axial plain CT chest images show small focal areas of subpleural and bronchocentric opacities and ground glass attenuation in both lungs, predominantly involving peripheral basal segments of bilateral lower lobes. Few of these show reverse halo sign (Figure 1-2)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-08//16972_3_1.jpg?itok=xdv0RQid",
            "caption": "Figure1-5 Axial plain CT chest images show small focal areas of subpleural and bronchocentric opacities and ground glass attenuation in both lungs, predominantly involving peripheral basal segments of bilateral lower lobes. Few of these show reverse halo sign (Figure 1-2)."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-08//16972_4_1.jpg?itok=wCJFFiTl",
            "caption": "Figure1-5 Axial plain CT chest images show small focal areas of subpleural and bronchocentric opacities and ground glass attenuation in both lungs, predominantly involving peripheral basal segments of bilateral lower lobes. Few of these show reverse halo sign (Figure 1-2)."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-08//16972_5_1.jpg?itok=aTHOl7HU",
            "caption": "Figure1-5 Axial plain CT chest images show small focal areas of subpleural and bronchocentric opacities and ground glass attenuation in both lungs, predominantly involving peripheral basal segments of bilateral lower lobes. Few of these show reverse halo sign (Figure 1-2)."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/16972",
    "time": "13.08.2020"
  },
  "16984": {
    "case_id": 16984,
    "title": "Primary malignant melanoma of the oesophagus: a case report.",
    "section": "Chest imaging",
    "age": "80",
    "gender": "male",
    "diagnosis": "Primary malignant melanoma of the oesophagus",
    "history": "An 80-year-old male patient consulted his primary care physician after presenting progressive dysphagia to solids and unquantified weight loss. Previous medical history accounts for a hyperplastic colorectal polyp.\nHe was referred for initial diagnostic workup. Upper gastrointestinal endoscopy was requested, followed by contrast-enhanced 18F-FDG pneumo PET/CT.",
    "image_finding": "Upper gastrointestinal endoscopy revealed a brownish oesophageal lesion that occluded 70% of the oesophagal lumen, located 25cms from the incisors (fig. 1). It was identified, by biopsy, as melanoma. \nContrast-enhanced 18F-FDG pneumo PET/CT showed a hypermetabolic mass of 44x33x100 mm. (mean SUV: 6.4), protruding into the oesphageal lumen (fig. 2). Other hypermetabolic findings (metastases) included mediastinal lymph nodes, right acromion, transverse process of T11 and pedicle of L5 vertebrae. Increased FDG uptake at the left acromioclavicular joint was consistent with degenerative joint disease (fig. 3). This study was executed placing, transnasally, a Foley catheter (below the cricopharyngeal muscle). Distension was achieved with a CO2 pump and intravenous hyoscine N-butylbromide administration. \nDiagnosis of primary malignant melanoma of the oesophagus was made since no other pigmented lesions were observed (skin, eyes, and anus). After diagnosis was established, he returned his home province for treatment planning. This patient was lost to follow-up.",
    "discussion": "Primary malignant melanoma of the oesophagus (PMMO) is a rare neoplasm and its reported prevalence accounts for up to 0.5% of all oesophageal malignancies. It is more prevalent during the 6th and 7th decades of life with a male to female ratio of 2:1. Most PMMO are commonly located in the middle or lower oesophagus, probably due to the melanocytes concentrated in this area. While primary melanoma of the gastrointestinal tract is extremely rare, cutaneous melanoma can metastasize to the gastrointestinal tract. PMMO diagnosis can be accepted in patients with no history of melanoma and absence of melanoma involving other frequent sites (skin, eyes, anus, or vagina) [1].\nMajor risk factors have not been defined yet. Still melanosis, a benign condition, has been reported as a predisposing factor [2]\u00a0. \nMost common symptoms include dysphagia and weight loss [3]. Symptoms are usually present for 3 months [2,4]. Gross specimens are usually polypoid shaped, vary in size and colour (ranging from black to white for amelanotic forms), and are covered by normal mucosa [4]. Immunohistochemical staining is of paramount importance, positive HMB-45 and S-100 protein allows accurate diagnosis [1-4].\nPMMO is usually diagnosed at advanced stages; metastases are found in up to 40-50% of the cases at the time of diagnosis [1-4]. Commonly involved sites are paraesophageal, supraclavicular and celiac lymph nodes, brain, liver, lungs, and bones [1,2,4]. In this regard, Caldwell et. al mentioned the presence of regional nodal metastases in 66% of cases [5]. \nThe overall prognosis for PMMO is poor with estimated survival of 10-13 months at the time of the diagnosis [1-4].\nImaging plays a central role in pretreatment staging and therapeutic strategy planning in cancer patients. PET CT has revolutionised medical diagnosis owing to its high sensitivity for malignant lesions. Pneumo PET CT, an emerging useful tool, provides information about the oesophageal and gastric walls as well as the benefits of functional imaging (evaluation of distant metastatic disease) in a \u201cone-shot\u201d study [6].\nTreatment strategy has not been yet established on account of debatable evidence and number of reported cases. While oesophagectomy remains the backbone of PMMO treatment, it is not always possible and is related to high postoperative morbidity and mortality. The role of radiotherapy, chemotherapy, and immunotherapy is still unclear but may play a part in palliative treatment [7,8].",
    "differential_diagnosis": "Primary, malignant, melanoma, of, the, oesophagus, Squamous, cell, carcinoma, Sarcoma, Oat, cell, carcinoma, Metastasis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-08//16984_1_1.jpg?itok=y-49oiuC",
            "caption": "Upper gastrointestinal endoscopy revealed large exophytic, irregular and brownish tumour (arrow)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-08//16984_2_1.jpg?itok=oUArdo0U",
            "caption": "Contrast-enhanced Pneumo PET-CT in axial (A) and sagittal (B) CT reconstructions show a large and irregular tumour (short-axis and long-axis diameter measurements) affecting the thoracic oesophagus. PET-CT fusion images show pathological 18F-FDG uptake (mean SUV: 6.45, min: 5.1, max: 7.7) in axial (C) and sagittal (D) reconstructions."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-08//16984_2_2.jpg?itok=CARof4LN",
            "caption": "Contrast-enhanced Pneumo PET-CT in axial (A) and sagittal (B) CT reconstructions show a large and irregular tumour (short-axis and long-axis diameter measurements) affecting the thoracic oesophagus. PET-CT fusion images show pathological 18F-FDG uptake (mean SUV: 6.45, min: 5.1, max: 7.7) in axial (C) and sagittal (D) reconstructions."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-08//16984_2_3.jpg?itok=qOCi1dFn",
            "caption": "Contrast-enhanced Pneumo PET-CT in axial (A) and sagittal (B) CT reconstructions show a large and irregular tumour (short-axis and long-axis diameter measurements) affecting the thoracic oesophagus. PET-CT fusion images show pathological 18F-FDG uptake (mean SUV: 6.45, min: 5.1, max: 7.7) in axial (C) and sagittal (D) reconstructions."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-08//16984_2_4.jpg?itok=-CaWIkqB",
            "caption": "Contrast-enhanced Pneumo PET-CT in axial (A) and sagittal (B) CT reconstructions show a large and irregular tumour (short-axis and long-axis diameter measurements) affecting the thoracic oesophagus. PET-CT fusion images show pathological 18F-FDG uptake (mean SUV: 6.45, min: 5.1, max: 7.7) in axial (C) and sagittal (D) reconstructions."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-08//16984_3_1.jpg?itok=D5cSqljW",
            "caption": "Contrast-enhanced Pneumo PET-CT in coronal reconstruction as fusion and PET images (A-D), as well coronal and sagittal MIP PET images (E) show additional hypermetabolic findings: mediastinal lymph nodes (arrows in A, B and E), oesophageal tumour (asterisks in B, C and E), right acromial focus (open arrows in B and E) and D11 and L5 vertebral foci (dashed arrows in D and E). Other, non-related, findings include left acromioclavicular degenerative disease (small curved arrow in C and E)."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-08//16984_3_2.jpg?itok=WzFRVYHL",
            "caption": "Contrast-enhanced Pneumo PET-CT in coronal reconstruction as fusion and PET images (A-D), as well coronal and sagittal MIP PET images (E) show additional hypermetabolic findings: mediastinal lymph nodes (arrows in A, B and E), oesophageal tumour (asterisks in B, C and E), right acromial focus (open arrows in B and E) and D11 and L5 vertebral foci (dashed arrows in D and E). Other, non-related, findings include left acromioclavicular degenerative disease (small curved arrow in C and E)."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-08//16984_3_3.jpg?itok=uMtmlhUs",
            "caption": "Contrast-enhanced Pneumo PET-CT in coronal reconstruction as fusion and PET images (A-D), as well coronal and sagittal MIP PET images (E) show additional hypermetabolic findings: mediastinal lymph nodes (arrows in A, B and E), oesophageal tumour (asterisks in B, C and E), right acromial focus (open arrows in B and E) and D11 and L5 vertebral foci (dashed arrows in D and E). Other, non-related, findings include left acromioclavicular degenerative disease (small curved arrow in C and E)."
          },
          {
            "number": "Figure 3d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-08//16984_3_4.jpg?itok=axF0b5-G",
            "caption": "Contrast-enhanced Pneumo PET-CT in coronal reconstruction as fusion and PET images (A-D), as well coronal and sagittal MIP PET images (E) show additional hypermetabolic findings: mediastinal lymph nodes (arrows in A, B and E), oesophageal tumour (asterisks in B, C and E), right acromial focus (open arrows in B and E) and D11 and L5 vertebral foci (dashed arrows in D and E). Other, non-related, findings include left acromioclavicular degenerative disease (small curved arrow in C and E)."
          },
          {
            "number": "Figure 3e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-08//16984_3_5.jpg?itok=ZIlzL6Ym",
            "caption": "Contrast-enhanced Pneumo PET-CT in coronal reconstruction as fusion and PET images (A-D), as well coronal and sagittal MIP PET images (E) show additional hypermetabolic findings: mediastinal lymph nodes (arrows in A, B and E), oesophageal tumour (asterisks in B, C and E), right acromial focus (open arrows in B and E) and D11 and L5 vertebral foci (dashed arrows in D and E). Other, non-related, findings include left acromioclavicular degenerative disease (small curved arrow in C and E)."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Nuclear medicine",
      "Oncology"
    ],
    "imaging_technique": [
      "CT-Enterography"
    ],
    "link": "https://www.eurorad.org/case/16984",
    "time": "26.08.2020"
  },
  "16985": {
    "case_id": 16985,
    "title": "Non-traumatic Tension Gastrothorax, Rare But Life Threatening",
    "section": "Chest imaging",
    "age": "85",
    "gender": "female",
    "diagnosis": "Diaphragmatic hernia with organoaxial gastric volvulus and Tension Gastrothorax",
    "history": "85-year-old female brought with complaints of shortness of breath and for last 6 days. Laboratory results showed leucocytosis with deranged renal function test. Patient has solitary right kidney since birth. Chest X-Ray was done but inconclusive. Then, non-contrast CT chest and upper abdomen was done for further evaluation.",
    "image_finding": "Chest X-Ray PA view (Figure 1a) shows a huge round gas collection in the lower part of \u00a0right hemithorax. Right diaphragm is not clearly delineated. There is opacification of the rest of the right hemithorax with combination of pleural effusion, consolidation and atelectasis. Follow up X-Ray (Figure 1b) after one day showed increased size of the gas collection. Non-contrast CT chest and abdomen \u00a0shows markedly widened oesophageal hiatus with herniation of stomach and transverse colon in to right hemithorax (Figure 2a). Stomach is distended, rotated along its long axis with greater curvature displaced superiorly and lesser curvature inferior and medially with abrupt narrowing at antro-pyloric region. Gastro-esophageal junction is proximally displaced to the level of carina with kinking and \u00a0fluid filled distended esophagus (Figure 2b). The distended stomach is causing compressive atelectasis of right middle and lower lobe, contralateral mediastinal shift, compression of right atrium and inferior vena cava(Figure 3). Collapse consolidation of right upper lobe with massive right sided pleural effusion is seen (Figure 4). \u00a0Patient passed away shortly after.",
    "discussion": "Tension Gastrothorax is a rare condition but life threatening. Incidence of spontaneous gastrothorax is not clearly reported. Term tension gastrothorax first appeared in literature in 1984 as a complication of rupture of diaphragm [1]. It is always associated with diaphragmatic hernia. Diaphragmatic hernia can be congenital or acquired. The weak points through which the abdominal organs can enter the thorax are the natural hiatuses that allow important structures to pass between thorax and abdomen or at the points of failure of embryonic fusion of diaphragm through the foramen of Morgagni or foramen of Bochdalek. Spontaneously acquired hernia \u00a0in elderly people most often invovles esophageal hiatus can\u00a0occur through these hiatuses. The precipitating factors can be Valsalva maneuver, exercise related to weight lifting or even childbirth [2,3]. \u00a0Most common organs migrating through the hernia are the stomach and colon [4,5].\nIn our case, there is spontaneous herniation of the stomach into the right thoracic cavity through the oesophageal hiatus. It is associated with organo-axial volvulus of the stomach. Most of the literature has described this event commonly on the left side. The reason behind it is probably the buffering effect of the liver on the right hemidiaphragm. When the whole stomach suddenly rises up to the thorax, tension gastrothorax may develop especially when the stomach is grossly distended by the air, fluid or food particles through the one wayone-way valve mechanism caused by the angulation of the gastro-oesophageal junction combined with gastric outlet obstruction. This may lead to sudden lung collapse followed by \u00a0hypoxiaby hypoxia and pulmonary hypertension. Severe hemodynamic compromise precipitates even further with mediastinal shift and compression of cardiac chambers [5,6]. Chest radiography is useful in the initial surveillance. It helps to differentiate with the tension pneumothorax which could be difficult to differentiate clinically because of the severe respiratory distress and reduced breath sounds. In tension pneumothorax, diaphragm is depressed flattened and clearly defined but in tension gastrothorax it is hard to delineate. Barium swallow is useful for diagnosis in stable patients. CT chest is the most reliable modality for the diagnosis. It can clearly delineate the diaphragmatic outline, extent of the defect, contents of the hernia as well as relationship with the adjacent organs [7]. \nTension gastrothorax is a very rare but potentially fatal condition. Immediate diagnosis is warranted and should be followed by emergency decompression of the distended stomach through nasogastric tube if possible and later with surgical reduction of the herniated content into the abdomen and diaphragmatic repair.",
    "differential_diagnosis": "Diaphragmatic, hernia, with, organoaxial, gastric, volvulus, and, Tension, Gastrothorax, Traumatic, Diaphragmatic, Injury, Bochdalek\u2019s, or, Morgagni, Diaphragmatic, hernia",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-08//16985_1_1.jpg?itok=tQNMHTMa",
            "caption": "Chest X-Ray PA view shows  huge round gas collection in the lower part of  right hemithorax. Right diaphragm is not clearly delineated. Large part of right hemithorax are opacified by a combination of pleural effusion, consolidation and atelectasis."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-08//16985_1_2.jpg?itok=Wpm8_Rmv",
            "caption": "Follow up AP radiograph after 1 day showed mild increase in the size of the gas collection. ECG leads and wires seen."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-08//16985_2_1.jpeg?itok=hS5nhgDe",
            "caption": "Coronal non-contrast CT chest shows air distended stomach (S) within the right hemithorax. Abnormal rotation of the stomach (S) around its axis with greater curvature (GC) superior and lesser curvature (LC) inferior. Pylorus (P) Right pleural effusion (PE). Heart (H) displaced to left."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-08//16985_2_2.jpeg?itok=kkOokx_M",
            "caption": "Coronal non-contrast CT posterior to 2a,  shows Gastro-oesophageal junction (black star) is proximally displaced with kinking of fluid filled distended esophagus (E).  Borders of stomach marked by open arrows."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-08//16985_3_1.JPG?itok=HaX62L1y",
            "caption": "Axial non-contrast CT shows distended stomach with air fluid level and transverse colon (TC) in right hemithorax causing compression of cardiac chambers (H) and mediastinal shift to the left side."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-08//16985_4_1.png?itok=7ghGsu-q",
            "caption": "Sagittal non-contrast CT chest shows distended stomach and transverse colon (TC) in thorax. Collapsed right lung (RL) and pleural effusion (PE) Note the collapsed pylorus (orange star)."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Stomach (incl. Oesophagus)",
      "Thorax"
    ],
    "imaging_technique": [
      "CT",
      "Digital radiography"
    ],
    "link": "https://www.eurorad.org/case/16985",
    "time": "27.08.2020"
  },
  "16994": {
    "case_id": 16994,
    "title": "Significance of chest computed tomography (CT) in\u00a0COVID-19 pneumonia in obstetrics: a case report.",
    "section": "Chest imaging",
    "age": "34",
    "gender": "female",
    "diagnosis": "Coronavirus Disease-19 (COVID-19)",
    "history": "A pregnant 34-year-old woman was taken to our hospital in the clinical condition of mechanical ventilation (dependence on oxygen was 60%). On admission: SpO2 was 83% with a single decline episode to 68%, laboratory tests showed high\u00a0CRP 46,58 mg/L, ERS 91 mm/h, IL-6 36,58 pgr/mL, initial RT-PCR test for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was negative, pregnancy 28-29 weeks.",
    "image_finding": "CT examinations were performed using a multi-detector CT scanner with 64 channels. The detailed parameters were: 120 kVp tube voltage, 78 mAs tube current (at the first examination), lung reconstruction algorithm, 1 mm slice thickness, 1 mm reconstruction interval. CT was performed using a low-dose protocol and personal radiation protection equipment to optimize the protection and safety of the fetus in accordance with Radiation Safety Standards [28,19]. \nOn chest CT at the first examination we can see multiple bilateral ground-glass opacities (GGO) in the front fields predominantly (Fig.1a), consolidative opacities and air bronchogram in the lower lobes mostly (Fig.1b). \nAbout 50% of lung parenchyma was affected bilaterally. \nFollow CT - surveys in 19 and 23 days showed appearance of clear interlobular septal thickening and visible intralobular lines (\u201ccrazy-paving\u201d pattern) (Fig.2).\nIn the upper right lobe, a central ground-glass opacity surrounded by a denser consolidation of annular shape was also noticed which was interpreted as an emerging atoll sign (Fig.3a, Fig.3b).\nFibrous stripes and subpleural lines were also found in the lower lobes (Fig.4a, Fig.4b).",
    "discussion": "Background\nAt the end of December in 2019 a new virus started in Wuhan, China, named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and had a wide spreading all over the world. This infectious disease is known internationally as COVID-19. In Russia we faced these challenges in March 2019, when a lot of new cases were registered and high level of the infection was achieved in April \u2013 May 2020.\nClinical Perspective \nMost patients affected by COVID-19 have\u00a0 fever, dry cough, myalgia or fatigue,\nothers may not have any clinical symptoms. Patients with severe ARDS require mechanical ventilation\u00a0 for improvement respiratory function. In pregnant women\u00a0 with severe ARDS \u00a0it is very important to evaluate condition of mother\u2019s vital functions\u00a0 and condition of fetus, considering gestational age\u00a0 and solve the issue of urgent delivery.\u00a0 \nAs in our case, on admission it was decided to refuse urgent delivery, perform complex intensive care, including antibacterial, antiviral therapy, control of the laboratory indicators and condition of mother and fetus. However considering extremely serious condition and negative dynamics on the 5th day of hospitalization, urgent childbirth was performed with the use of Cesarean section\u00a0 at 29-30 gestational\u00a0 weeks due to mother\u2019s acute severe medical conditions: hypotension 90 and 50 mm Hg., tachycardia up to 120 bpm, sharp increase IL 6 -19820 pg/ml (normal value <5,9 pgr/ml), and leucocyte blood formulae shift to new forms. \nThe caesarean section was performed without complications.\nApgar Score for Newborn Health Assessment was 5-7. The child's condition was assessed as satisfactory according to the gestational age. The child had a negative RT-PCR test for SARS-CoV-2 after birth.\nImaging Perspective\nCT- examination is necessary in definition of COVID-19 pneumonia, there are some significant specific signs that help diagnose, such as ground-glass opacity on the initial examinations preferably, consolidation, crazy paving and fibrous stripes, that become the dominant CT \u2013keys on the following surveys (in 2 weeks approximately).\nOutcome\nChest CT plays an important role in the diagnosis of new type of viral pneumonia, especially supporting early diagnosis in case when RT-PCR may not yet be positive. CT \u2013 specific signs for COVID-19 pneumonia help not only in early definition of diagnosis, as well correct interpretation of these imagings influence on therapeutic options, prognosis and therapy planning, as it helps to evaluate the severity extent of lung\u2019s involvement and understand how to monitor specialized patients, for example as in our case, to continue observation of pregnant woman or perform emergency delivery.\nAs the result, the woman and the child checked out of\u00a0 the hospital in a satisfactory condition.",
    "differential_diagnosis": "Coronavirus, Disease-19, (COVID-19), Bacterial, pneumonia, Viral, pneumonia",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-10//16994_1_1.jpg?itok=9ezWmZyq",
            "caption": "On chest CT at the first examination we can see multiple bilateral ground-glass opacities"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-10//16994_1_2.jpg?itok=6vKLqtPx",
            "caption": "On chest CT at the first examination we can see consolidative opacities and air -bronchogram in the lower lobes mostly"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-10//16994_2_1.jpg?itok=SmfbYDrc",
            "caption": "Follow CT - surveys in 19 and 23 days showed proceeding bilateral ground-glass opacities, decrease size of consolidative opacities, appearance of clear interlobular septal thickening and visible intralobular lines (\u201ccrazy-paving\u201d pattern)"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-10//16994_3_1.jpg?itok=ECMsm0Vo",
            "caption": "In the upper right lobe, a central ground-glass opacity surrounded by a denser consolidation of annular shape was also noticed which was interpreted as an emerging atoll sign"
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-10//16994_3_2.jpg?itok=gzr0uFuQ",
            "caption": "A central ground-glass opacity surrounded by a denser consolidation of annular shape was also noticed which was interpreted as an emerging atoll sign, sagittal plane"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-10//16994_4_1.jpg?itok=6BbmMJ_o",
            "caption": "Fibrous stripes and subpleural lines were also found in the lower lobes, coronal plane"
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-10//16994_4_2.jpg?itok=SqPNCyUZ",
            "caption": "Fibrous stripes and subpleural lines were also found in the lower lobes, coronal plane"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/16994",
    "time": "07.10.2020"
  },
  "17005": {
    "case_id": 17005,
    "title": "PNEUMOMEDIASTINUM AND PNEUMORRHACHIS in COVID-19: unusual findings seen with extensive lung disease.",
    "section": "Chest imaging",
    "age": "40",
    "gender": "male",
    "diagnosis": "Pulmonary barotrauma by non-invasive ventilation in a patient with COVID-19 pneumonia",
    "history": "A 40-year-old male patient presented with a history of fever, dry cough, and breathlessness for 5 days. He tested positive for RT-PCR COVID-19 and showed bilateral predominantly basal air space opacities on his chest x-ray (Fig 1) - consistent with COVID pneumonitis.",
    "image_finding": "On developing severe dyspnoea on day 15 a non-contrast HRCT chest was done which displayed extensive (>75% lung involvement) bilateral ground-glass opacifications (GGO) with superimposed septal thickening (together termed as \u201ccrazy paving pattern\"), bilateral basal consolidation (Fig 2a), Pneumomediastinum (PM) (Fig 2b,c), subcutaneous emphysema in the cervical and axillary regionsand Epidural Pneumorrhachis(PR) (Fig 2d-f) at multiple thoracic levels.\nRepeat CT on day 18 showed a complete resolution of PM (Fig 3a), subcutaneous emphysema, and PR (Fig 3b), with persistent COVID parenchymal changes and additional traction bronchiectasis.",
    "discussion": "With the Novel Coronavirus disease still evolving, we are learning its implications and complications with time. Although the diagnosis of the disease is suspected from flu-like symptoms, and the confirmed diagnosis is made by RT-PCR. The radiological findings aid in understanding the extent of the disease, various complications associated with it, and also in the follow-up.\nTypical CT findings of the disease include bilateral, multiple areas of GGOwith subpleural and basal predominance [1].\n\u00a0Pneumomediastinum and Pneumorrhachis are unusual findings and their possible explanation can be given through \"The Macklin effect\", which describes that the air in the mediastinum in such cases comes after breaking in from the alveoli, into the interstitium, and then by travelling along the pulmonary vascular sheaths, towards the hilum. [2] It appears on thoracic computed tomography (CT) as linear collections of air adjacent to the broncho-vascular sheaths [3] (Fig 4a-c)\nThis air on reaching the mediastinum can now travel along the fascial planes to reach the subcutaneous tissues of the neck, can rupture the mediastinal pleura leading to pneumothorax[4] and can rarely also enter the spinal canal (known as Pneumorrhachis) via the neural foramina. Pneumorrhachis in itself is a rare finding. And it's occurrence in a COVID-19 patient is by far atypical. And this is the first case that we have encountered. \nPneumorrhachis usually present asymptomatically but can also be symptomatic. It can produce neurological symptoms, in the form of motor and sensory deficits.\nThe patient was put on Non-Invasive Ventilation (NIV) due to worsening dyspnoea and the pressure was adjusted to values, associated uncommonly with any barotrauma. But despite the permissible pressure values used, there was a development of the above discussed complications, likely due to\u00a0extensive lung parenchymal involvement (>75%), which increases the alveolar susceptibility to injury.\nAbove explanation indicates a possible relationship between the percentage of lung involved and the propensity to develop barotrauma despite the use of permissible ventilator pressures. This information can aid the physicians in planning their treatment accordingly for patients of \u2018COVID pneumonia with extensive lung involvement\u2019 and in preventing any future complications by choosing the type of ventilation and their pressures judiciously.",
    "differential_diagnosis": "Pulmonary, barotrauma, by, non-invasive, ventilation, in, a, patient, with, COVID-19, pneumonia, Barotrauma, Spontaneous, Pneumomediastinum, Esophageal/tracheobronchial, injury",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-10//17005_1_1.PNG?itok=ePOUF0Mv",
            "caption": "X-ray chest (frontal view) on day 1. Depicting inhomogeneous air space opacities in bilateral lung fields with a basal predominance"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-10//17005_2_1.PNG?itok=FsCWKJd_",
            "caption": "NCCT thorax (axial section) on day 15 depicting features of COVID Pneumonitis including GGOs with superimposed septal thickening and basal consolidation (black arrows)"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-10//17005_2_2.PNG?itok=edm0Y_5_",
            "caption": "NCCT thorax (axial section) on day 15 depicting Pneumomediastinum, with air outlining the brachiocephalic artery (red arrows) (Blue star-trachea)"
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-10//17005_2_3.PNG?itok=drcKK1V0",
            "caption": "NCCT thorax (axial section) on day 15 depicting Pneumomediastinum- Red arrow"
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-10//17005_2_4.PNG?itok=xCRR86vv",
            "caption": "NCCT thorax (axial section, mediastinal window) on day 15 depicting Epidural Pneumorrhachis (yellow arrows), Orange star-spinal cord"
          },
          {
            "number": "Figure 2e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-10//17005_2_5.PNG?itok=f--BWMgK",
            "caption": "NCCT thorax (axial section, lung window, zoomed image) on day 15 depicting Pneumorrhachis (yellow arrow)"
          },
          {
            "number": "Figure 2f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-10//17005_2_6.PNG?itok=QrjXA0LA",
            "caption": "NCCT thorax (sagittal section, lung window) on day 15. depicting Epidural Pneumorrhachis (yellow arrows)"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-10//17005_3_1.PNG?itok=yeQ7g2wt",
            "caption": "NCCT thorax (axial section) on day 18 depicting resolution of Pneumomediastinum"
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-10//17005_3_2.PNG?itok=ZQwAjpf3",
            "caption": "NCCT thorax (axial section) on day 18 depicting resolution of Pneumorrhachis"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-10//17005_4_1.PNG?itok=n-34Ytle",
            "caption": "NCCT thorax depicting MACKLIN EFFECT on day 15 (a) axial section - air outlining a branch of a pulmonary vessel (red arrows)"
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-10//17005_4_2.PNG?itok=k4eZI76L",
            "caption": "Sagittal section- air outlining a branch of a pulmonary vessel (red arrow)"
          },
          {
            "number": "Figure 4c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-10//17005_4_3.PNG?itok=h1bui1dz",
            "caption": "Zoomed image: blue star- pulmonary vessel branch, Red arrows- air surrounding it"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Mediastinum",
      "Thorax"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/17005",
    "time": "27.10.2020"
  },
  "17007": {
    "case_id": 17007,
    "title": "Ventilation / perfusion mismatch in patient with chronic dyspnea after COVID-19 recovery.",
    "section": "Chest imaging",
    "age": "56",
    "gender": "female",
    "diagnosis": "Lung ventilation/perfusion mismatch in passed COVID infection.",
    "history": "A 56-year-old female presented with persisting dyspnea. Four months before she was hospitalized with PCR confirmed SARS-CoV2 pulmonary infection, requiring tracheal intubation in ICU because of ARDS. In the moment of the consultation she was SARS-CoV2 RT-PCR -, and blood test showed IgM \u2013, IgG+ antibodies. Oxygen saturation was 92%.",
    "image_finding": "Dual-energy chest CT after intravenous contrast administration was performed in order to depict complications such as pulmonary fibrosis, pulmonary thromboembolic disease or perfusion disturbances. \nCT revealed persistence of diffuse multifocal, bilateral and peripheral ground-glass opacities predominantly in upper lobes and right middle lobe, and areas of crazy paving. Dilated subsegmental vessels were seen proximal and within the opacities. Subpleural bands and architectural distortion areas were present in both lower lobes (Fig 1 a-c) Filling defects were not present in pulmonary arteries or branches, showing no signs of pulmonary embolism. No pleural fluid or enlarged lymph nodes were present. \u00a0\nPulmonary blood volume showed wedge-shaped areas of decreased perfusion predominantly in posterior segments of both lower lobes, not demonstrating correlation with the areas of ground glass opacities or crazy paving. There weren\u2019t areas of complete absence of perfusion suggesting pulmonary infarction (Fig 2a, 2b, 3a and 3b).",
    "discussion": "Background\nSARS-CoV-2 has high affinity for angiotensin-converting-enzyme 2 (ACE 2)Virus complex enters via endocytosis, ACE2 surface is downregulated,leadin+g to increased circulating angiotensin II (AT-II) and AT-II receptor activation [1, 2]. Angiotensin \u00a0stimulates vasodilatation and nitric oxide production. AT-II promotes vasoconstriction and fibrosis [3].Pyroptosis secondary to virus infection of alveoli cells, promotes an intense pro-inflammatory cascade [1], damaging alveolar-capillary barrier [1,2],leading to a generalized vascular disturbance.\nClinical perspective \n\u00a0\nImaging Perspective \nSome studies show different abnormal lung perfusion patterns in COVID infection. Four of them were described by Lang M [6 - 8]: areas of heterogeneity on the pulmonary blood volume images with alternating higher and lower perfusion (mosaic perfusion); areas of relative increase in perfusion compared to background lung (focal hyperemia pattern); areas of relative decrease in perfusion compared to background lung (focal oligemia pattern); rim of increased perfusion around an area of lung perfusion compared to background lung, corresponding to parenchymal opacity (\u201chyperemic halo\u201d sing) Those imaging manifestations are explained by an increased blockage of ACE2 receptors\u00a0 in the lung endothelium, increased local levels of angiotensin II, and subsequent vasoconstriction and ventilation / perfusion mismatch [1].\nComplete pulmonary emboli usually manifests as wedge-shaped perfusion defects at the subpleural portion of the corresponding lung parenchyma. Incomplete occlusion may not show perfusion defects. [9]\nMotion artifacts can be seen as bandlike or crescent-shaped defects in color-coded perfusion maps [9]. In our case, perfusion defects were more extensive than explained by those artifacts. \n\u00a0\nOutcome \nAfter discharge, patients with severe acute respiratory syndrome (SARS) can suffer symptoms as exertional dyspnea for long time due to residual pathological changes or muscle weakness [10, 11]. In patients with COVID-19, pathological changes are not dominant, suggesting a different underlying cause.\nClinical trials suggest that pulmonary rehabilitation combined with patient exercises is effective for improving dyspnea after COVID-19 infection [11]. Recently, guidelines have been created to advise people with \u201clong covid\u201d in daily routine (www.longcovid.org) [12]. Multidisciplinary approach and follow-up are essential to individualized care plans and to evidence long-term outcomes.\n\u00a0\nTake-Home Message / Teaching Points\nDual-energy CT imaging shows vascular lung disturbances in patients with passed COVID infection and persisting symptoms.\nFurther studies are needed to understand the prognostic implication of such radiological features.",
    "differential_diagnosis": "Lung, ventilation/perfusion, mismatch, in, passed, COVID, infection., Pulmonary, embolism, Adenovirus, pulmonary, infection, High, altitude, pulmonary, edema, (HAPE), Vasculitis, Pulmonary, hypertension",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-10//17007_1_1.PNG?itok=P2ehArJC",
            "caption": "(a,b). Dual chest CT after intravenous contrast show diffuse multifocal, bilateral and peripheral ground-glass opacities predominantly in upper lobes and right middle lobe."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-10//17007_1_2.PNG?itok=VyRknpSS",
            "caption": "(a,b). Dual chest CT after intravenous contrast show diffuse multifocal, bilateral and peripheral ground-glass opacities predominantly in upper lobes and right middle lobe."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-10//17007_2_1.PNG?itok=b9lSYq3m",
            "caption": "(a-c). Pulmonary blood volume showed wedge-shaped areas of decreased perfusion predominantly in posterior segments of both lower lobes, not demonstrating correlation with the areas of ground glass opacities or crazy paving. There weren\u2019t areas of complete absence of perfusion suggesting pulmonary infarction."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-10//17007_2_2.PNG?itok=T0UbfE43",
            "caption": "(a-c). Pulmonary blood volume showed wedge-shaped areas of decreased perfusion predominantly in posterior segments of both lower lobes, not demonstrating correlation with the areas of ground glass opacities or crazy paving. There weren\u2019t areas of complete absence of perfusion suggesting pulmonary infarction."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-10//17007_2_3.PNG?itok=u1JrjobK",
            "caption": "(a-c). Pulmonary blood volume showed wedge-shaped areas of decreased perfusion predominantly in posterior segments of both lower lobes, not demonstrating correlation with the areas of ground glass opacities or crazy paving. There weren\u2019t areas of complete absence of perfusion suggesting pulmonary infarction."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-10//17007_3_1.PNG?itok=hl_RB1Co",
            "caption": "(a,b). Volume rendering lung reconstruccion show wedge-shaped areas of decreased perfusion predominantly in posterior segments of both lower lobes."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-10//17007_3_2.PNG?itok=WO6LMc8C",
            "caption": "(a,b). Volume rendering lung reconstruccion show wedge-shaped areas of decreased perfusion predominantly in posterior segments of both lower lobes."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT",
      "CT-Angiography",
      "CT-High Resolution"
    ],
    "link": "https://www.eurorad.org/case/17007",
    "time": "27.10.2020"
  },
  "17011": {
    "case_id": 17011,
    "title": "Diffuse mediastinal hypervascular lymphadenopathies: a very uncommon presentation of epithelioid hemangioendothelioma.",
    "section": "Chest imaging",
    "age": "65",
    "gender": "male",
    "diagnosis": "Mediastinal Epitelioid Hemangioendothelioma",
    "history": "A 65-year-old man was admitted to the emergency department with complaints of progressive dyspnea in the last weeks. Personal history of pericardial effusion followed up since 2010. The patient underwent several imaging tests (chest X-ray, contrast-enhanced CT, and FDG PET/TC) as well as histological analysis.",
    "image_finding": "Initial chest X-Ray (fig. 1)\u00a0showed a superior mediastinal enlargement, focal increase in density projected in the subcarinal area, moderate cardiomegaly, small right pleural effusion, and few areas of hypoventilation.\nContrast-enhanced CT\u00a0demonstrated small pericardial effusion and uncountable nodular ring-enhancing lesions throughout the mediastinum, consistent with hypervascular adenopathies (fig. 2 and fig. 3). Some of them were confluent and formed an infiltrating conglomerate in the subcarinal region. \nCervical mediastinoscopy\u00a0was performed and samples of some lymphadenopathies were obtained (fig. 4) to be histologically analyzed.\nFollow-up chest X-Ray (fig. 5)\u00a0was performed due to an episode of clinical deterioration. It revealed an increase in the right pleural effusion. \nPET/TC revealed\u00a0avid FGD uptake within the lymphadenopathies (fig. 6). Moderate nonmalignant right pleural and pericardial effusion. The disease was circumscribed to the mediastinum as no evidence of FDG pathological uptake was demonstrated throughout the rest of the patient\u00b4s body.",
    "discussion": "Epithelioid hemangioendothelioma (EH) is the term used to name those vascular neoplasms that show a borderline biological behavior, intermediate between entirely benign hemangiomas and highly malignant angiosarcomas [1-4]. \nMost EH are low-grade vascular neoplasms, with a tendency to recur locally and a low metastatic potential, mostly to regional lymph nodes. EH, especially large lesions and those located in deep soft tissues, seems to have a more aggressive biological behavior. [1]\nHistologically, the tumour is composed of large epithelioid and spindle endotelial cells with round or elongated nuclei, prominent nucleoli, and abundant eosinophilic cytoplasm in a myxohyaline stroma. Intracytoplasmatic lumina appear as vacuoles that may contain intact or fragmented erythrocytes. [4] \nEH was initially described in soft tissues, bones and skin [1, 6, 7]. Posteriorly it was discovered in other solid organs such as lungs, liver, or the heart [6-8]. Few cases have been published of EH affecting the pleura and mediastinum [11, 12, 13]. Within the mediastinum, we have not found such atipycal presentation as hypervascular multiple lymphadenopathies as shown in our case.\u00a0 There was no evidence of a primary tumor in complementary Body-CT. However, in this location pleura and pericardium should be carefully reviewed. EH is one of the differential diagnoses which should be considered when facing a hypervascular mass, in any location. In the mediastinum, other pathological entities such as Castleman disease, Kaposi sarcoma, and hypervascular lymph node metastases should be kept in mind. The latter most often originate from vascular primary tumors such as primary renal cell carcinoma, melanoma, neuroendocrine tumors and thyroid carcinoma [5].\nRadiological appearances may vary depending on the tissue where it originates [1-13]. As a highly vascularized tumor, it commonly shows prominent enhancement on contrast-enhanced CT or MR.\u00a0 Nuclear Medicine is helpful as HE shows avid FDG uptake on PET-TC, which is crucial not only to accurate staging and for biopsy guidance but also to assess therapy response or post-treatment recurrence [2, 14, 15]. \nThere is no standard therapeutic strategy for the treatment and follow-up of EH because of its rarity and variable clinical course. A combination of chemotherapy and surgical resection when possible is the main choice. The prognostic factors of EH remain unclear, although some authors have reported that the presence of symptoms, older age, and elevated serum carbohydrate antigen 19-9 negatively affect outcome [2, 10].",
    "differential_diagnosis": "Mediastinal, Epitelioid, Hemangioendothelioma, Papillary, thyroid, carcinoma, Renal, cell, carcinoma, Angioimmunoblastic, T, cell, lymphoma, Castleman, and, Kimura, diseases, Kaposi, sarcoma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-10//17011_1_1.png?itok=LPnkVGdy",
            "caption": "original (A) and illustrated (B) posteroanterior chest X-ray (A) shows a superior mediastinal enlargement due to the displacement of both right and left paratracheal mediastinal lines (white arrows). There is also moderate cardiomegaly, blunting of the right costophrenic angle (black arrow) owing to small pleural effusion, and few areas of atelectasis from hypoventilation (black stars) in both pulmonary bases."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-10//17011_1_2.png?itok=e4tQeAlx",
            "caption": "original (A) and illustrated (B) posteroanterior chest X-ray (A) shows a superior mediastinal enlargement due to the displacement of both right and left paratracheal mediastinal lines (white arrows). There is also moderate cardiomegaly, blunting of the right costophrenic angle (black arrow) owing to small pleural effusion, and few areas of atelectasis from hypoventilation (black stars) in both pulmonary bases."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-10//17011_2_1.png?itok=naYCxIJD",
            "caption": "Post-contrast axial arterial-phase CT images demonstrated uncountable nodular high attenuated lesions with low-density center (arrows in A) throughout the mediastinum, consistent with hypervascular adenopathies. The greatest was in the prevascular region (arrow in B). Some of them (as shown in C in the subcarinal region) were confluent and formed an infiltrating conglomerate. Small pericardial effusion (white arrows in D)."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-10//17011_2_2.jpg?itok=ckGs9GZk",
            "caption": "Post-contrast axial arterial-phase CT images demonstrated uncountable nodular high attenuated lesions with low-density center (arrows in A) throughout the mediastinum, consistent with hypervascular adenopathies. The greatest was in the prevascular region (arrow in B). Some of them (as shown in C in the subcarinal region) were confluent and formed an infiltrating conglomerate. Small pericardial effusion (white arrows in D)."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-10//17011_2_3.png?itok=o46PV3YR",
            "caption": "Post-contrast axial arterial-phase CT images demonstrated uncountable nodular high attenuated lesions with low-density center (arrows in A) throughout the mediastinum, consistent with hypervascular adenopathies. The greatest was in the prevascular region (arrow in B). Some of them (as shown in C in the subcarinal region) were confluent and formed an infiltrating conglomerate. Small pericardial effusion (white arrows in D)."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-10//17011_2_4.jpg?itok=bGkFzg2D",
            "caption": "Post-contrast axial arterial-phase CT images demonstrated uncountable nodular high attenuated lesions with low-density center (arrows in A) throughout the mediastinum, consistent with hypervascular adenopathies. The greatest was in the prevascular region (arrow in B). Some of them (as shown in C in the subcarinal region) were confluent and formed an infiltrating conglomerate. Small pericardial effusion (white arrows in D)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-10//17011_3_1.jpg?itok=yFwJ647h",
            "caption": "Post-contrast sagittal (A) and coronal (B) arterial phase CT images show from another point of view the predominant lesion in the prevascular space (arrow in A) and the paratracheal and subcarinal lesions (arrow in B)."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-10//17011_3_2.jpg?itok=71MjS9gJ",
            "caption": "Post-contrast sagittal (A) and coronal (B) arterial phase CT images show from another point of view the predominant lesion in the prevascular space (arrow in A) and the paratracheal and subcarinal lesions (arrow in B)."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-10//17011_4_1.png?itok=Otmkq2mY",
            "caption": "Lymph node parenchyma is seen with sinus anthracosis, interstitial fibrosis and partially infiltrated by a proliferation of small capillary structures, organized in broad lobes (A; HE X1,6). Lobulated collections of round to oval cells, with round, vesicular nucleus forming small intracelular lumens, surrounded by a moderately fibrous stroma. The vascular structures are lined by a prominent endothelium with mild atypia and slight proliferative activity (B; HE X20). The flattened cells of the vascular spaces showed both membranous and cytoplasmic stainig for anti-CD31 monoclonal antibody (C; CD31 Immunostaining, original magnification X40). The cell proliferation index (Ki) is 15% (D; Ki Inmmunostainig, original magnification X40). Theses features were consistent with hemangioendotelioma."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-10//17011_4_2.jpg?itok=cFO-2sYI",
            "caption": "Lymph node parenchyma is seen with sinus anthracosis, interstitial fibrosis and partially infiltrated by a proliferation of small capillary structures, organized in broad lobes (A; HE X1,6). Lobulated collections of round to oval cells, with round, vesicular nucleus forming small intracelular lumens, surrounded by a moderately fibrous stroma. The vascular structures are lined by a prominent endothelium with mild atypia and slight proliferative activity (B; HE X20). The flattened cells of the vascular spaces showed both membranous and cytoplasmic stainig for anti-CD31 monoclonal antibody (C; CD31 Immunostaining, original magnification X40). The cell proliferation index (Ki) is 15% (D; Ki Inmmunostainig, original magnification X40). Theses features were consistent with hemangioendotelioma."
          },
          {
            "number": "Figure 4c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-10//17011_4_3.jpg?itok=x3wC1RWg",
            "caption": "Lymph node parenchyma is seen with sinus anthracosis, interstitial fibrosis and partially infiltrated by a proliferation of small capillary structures, organized in broad lobes (A; HE X1,6). Lobulated collections of round to oval cells, with round, vesicular nucleus forming small intracelular lumens, surrounded by a moderately fibrous stroma. The vascular structures are lined by a prominent endothelium with mild atypia and slight proliferative activity (B; HE X20). The flattened cells of the vascular spaces showed both membranous and cytoplasmic stainig for anti-CD31 monoclonal antibody (C; CD31 Immunostaining, original magnification X40). The cell proliferation index (Ki) is 15% (D; Ki Inmmunostainig, original magnification X40). Theses features were consistent with hemangioendotelioma."
          },
          {
            "number": "Figure 4d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-10//17011_4_4.jpg?itok=iOxcAv75",
            "caption": "Lymph node parenchyma is seen with sinus anthracosis, interstitial fibrosis and partially infiltrated by a proliferation of small capillary structures, organized in broad lobes (A; HE X1,6). Lobulated collections of round to oval cells, with round, vesicular nucleus forming small intracelular lumens, surrounded by a moderately fibrous stroma. The vascular structures are lined by a prominent endothelium with mild atypia and slight proliferative activity (B; HE X20). The flattened cells of the vascular spaces showed both membranous and cytoplasmic stainig for anti-CD31 monoclonal antibody (C; CD31 Immunostaining, original magnification X40). The cell proliferation index (Ki) is 15% (D; Ki Inmmunostainig, original magnification X40). Theses features were consistent with hemangioendotelioma."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-10//17011_5_1.jpg?itok=L0sbJWhZ",
            "caption": "months after the diagnosis a new posteroanterior chest X-ray was performed after an episode of clinical deterioration. The frontal film reveals a meniscus sign as owing to increased pleural effusion."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-10//17011_6_1.jpg?itok=P13QU8Ei",
            "caption": "Axial FDG PET-TC images showing avid FGD uptake within the adenopathies (arrows in A) which also had experienced a small increase in size. Moderate right pleural effusion (white arrow in D). No evidence of FDG pathological uptake throughout the rest of the patient\u00b4s body. It provided valuable staging information and biopsy guidance."
          },
          {
            "number": "Figure 6b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-10//17011_6_2.jpg?itok=USIuD_nW",
            "caption": "Axial FDG PET-TC images showing avid FGD uptake within the adenopathies (arrows in A) which also had experienced a small increase in size. Moderate right pleural effusion (white arrow in D). No evidence of FDG pathological uptake throughout the rest of the patient\u00b4s body. It provided valuable staging information and biopsy guidance."
          },
          {
            "number": "Figure 6c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-10//17011_6_3.jpg?itok=rC97Ua2N",
            "caption": "Axial FDG PET-TC images showing avid FGD uptake within the adenopathies (arrows in A) which also had experienced a small increase in size. Moderate right pleural effusion (white arrow in D). No evidence of FDG pathological uptake throughout the rest of the patient\u00b4s body. It provided valuable staging information and biopsy guidance."
          },
          {
            "number": "Figure 6d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-10//17011_6_4.jpg?itok=95i1vCmq",
            "caption": "Axial FDG PET-TC images showing avid FGD uptake within the adenopathies (arrows in A) which also had experienced a small increase in size. Moderate right pleural effusion (white arrow in D). No evidence of FDG pathological uptake throughout the rest of the patient\u00b4s body. It provided valuable staging information and biopsy guidance."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Haematologic",
      "Mediastinum",
      "Thorax"
    ],
    "imaging_technique": [
      "CT-High Resolution",
      "PET-CT"
    ],
    "link": "https://www.eurorad.org/case/17011",
    "time": "28.10.2020"
  },
  "17019": {
    "case_id": 17019,
    "title": "Progression of COVID-19 pneumonia in chest CT scan",
    "section": "Chest imaging",
    "age": "62",
    "gender": "male",
    "diagnosis": "COVID-19 infection confirmed by PCR, pulmonary involvement by chest CT.",
    "history": "A 62-year-old male patient who arrived at the emergency department presenting fever of 3 days (38.5\u00baC) and dry cough, no other symptoms associated. Co-morbidities: hypertension treated with valsartan. Negative PCR for influenza A and B.",
    "image_finding": "Non-contrast chest CT was obtained with the patient in supine position at the end of inspiration. The CT study was performed in a multidetector GE CT scanner, 128 slices, using international high-resolution protocols.\nFigures 1 and 2 show the dynamic changes on chest CT in a patient with COVID-19 infection confirmed by PCR, at three and five days after the onset of symptoms. Figures 1A and 2A show subtle peripheral ground-glass opacities in the lower lobes. Figures 2A and 2B (at the same level as Figures 1A and 1B) show the progression of the lesions that have increased in size and density. Some of them have a rounded shape and interlobular septal thickening; note new ground-glass opacities in Figure 1B.",
    "discussion": "Background: COVID-19 was described in December 2019 in Wuhan, China, as a cause of pneumonia [1], is caused by SARS-COV-2 virus. Since then, this virus has spread around the world causing several cases of low respiratory tract infection with variable severity affecting most commonly patients between 30-79 years old [2]. \nClinical Perspective: The main symptoms include fever, myalgia, dry cough, dyspnoea and loss of senses of taste and smell; uncommon symptoms may include headache, sputum production, diarrhoea and haemoptysis [2]. Pneumonia is present in most of cases of infection for SARS-COV-2 ant that is why imaging play an important role in the assessment and prognosis of the disease. Studies indicate that chest CT has a sensitivity of 97% in patients with positive RT-PCR and 75% with negative RT-PCR. This suggests that chest CT is a sensitivity modality to detect COVID-19 infection2.\nImaging Perspective: the main findings in the COVID-19 pneumonia are ground-glass opacities (GGO) with round morphology with peripheral and posterior distribution, commonly bilateral and affecting two or more lobes, and GGO with consolidation or with interlobular septal thickening. Other findings include reticulation pattern, pleural effusion, pericardial effusion and lymphadenopathy3. Chest CT has a high sensitivity for the diagnosis of COVID-19 pneumonia, but always the diagnosis needs to be confirmed by PCR [2,3].\nOutcome: imaging has an important role in the diagnosis, treatment and prognosis of the infection course, it allows the physicians to evaluate the most adequate therapy and the response to it and, finally, it is important to exclude other causes of pulmonary disease that manifest at CT scans with other patterns such as \u201ctree in bud\u201d, which is not commonly seen in COVID-19 infections, and exclude complications. Its role in therapeutic procedures is not well defined because of the lack of complications (in most of the cases seen at this time) such as pleural o pericardial effusions. \nTake-Home Message / Teaching Points: The principal imaging findings in COVID-19 pneumonia include focal or multifocal ground-glass opacities, crazy paving pattern or consolidations with peripheral distribution. The presence of pleural effusion, \u201ctree in bud\u201d appearance or adenopathy is less consistent with COVID-19 infection",
    "differential_diagnosis": "COVID-19, infection, confirmed, by, PCR,, pulmonary, involvement, by, chest, CT., Influenza, pneumonia, COVID-19, pneumonia, Organising, pneumonia, Drug, toxicity, Connective, tissue, disease",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-10//17019_1_1.png?itok=1BFw6lzk",
            "caption": "High resolution CT scan of the thorax. A. Red circle demarks a small area of \u201cground glass\u201d opacity in the apical segment of the right lower lobe wich has incrised his size and density in B (2 days after). Note new \u201cground glass\u201d opacities in lingula and the left lower lobe."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-10//17019_1_2.png?itok=fPvFN-6H",
            "caption": "High resolution CT scan of the thorax. A. Red circle demarks a small area of \u201cground glass\u201d opacity in the apical segment of the right lower lobe wich has incrised his size and density in B (2 days after). Note new \u201cground glass\u201d opacities in lingula and the left lower lobe."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-10//17019_2_1.png?itok=s9nprT0X",
            "caption": "High resolution CT scan of the thorax inthe same patient of the figure 1. It shows the progression in size and density of the \u201cground glass\u201d opacities in A and a new opacity in the left pulmanry base, aditional there is interlobular septal thickening."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-10//17019_2_2.png?itok=S9OrGBYl",
            "caption": "High resolution CT scan of the thorax inthe same patient of the figure 1. It shows the progression in size and density of the \u201cground glass\u201d opacities in A and a new opacity in the left pulmanry base, aditional there is interlobular septal thickening."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/17019",
    "time": "28.10.2020"
  },
  "17037": {
    "case_id": 17037,
    "title": "Tracheal diverticul",
    "section": "Chest imaging",
    "age": "56",
    "gender": "female",
    "diagnosis": "Tracheal diverticulum",
    "history": "Female, 56 years old, longtime smoker (10 cigarettes a day for 43 years), complaining of daily chronic cough and dyspnea for about 1 year, worsening in the last 4 months. She also reported frequent episodes of rhinitis. She denies other comorbidities or medications for continuous use.",
    "image_finding": "The chest computer tomography (CT), performed with intravenous contrast, demonstrated signs of chronic obstructive pulmonary disease and centrilobular emphysema, predominant in pulmonary apexes. The cardiovascular system was normal. Another finding was a cystic, lobulated image, with a gaseous content, adjacent to the right posterolateral aspect of the upper third of the trachea (Figures 1 to 3). This image showed little communication with the trachea in its inferior aspect (Fig. 4), and the diagnosis of incidental tracheal diverticulum was considered.\nA follow-up with the pulmonologist was required for the patient for a conservative treatment.",
    "discussion": "Tracheal diverticula (TD) were first described by Rokitansky in 1838 and are small, single or multiple tracheal evaginations, full of air and communicating with the trachea, which are usually found in incidental CT scans of the neck, cervical spine or chest [1-8]. Its estimated prevalence was around 1% in the series of autopsies performed by MacKinnon [9], but with the advent of multidetector computed tomography, some studies have shown a higher incidence, ranging from 2.4 - 8.1 * [3, 4, 6,10,11]. However, until today there are few cases of TD reported. It can be confused with a laryngocele, that is located more superiorly, laterally to the false vocal cord, and it has higher incidence [2]. Other differential diagnoses include pharyngoceles, Zenker's diverticula, apical pulmonary hernias, pneumomediastinum or bullae [1,2,5,10,12].\nTDs are classified as congenital or acquired, the former being less common and generally of smaller dimensions [2,7,8). In a histological evaluation, the congenital TDs are composed of respiratory epithelium, smooth muscle and cartilage, and those acquired are formed from respiratory epithelium only [1,2,4,5,7,8,12]. The aetiology is still uncertain, but it is believed that acquired cases, such as the one described here, may be produced by hernias of the mucosa through a weak spot, as a result of increased intraluminal pressure [1-7,11, 12]. They occur more commonly in the right posterolateral aspect because the cartilaginous rings are deficient and there is no oesophagus for support [1-3, 6-8,10,12]. Most cases are asymptomatic, however in rare occurrences they can be linked to recurring infections [4,5,11,12], chronic cough [1-4,9,12] recurrent laryngeal nerve palsy and hoarseness [2-5,7 , 11,12], difficulty in intubation [2-5,13], hemoptysis, dyspnoea and dysphagia [2,4,5,11,12].\nThe exam of choice to detect TD is CT, which provides the location, origin and size of the lesion, with excellent precision, thus helping to distinguish between congenital and acquired [2,4,11,12]. Techniques such as three-dimensional reconstruction also contribute to the morphological diagnosis of this condition. Bronchoscopy is useful to confirm the diagnosis, although there are cases where a connection was not visible, for example, in diverticula with a very narrow opening or those connected to the trachea by only one fibrous tract [2,5].\nMost cases of TD do not need treatment, except when they are symptomatic or large. Several approaches in these cases have been described, including surgical resection and endoscopic cauterization [2,4,12].\n* Statistics included all paratracheal air cysts: tracheal diverticula, tracheoceles, lymphoepithelial and bronchogenic cysts.",
    "differential_diagnosis": "Tracheal, diverticulum, Tracheocele, Zenker's, diverticula, Paratracheal, air, cyst, Pharyngocele, Laryngocele",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-11//17037_1_1.png?itok=dSwu_jqf",
            "caption": "Topogram and minMIP (CT) in the coronal plane showing a saccular structure with gaseous content (tracheal diverticulum - arrows)."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-11//17037_1_2.png?itok=p10RmHKC",
            "caption": "Topogram and minMIP (CT) in the coronal plane showing a saccular structure with gaseous content (tracheal diverticulum - arrows)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-11//17037_2_1.png?itok=9mFY0FWJ",
            "caption": "CT in lung window, showing diverticulum in the right posterolateral aspect of the trachea (arrow)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-11//17037_3_1.png?itok=lPYYAkRm",
            "caption": "3D reconstruction of the chest CT with anterior (a), lateral (b) and enlarged (c) views. Note the tenuous communication between the diverticulum and the trachea in its inferior aspect (arrow)."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-11//17037_3_2.png?itok=J-f4P5-V",
            "caption": "3D reconstruction of the chest CT with anterior (a), lateral (b) and enlarged (c) views. Note the tenuous communication between the diverticulum and the trachea in its inferior aspect (arrow)."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-11//17037_3_3.png?itok=xdrQ8_GB",
            "caption": "3D reconstruction of the chest CT with anterior (a), lateral (b) and enlarged (c) views. Note the tenuous communication between the diverticulum and the trachea in its inferior aspect (arrow)."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-11//17037_4_1.png?itok=7AJJ-_AS",
            "caption": "CT in mediastinal window, showing the communication between the diverticulum and the trachea (arrow)."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Respiratory system",
      "Thorax"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/17037",
    "time": "02.11.2020"
  },
  "17053": {
    "case_id": 17053,
    "title": "xtraskeletal Ewing\u2019s sarcoma \u2013 A rare mediastinal lesion",
    "section": "Chest imaging",
    "age": "27",
    "gender": "male",
    "diagnosis": "Mediastinal extra skeletal Ewing\u2019s sarcoma",
    "history": "A 27-year-old male patient presented with complaints of exertional dyspnea and dry cough for a duration of 2 weeks. History of loss of weight was present.",
    "image_finding": "Scout film showed a right anterior mediastinal mass lesion with mild mediastinal displacement to left (Fig 1). Plain and contrast CT sections of thorax obtained at settings of 120kV and 160 mA showed a large heterogeneously enhancing lesion arising from anterior mediastinum towards right, with cystic areas and areas of blood density within (Fig 2, 3). Pleural contact and displacement of mediastinal structures to left was noted (Fig 4 ). Mild compression of superior vena cava by tumour was noted (Fig 5). Mild right pleural effusion was noted.",
    "discussion": "Extraskeletal Ewing\u2019s sarcoma comes under primitive neuroectodermal family of tumours and is characterised by presence of translocation (11:22) [1]. It is a rare disease which usually occurs in the extremities, paravertebral, intercostal regions, head and neck and pelvis. Mediastinal extraskeletal Ewing\u2019s sarcoma is extremely rare, affecting children and young adults with male predilection [2].\nThe classic histological finding is solid sheets of small round blue cells with hyperchromatic nuclei and scant eosinophilic cytoplasm (3). It is a highly malignant tumour showing variable degrees of neuroectodermal differentiation. Highly variable clinical features are mainly due to its aggressive nature with a high incidence of local recurrence and distant metastases.\nCommon imaging differential diagnosis for an anterior mediastinal soft tissue density lesion includes germ cell tumour, lymphoma and thymic neoplasm [4]. Visualisation of fat density areas, fat fluid levels, and large calcific foci within favours germ cell tumour [4].\u00a0 Presence of convex round thymus gland with irregular margins and heterogeneity due to cystic change, necrosis or haemorrhage may point towards thymic neoplasm [4]. A homogeneous lobulated soft-tissue mass with mild to moderate contrast enhancement favours the diagnosis of lymphoma [4].\n\u00a0Since our patient had an anterior mediastinal lesion with areas of cystic change and haemorrhage within, he was given an imaging diagnosis of anterior mediastinal lesion with possibilities being germ cell tumour and malignant thymic neoplasm. Surgical resection by thoracotomy was attempted, however, he expired on third post-operative day. Histopathology reports showed malignant round cell neoplasm suggestive of extraskeletal Ewing\u2019s sarcoma with CD 99 tumour marker being positive.\nOn imaging, extraskeletal Ewings sarcoma manifests as large heterogeneously enhancing mass lesion with necrosis, cystic areas and hemorrhagic areas within [3]. Tumour displaces adjacent structures and calcifications are rare[5]. Associated destruction of ribs and/ or sternum may be seen [6]. MRI findings are nonspecific, generally low to isointense to muscle on T1 weighted image and hyperintense on T2 weighted image with heterogenous post-contrast enhancement [7]. PET imaging shows intensely increased uptake.\nDue to its rarity, management protocols are not well established with surgery traditionally being used to resect the tumour. Radiotherapy and chemotherapy are other modalities in use. 5-year survival rates are 60 to 70% with aggressive management [8].\nMediastinal Ewing\u2019s sarcoma is an extremely rare cause of anterior mediastinal mass lesion requiring adequate awareness among practising radiologists as very few cases have been reported in literature.",
    "differential_diagnosis": "Mediastinal, extra, skeletal, Ewing\u2019s, sarcoma, Germ, cell, tumour, Thymic, neoplasm, Lymphoproliferative, disorder",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-11//17053_1_1.jpg?itok=9ymFfbSO",
            "caption": "Scout film shows right anterior mediastinal mass lesion with mild mediastinal displacement to left."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-11//17053_2_1.jpg?itok=WJzhevAj",
            "caption": "Plain axial CT image shows right anterior mediastinal soft tissue density lesion with heterodense areas."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-11//17053_3_1.jpg?itok=_GYv_u_B",
            "caption": "Contrast-enhanced CT axial image shows heterogenous enhancement of soft tissue density lesion in right anterior mediastinum"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-11//17053_4_1.jpg?itok=kZT8ow09",
            "caption": "Contrast-enhanced CT axial image shows heterogenously enhancing soft tissue density lesion in right anterior mediastinum with displacement of mediastinal structures."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-11//17053_5_1.jpg?itok=F2tmEqsK",
            "caption": "Contrast-enhanced CT axial image shows heterogenously enhancing soft tissue density lesion in right anterior mediastinum with mild compression of superior vena cava."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Mediastinum"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/17053",
    "time": "16.11.2020"
  },
  "17055": {
    "case_id": 17055,
    "title": "Late diagnosis of cystic fibrosis: A case-based radiological approach",
    "section": "Chest imaging",
    "age": "20",
    "gender": "male",
    "diagnosis": "Atypical cystic fibrosis with superinfected cystic bronchiectasis",
    "history": "A 20-year-old male with a history of recurrent lower tract infections arrived at the hospital with cough and low-grade fever (38.6 C), at physical examination fine rales at the right lung base were evident, for which a chest X-ray and a high-resolution computed tomography (HRCT) were performed.",
    "image_finding": "A Posteroanterior (PA) chest X-ray was performed showing diffuse bronchiectasis, predominantly at lower lobes, with ground-glass opacities at the right lung base, and pulmonary hyperinflation (Fig 1).\nTo characterized better the lesions, a chest HRCT was performed, showing bilateral centrally distributed cystic bronchiectasis associated with mucous plugging, moreover, ground-glass opacities and tree-in-bud pattern at the lateral segment of the right lower lobe are seen, suggesting an inflammatory disease of the distal airway (Fig 2).\nBased on the patient's clinical history and the radiological findings, the initial diagnosis was residual post-infectious bronchiectasis versus cystic fibrosis (CF). The final diagnosis was confirmed with a sweat chloride test supporting CF.",
    "discussion": "CF is an autosomal recessive inherited disease caused by dysfunction of the chloride channels of exocrine glands, specifically the CF transmembrane conductance regulator (CFTR) protein [1\u20133]. The mutation leads to a decrease in chloride secretion and an increased sodium absorption which reduces the amount of water from secretions, making them more viscous [1].\nCF is a multisystemic condition with a worldwide incidence of 1:2500 live births [3], the classic disease is mainly diagnosed in the first 3 years of life, however, late diagnosis may occur in some atypical variants, which manifests as a milder disease usually affecting 1 organ system [3,4,5].\nWhen CF is diagnosed in adults, the clinical presentation differs from paediatrics, mainly presenting as chronic superinfected bronchiectasis, usually caused by pathogens such as\u00a0Pseudomonas aeruginosa [6,7], which is responsible for more than 90% of fatal events [3,5]. \nThe advances in image modalities have highly contributed to increasing the clinical suspicion of CF in adults, mainly through the visualization of lung hyperinflation, lobar collapse, pulmonary hypertension, and bronchiectasis with diffuse distribution, which are initially cylindrical with progression to varicose and cystic bronchiectasis (Fig 3) [8]. The acute complications of CF are mainly lobar pneumonia and pneumothorax. Several studies have described the Brasfield and Wisconsin scoring systems, which are useful to assess CF severity on chest X-ray with a good interobserver agreement, nevertheless, it is time-consuming [9].\nIt is important to interpret the detection of mucous plugging in chest HRCT as a trigger for pulmonary infections, being highly effective to predict exacerbations [8].\nThe gold standard for CF diagnosis is the sweat chloride test, being suggestive when the result is between 40-60 mEq/L and positive if > 60 mEq/L, nevertheless, patients with atypical cystic fibrosis may or may not have elevated sweat chloride test, for which a genetic analysis must be performed [2,5].\nThe mainstay of treatment is respiratory therapy plus dornase alfa, recently the usage of CFTR modulators such as ivacaftor and lumacaftor have demonstrated benefits [10]. Angiography is reserved for bronchial artery embolization in patients with severe hemoptysis [11]. The prognosis of CF has improved in recent years, presenting an average life expectancy of 50 years [9], however, it seems to be better when the disease is diagnosed in adulthood [3]. \nTeaching point: The diagnosis of CF should not only be considered in children but also in adults, especially if the clinical history reveals recurrent pneumonia and diffuse bronchiectasis in HRCT.\nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Atypical, cystic, fibrosis, with, superinfected, cystic, bronchiectasis, Postinfectious, bronchiectasis, Allergic, bronchopulmonary, aspergillosis, Primary, ciliary, dyskinesia.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-11//17055_1_1.jpg?itok=yDDnaH1h",
            "caption": "PA chest X-ray showing diffuse bronchiectasis, predominantly at lower lobes, with ground-glass opacities at the right lung base, and pulmonary hyperinflation"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-11//17055_2_1.jpg?itok=NKeFVVAs",
            "caption": "Chest HRCT in lung window, shows bilateral centrally distributed cystic bronchiectasis associated with mucous plugging, moreover, ground-glass opacities and tree-in-bud pattern at the lateral segment of the right lower lobe are seen, suggesting an inflammatory disease of the distal airway"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-11//17055_3_1.png?itok=iz2QLN_H",
            "caption": "The image illustrates the types of bronchiectasis. Cylindrical bronchiectasis (blue arrow), varicose bronchiectasis (red arrow), and cystic bronchiectasis (purple arrow)."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT-High Resolution"
    ],
    "link": "https://www.eurorad.org/case/17055",
    "time": "19.11.2020"
  },
  "17056": {
    "case_id": 17056,
    "title": "Diffuse large B-cell lymphoma in the posterior mediastinum.",
    "section": "Chest imaging",
    "age": "84",
    "gender": "female",
    "diagnosis": "Diffuse large B-cell lymphoma",
    "history": "An 84-year-old woman was admitted to the emergency department with complaints of medical treatment-refractory upper back pain with irradiation to right hypochondrium and epigastrium. No respiratory symptoms. The blood test revealed a slight increase in cholestasis enzymes, acute phase reactants, and lymphopenia.",
    "image_finding": "Initial chest X-Ray (fig. 1) showed increased density and widening of the lower posterior mediastinum due to lateral displacement of both right and left paraspinal lines. \nContrast-enhanced CT (fig. 2) demonstrated a homogeneous infiltrative soft-tissue mass along the right and left paravertebral areas, with smooth and regular margins towards the lung parenchyma, elevating and encasing the descending thoracic aorta in 360 \u00b0. Patent intercostal arteries traversed the mass and at the dorsal levels D3-D6, it extends into the spinal canal through the widened conjunction foramina. There was no evidence of pleural effusion or adenopathies within the mediastinum.\u00a0 \nTransthoracic biopsy of the mass (fig. 3) was performed under CT guidance, and samples of tissue were obtained and sent to the Department of Anatomic Pathology to be histologically analyzed (fig. 4). \nFollow-up 18 F-FDG PET/CT (fig. 5) was performed after medical treatment, showing complete disappearance of the mass and absence of radiopharmaceutical uptake.",
    "discussion": "Chest lymphoma involvement can occur in various anatomical locations such as mediastinal nodes, \u00a0the lung, oesophagus, chest wall or breast [1,2]. Within the mediastinum, it commonly emerges as multiple lymphadenopathies. Lymphoma is also well known as one of the most common causes of a mass in the anterior mediastinum, either with extranodal origin in the thymus or nodal affecting lymphatic ganglia [1-3].\nRarely is the posterior mediastinum the site of lymphoma. In any location imaging tests are an essential tool to suggest the diagnosis and guide the interventional procedures for its histological analysis [3,6,7]. Conventional radiology was a key point in our patient, demonstrating displacement of both right and left paraspinal lines, which helped to suggest its subsequently posterior mediastinal location.\nIn CT, these tumours manifest as a homogeneous and infiltrative mass. However, areas of necrosis appear within the mass if remarkable size is reached, giving it a heterogeneous appearance. Moreover, CT is useful to assess local extension and distant nodal involvement, relevant for its correct staging [4,5].\nSeveral findings supported the suspicion of lymphoma: firstly, the encasement of the thoracic descending aorta without transmural invasion, known as the \u201cfloating aorta sign\u201c [1]; secondly, the presence of patent intercostal arteries traversing the mass at their origin, known as \u201cvessel penetrating sign\u201c; thirdly, its extension into the spinal canal through the widened conjunction foramina; finally,\u00a0 the absence of destruction of vertebrae cortices. Other findings that may be present are pleural effusion or nodular thickening in the adjacent pleura and vertebral pathological fractures [1,4].\u00a0 \nMR is a useful imaging technique when secondary spinal cord or nerve compression is suspected and in some cases of bone marrow or muscle involvement.\u00a0 On the other hand, PET-CT imaging is more sensitive in diagnosing nodal involvement and it is helpful in monitoring and assessing response to chemotherapy [1,3].\nFinal diagnosis was achieved after transthoracic biopsy. Results confirmed diffuse large B-cell lymphoma, which is characterized by the presence of lymphoid cells with nuclear size equal or exceeding normal macrophage nuclei or more than twice the size of a normal lymphocyte with a diffuse growth pattern, effacing the architecture and infiltrating the adipose tissue. Signet ring cells and occasional mitosis are seen. A combination of chemotherapy and the monoclonal antibody rituximab, with or without radiation therapy, can lead to disease remission in a large number of patients with this form of lymphoma. . However, the prognosis is fatal if left untreated [8].\nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Diffuse, large, B-cell, lymphoma, Neurogenic, tumours., Extramedullary, haematopoiesis., Paravertebral, abscess, or, haematoma.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-11//17056_1_1.jpg?itok=oMXNsy_9",
            "caption": "original (A) and illustrated (B) postero-anterior chest X-ray (A) show increased density and widening of the lower mediastinum, due to lateral displacement of both right and left paraspinal lines (black and grey arrowheads), from the aortic arch level to the diaphragm."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-11//17056_1_2.jpg?itok=oRZNXwow",
            "caption": "original (A) and illustrated (B) postero-anterior chest X-ray (A) show increased density and widening of the lower mediastinum, due to lateral displacement of both right and left paraspinal lines (black and grey arrowheads), from the aortic arch level to the diaphragm."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-11//17056_2_1.jpg?itok=mDgDwDQ6",
            "caption": "Post-contrast axial arterial-phase CT images demonstrates a homogeneous infiltrative soft-tissue mass along the right and left paravertebral areas (white arrows in A), with smooth and regular margins towards the lung parenchyma (A, B, C), elevating and encasing the descending thoracic aorta in 360 \u00b0 (B). Patent intercostal arteries traverse the mass (C) and at the dorsal level D3-D6, it extends into the spinal canal through the widened conjunction foramina (* in B). A slight fat plane was conserved between the mass and the descending aorta (black arrowheads in D)."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-11//17056_2_2.jpg?itok=lKzRxSv8",
            "caption": "Post-contrast axial arterial-phase CT images demonstrates a homogeneous infiltrative soft-tissue mass along the right and left paravertebral areas (white arrows in A), with smooth and regular margins towards the lung parenchyma (A, B, C), elevating and encasing the descending thoracic aorta in 360 \u00b0 (B). Patent intercostal arteries traverse the mass (C) and at the dorsal level D3-D6, it extends into the spinal canal through the widened conjunction foramina (* in B). A slight fat plane was conserved between the mass and the descending aorta (black arrowheads in D)."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-11//17056_2_3.png?itok=PRAi3pWK",
            "caption": "Post-contrast axial arterial-phase CT images demonstrates a homogeneous infiltrative soft-tissue mass along the right and left paravertebral areas (white arrows in A), with smooth and regular margins towards the lung parenchyma (A, B, C), elevating and encasing the descending thoracic aorta in 360 \u00b0 (B). Patent intercostal arteries traverse the mass (C) and at the dorsal level D3-D6, it extends into the spinal canal through the widened conjunction foramina (* in B). A slight fat plane was conserved between the mass and the descending aorta (black arrowheads in D)."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-11//17056_2_4.jpg?itok=HD1ZAozi",
            "caption": "Post-contrast axial arterial-phase CT images demonstrates a homogeneous infiltrative soft-tissue mass along the right and left paravertebral areas (white arrows in A), with smooth and regular margins towards the lung parenchyma (A, B, C), elevating and encasing the descending thoracic aorta in 360 \u00b0 (B). Patent intercostal arteries traverse the mass (C) and at the dorsal level D3-D6, it extends into the spinal canal through the widened conjunction foramina (* in B). A slight fat plane was conserved between the mass and the descending aorta (black arrowheads in D)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-11//17056_3_1.jpg?itok=dv-brRlK",
            "caption": "Transthoracic biopsy of the right paraspinal part of the mass was performed under CT guidance and samples of tissue were obtained and sent to the Department of Anatomic Pathology to be histologically analysed."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-11//17056_4_1.jpg?itok=ee3rNFfn",
            "caption": "histologically, the neoplasm is composed of malignant lymphocytes with a moderately abundant cytoplasm, and irregular ovoid nuclei with prominent nucleoli and occasional mitoses (circle). Also signet ring cells are present (arrow) (A; HE X20). At higher magnification, the nuclear pleomorphism and cellular atypia are appreciated (B; HE X40). The membrane and cytoplasm is strongly stained in all the neoplastic B lymphocytes (C; CD20 Inmmunostaining, original magnification X40). The cell proliferation index (Ki) is 90% (D; Ki Inmmunostaining, original magnification X40)."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-11//17056_4_2.jpg?itok=xjLljvas",
            "caption": "histologically, the neoplasm is composed of malignant lymphocytes with a moderately abundant cytoplasm, and irregular ovoid nuclei with prominent nucleoli and occasional mitoses (circle). Also signet ring cells are present (arrow) (A; HE X20). At higher magnification, the nuclear pleomorphism and cellular atypia are appreciated (B; HE X40). The membrane and cytoplasm is strongly stained in all the neoplastic B lymphocytes (C; CD20 Inmmunostaining, original magnification X40). The cell proliferation index (Ki) is 90% (D; Ki Inmmunostaining, original magnification X40)."
          },
          {
            "number": "Figure 4c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-11//17056_4_3.jpg?itok=E1ysn6IB",
            "caption": "histologically, the neoplasm is composed of malignant lymphocytes with a moderately abundant cytoplasm, and irregular ovoid nuclei with prominent nucleoli and occasional mitoses (circle). Also signet ring cells are present (arrow) (A; HE X20). At higher magnification, the nuclear pleomorphism and cellular atypia are appreciated (B; HE X40). The membrane and cytoplasm is strongly stained in all the neoplastic B lymphocytes (C; CD20 Inmmunostaining, original magnification X40). The cell proliferation index (Ki) is 90% (D; Ki Inmmunostaining, original magnification X40)."
          },
          {
            "number": "Figure 4d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-11//17056_4_4.jpg?itok=JN7o7txy",
            "caption": "histologically, the neoplasm is composed of malignant lymphocytes with a moderately abundant cytoplasm, and irregular ovoid nuclei with prominent nucleoli and occasional mitoses (circle). Also signet ring cells are present (arrow) (A; HE X20). At higher magnification, the nuclear pleomorphism and cellular atypia are appreciated (B; HE X40). The membrane and cytoplasm is strongly stained in all the neoplastic B lymphocytes (C; CD20 Inmmunostaining, original magnification X40). The cell proliferation index (Ki) is 90% (D; Ki Inmmunostaining, original magnification X40)."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-11//17056_5_1.jpg?itok=Hhou4CnJ",
            "caption": "Follow-up 18 F-FDG PET/CT was performed months after medical treatment, showing complete disappearance of the mass and absence of radiopharmaceutical uptake, signs of morphological and functional treatment response."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Haematologic",
      "Mediastinum",
      "Nuclear medicine"
    ],
    "imaging_technique": [
      "CT",
      "Digital radiography",
      "PET-CT"
    ],
    "link": "https://www.eurorad.org/case/17056",
    "time": "19.11.2020"
  },
  "17057": {
    "case_id": 17057,
    "title": "Acute esophageal necrosis (AEN) secondary to chemotherapy (\u201cmoth-eaten black esophagus\u201d)",
    "section": "Chest imaging",
    "age": "60",
    "gender": "female",
    "diagnosis": "Acute esophageal necrosis (necrotizing esophagitis) secondary to chemotherapy.",
    "history": "A 60-year-old female with prior history of stage I non-Hodgkin lymphoma and myelodysplastic syndrome secondary to acute myeloid leukaemia presented on day 15 after allogeneic stem cell transplantation with febrile neutropenia, vomiting, acute epigastric pain, dysphagia, tachycardia, hypotension and marked clinical deterioration. She also referred to an episode of self-limited haematemesis.",
    "image_finding": "CT scan performed 2 days before the onset of symptoms showed normal oesophagus (Fig. 1 a, b). Due to renal failure and to the abrupt clinical deterioration of the patient, a non-contrast CT scan was performed, which revealed a dilated and thickened distal oesophagus (4.5 mm thick, extending along 10 cm), with preservation the gastroesophageal junction. Small air-bubbles were identified within the oesophagal wall (Fig. 2 a, b). It was called the \u201cmoth-eaten black oesophagus\u201d sign. There was no evidence of mediastinitis. Bilateral pleural effusion and bilateral perihilar opacities with thickened interlobular septa in keeping with pulmonary oedema were also noted (Fig. 3 a, b). \nWith the presumptive radiological diagnosis of acute oesophagal necrosis (AEN), an emergency gastroscopy was performed, which showed esophagitis and circumferential black friable mucosa in distal oesophagus. Multiple linear tears were also identified (Fig 4 a, b).",
    "discussion": "Acute oesophagal necrosis (or \u201cblack oesophagus\u201d) (AEN) is an extremely rare entity, with a prevalence of 0.001 to 0.2% in different published endoscopic series [1]. On endoscopy, this disorder is characterized by diffuse and circumferential involvement of a black-appearing distal oesophagus, with preservation of the gastroesophageal junction (GEJ) [2]. Male and elderly patients with multiple medical comorbidities are at increased risk of developing AEN. \nAlthough the pathophysiology of the disease is still unclear, it appears to arise from the combination of oesophagal ischemia, impaired mucosal barrier systems, and the reflux injury caused by the chemical content of gastric secretions. Other associations, such as infections (cytomegalovirus, candida, herpes virus, klebsiella), drugs (broad-spectrum antibiotics, chemotherapy), drug abuse, mechanical obstructions or metabolic disorders have also been reported [3, 4].\nSigns of upper gastrointestinal bleeding (hematemesis, emesis in coffee grounds and melena), represent almost 90% of cases in the initial clinical presentation. Other symptoms such as dysphagia, vomiting, epigastric or pleuritic pain are more nonspecific. Sepsis is a typical associated clinical condition.\nDiagnosis is based on gastroscopy [5]. Radiological studies, such as chest X-ray and chest CT have classically been considered complementary tools to evaluate possible complications, including oesophagal perforation, pneumomediastinum, and development of mediastinitis [6]. Oesophagal necrosis is characterized by dilation and wall thickening of the distal oesophagus, with preservation of the GEJ. On CT studies, small air-bubbles can be seen within a thickened wall (Fig. 1b, d) [7, 8], taking on the appearance of a \u201cblack moth-eaten oesophagus\u201d. \nOther signs like blurring of the oesophagal wall and the perioesophageal fat (on unenhanced images) and postcontrast oesophagal-wall enhancement with definition of transmural necrosis are very specific of AEN, when identified together (two of three are present) CT has shown to be superior to endoscopy for treatment stratification of these patients [9].\nEmergency gastroscopy is the gold standard for diagnosis. It will show the classic black appearance of the necrotic distal oesophagal mucosa (\u201cblack oesophagus\u201d, Fig. 3a), with multiple linear tears (Fig. 3b) or longitudinal ulcers. Confirmation and aetiologic cause can be ascertained by oesophagal biopsy [10].\nThe development of AEN carries a generally poor prognosis. Oesophagal perforation is the most serious complication. Treatment depends on clinical experience. In most cases, initial management consists of volume expansion for patient stabilization and treatment of underlying diseases. Other options include gastric acid suppression with high-doses of intravenous proton pump inhibitors [11].\nRadiologists must be aware of the diseases that affect the oesophagus and consider rare entities, such as AEN, in the appropriate clinical context. Dilation and thickening of the walls of the distal oesophagus with small air bubbles (\"moth-eaten black oesophagus\" sign) can be seen on unenhanced chest CT scans in patients with AEN [12].",
    "differential_diagnosis": "Acute, esophageal, necrosis, (necrotizing, esophagitis), secondary, to, chemotherapy., Caustic, ingestion., Melanosis., Pseudomelanosis., Coal, dust, deposition., Alimentary, bolus., Pseudomembranous, esophagitis., Acanthosis, nigricans., Melanoma.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-11//17057_1_1.PNG?itok=XZ2DlMrC",
            "caption": "Unenhanced computed tomography (CT) 2 days before the onset symptoms. A, B. Revealed no significant findings, except for mild bilateral pleural effusion."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-11//17057_2_1.PNG?itok=tnAhlapF",
            "caption": "Acute esophageal necrosis with \u201cmoth-eaten black esophagus\u201d sign. A, B. Unenhanced chest CT performed after clinical deterioration. Dilated distal esophagus (white arrows) with preservation of the gastroesophageal junction (Fig B, white star) presenting small air-bubbles with within a thickened esophageal wall were observed (white arrow head). There was no evidence of perforation or mediastinitis."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-11//17057_3_1.PNG?itok=emAks7pO",
            "caption": "Pulmonary edema. A, B. Unenhanced CT scan showed diffuse bilateral ground glass opacities, interlobular thickening, and mild bilateral pleural effusion."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-11//17057_4_1.PNG?itok=o_dnJzz4",
            "caption": "Emergency gastroscopy. A. Classic \u201cblack esophagus\u201d appearance. B. Black colour represents necrosed esophageal mucosa with multiple linear tears."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Emergency",
      "Mediastinum",
      "Thorax"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/17057",
    "time": "19.11.2020"
  },
  "17078": {
    "case_id": 17078,
    "title": "Progressively enlarging cavitary lesion in an AIDS patient with Pneumocystis jirovecii pneumoni",
    "section": "Chest imaging",
    "age": "35",
    "gender": "female",
    "diagnosis": "Chronic pulmonary aspergillosis (SAIA)",
    "history": "A 35-year-old female with Acquired Immunodeficiency Syndrome (AIDS) and prior pneumocystis jirovecii pneumonia (PCP) presented to the ER for a 1-week history of cough and dyspnea. The patient had a history of multiple hospitalizations in our institution due to PCP. A new PCP was suspected based on clinical symptoms and later confirmed by PCR (polymerase chain reaction) of a sputum sample. Multiple chest-HRCT (high-resolution computed tomography) scans were obtained during hospitalization.",
    "image_finding": "Both old and contemporary chest-HRCT scans in our image database revealed typical features of PCP infection, such as multifocal ground-glass opacities, smooth septal thickening, crazy paving areas, cysts/pneumatoceles and pneumothorax. There was no evidence of pleural effusion or lymphadenopathies.\nDuring the current hospitalisation, our patient showed initial overall clinical improvement after initiating treatment for PCP. Follow-up chest-HRCTs were nevertheless obtained due to fluctuating clinical parameters. One of them (day-47) revealed thick-walled cavitation with a central soft-tissue attenuating rounded mass in the parenchyma in the apical segment of the right upper lobe. Foci of adjacent parenchymal consolidation were noted. Previous scan (day-13) showed no categorical cysts or other structural changes on that topography.\nSubsequent HRCT revealed an increase in cavity size and adjacent parenchymal consolidation over 1 month. Investigation for mycobacteria was negative.",
    "discussion": "Pneumocystis jirovecii is a fungus considered an opportunistic pathogen, being the cause of PCP in immunocompromised hosts. Multiple radiological findings in PCP have been described, but cavitating nodules are considered atypical. [1]\nIn our case, the diagnosis of PCP was straightforward, as the patient had multiple past episodes of this disease in the recent past, with clinical and imaging features pointing to the verdict and with laboratory findings (PCR of sputum) confirming it.\nDespite overall clinical improvement, the appearance of a progressively enlarging cavitating lung nodule associated with consolidations prompted the investigation of tuberculosis, which was excluded based on negative bronchoalveolar lavage fluid (BALF) samples. Positive galactomannan was eventually obtained in BALF, confirming the diagnosis of aspergillosis.\nAspergillus spp are ubiquitous saprophytic fungus to which humans are constantly exposed. Host underlying lung structural damage and varying grades of immunosuppression can promote colonization or invasion of lung tissue, leading to a varying spectrum of disease. [2]\nInvasive pulmonary aspergillosis (IPA) is usually seen in the setting of deep immunosuppression, particularly in neutropenic patients, and is often fatal. [2]\nChronic pulmonary aspergillosis (CPA) comprises entities such as subacute invasive aspergillosis (SAIA) and chronic cavitary pulmonary aspergillosis (CCPA). Although patients can be asymptomatic, shortness of breath, chronic cough, and sputum production are common. Haemoptysis is a source of morbidity and mortality. Imaging often shows the enlargement and wall thickening of a pre-existing cavity but it may also depict the formation and expansion of cavities, nodules and alveolar consolidations. [2, 3]\nSAIA usually affects patients with low-grade immunosuppression. The absence of a cavitary lesion prior to infection is usual, and radiological progress usually becomes evident within 1-3 months.\nCCPA usually affects patients with underlying structural lung disease. Infection usually starts in areas with pre-existing underlying structural parenchymal disease. Radiological course may take several years. [2, 3]\nIn our case-report, immunosuppression was present due to AIDS, despite absence of neutropenia typically associated with fulminant IPA. There also was structural lung disease consequent to concurrent and past PCPs, with presence of cysts and bronchiectasis.\nAspergillus infection seems to have started in a parenchymal area without cysts and significant bronchiectasis, and the relatively fast radiological course of 1 month is more suggestive of SAIA then of CCPA. Much overlap exists between these two entities, and it may be difficult or impossible to differentiate CCPA and SAIA without pathological evidence and/or further follow-up scans.\nVoriconazole was started on day-96, with HRCT revaluation at day-118 showed decreasing size and wall thickness of cavity and diminishing parenchymal adjacent infiltrates. \nPatient was soon discharged, clinically improved and awaiting outcare revaluation, with indication for long-term therapy with voriconazole.\nThis report is relevant because it describes the uncommon coinfection of PCP and pulmonary aspergillosis, and because it pictures the radiological progress of CPA through serial imaging scans. \nWritten informed consent was obtained.",
    "differential_diagnosis": "Chronic, pulmonary, aspergillosis, (SAIA), Pulmonary, tuberculosis, Chronic, cavitary, pulmonary, histoplasmosis, Pulmonary, non-tuberculous, mycobacterial, infection, Pulmonary, granulomatosis, with, polyangiitis, Rheumatoid, nodules",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-12//17078_1_1.jpg?itok=lSOse8zP",
            "caption": "Admission scan, with arrows highlighting bilateral ground-glass opacities associated with smooth interlobular septal thickening."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-12//17078_1_2.jpg?itok=dvanoojP",
            "caption": "Admission scan, with crazy paving area (arrowhead)."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-12//17078_1_3.jpg?itok=5dwmpgDX",
            "caption": "Small cystic lucency suggesting pneumatocele (arrow)."
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-12//17078_1_4.jpg?itok=kgyr5p0S",
            "caption": "Small pneumothorax in the right hemithorax (circle)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-12//17078_2_1.jpg?itok=okVDnulv",
            "caption": "Thick-walled cavitation with central soft tissue attenuating rounded mass in the right upper lobe. Foci of adjacent parenchymal consolidation were noted."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-12//17078_2_2.jpg?itok=v57_Z9_W",
            "caption": "Zoomed-in image in mediastinal window better depicting the soft tissue component."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-12//17078_3_1.jpg?itok=DMStaEci",
            "caption": "First scan (upper left), revealing no apparent structural or evolutive changes in the lung parenchyma of the RUL. The remaining scans reveal the development of the cavitation with central soft tissue component and the increase in adjacent parenchymal infiltrates."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-12//17078_4_1.jpg?itok=YOJdQ9_a",
            "caption": "There has been a change in morphology and slight decrease in size of the cavitation. Both the soft tissue central component and the parenchymal infiltrates have also diminished."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-12//17078_5_1.jpg?itok=mYoeIMwe",
            "caption": "Zoomed-in image of cavitation and parenchymal infiltrates better depicting the favourable response to antifungal therapy."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/17078",
    "time": "07.12.2020"
  },
  "17092": {
    "case_id": 17092,
    "title": "Post-primary pulmonary tuberculosis",
    "section": "Chest imaging",
    "age": "29",
    "gender": "male",
    "diagnosis": "Post-primary pulmonary tuberculosis",
    "history": "A patient from Honduras presented to the emergency department with night sweats and fever for the last four days. He also had dyspnea and a productive cough since one month ago. He was additionally a former smoker from one month ago and, he had been in prison ten years ago",
    "image_finding": "PA chest radiography shows multiple bilateral fibronodular opacities and ill-defined pulmonary nodules with an upper lung lobes predominance. Some cavitary lesions can also be observed.\nMultiple axial CT images through the lungs demonstrate multiple thick-walled pulmonary cavities predominantly in the apical and posterior segments of the upper lobes, as well as the superior segments of the lower lobes. There are multiple areas of nodularity and partial consolidation in a bilateral and peripheric distribution, forming a tree-in-bud pattern in some locations. Apical architectural distortion, fibrotic bronchiectasis and upper lung volume loss can additionally be observed. There are also small mediastinal lymphadenopathies.",
    "discussion": "The imaging findings in this case, along with the clinical presentation, were highly suggestive of tuberculosis reactivation. The final diagnosis was made by positive PCR on the sputum for Mycobacterium tuberculosis complex.\nTuberculosis is an infectious disease mostly transmitted by Mycobacterium tuberculosis, contained in airborne droplets [1,2]. It constitutes a world health issue, causing 9 million people new infections and 1.5 million deads every year [1]. Most cases occur in developing countries, particularly in Africa and Asia [1,2]. This bacteria reaches the terminal airspaces by inhalation, where most individuals will harbour the infection and will remain asymptomatic and noncontagious. However, some people will develop active tuberculosis within the first 1-2 years, while others will be able to control the initial infection, but the microorganism will remain dormant and reactivate many years after causing post-primary tuberculosis [1,2]. \nRegarding the clinical aspect, tuberculosis predominantly affects the pulmonary system, although it can involve any organ system [3]. The active disease presents with multiple symptoms, including fever, night sweats, productive cough that produces bloody sputum, and weight loss [1,2]. \nPost-primary pulmonary tuberculosis associates patchy and poorly defined consolidations involving the apical and posterior segments of the upper lobes and the superior segments of the lower lobes (1,2,3,4). Although the presence of cavities is considered the hallmark of reactivation tuberculosis, they are isolated to 20-45% of the subjects (1,2). The cavitary lesions typically have irregular and thick walls [1]. However, the most common CT findings in this disease are centrilobular and tree-in-bud nodules distributed in the lungs periphery and both the upper and lower lobes, known to be a highly suggestive sign of active infection [1,2]. \nStandard treatment of active pulmonary tuberculosis consists of one first regimen of isoniazid, rifampin, pyrazinamide, and ethambutol for two months (bactericidal phase); and a second regimen of isoniazid and rifampin during four more months (sterilizing phase) [1,4]. The length of the treatment can have variations depending on the presence of cavitation on the initial chest radiograph or having a positive tuberculosis positive culture after two months of therapy initiation [1].\nTuberculosis is still a leading cause of death worldwide. The combination of the clinical history with the typical imaging findings is the clue to suspect this entity, being able to start the treatment before making a microbiological diagnosis.\n\u00a0\nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Post-primary, pulmonary, tuberculosis, Sarcoidosis, Pulmonary, nocardiosis, Classic, non-tuberculous, mycobacterial, infection, Airway, invasive, aspergillosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-12//17092_1_1.jpg?itok=WD9LJKDc",
            "caption": "PA chest radiography shows multiple bilateral fibronodular opacities and ill-defined pulmonary nodules with an upper lung lobes predominance. Some cavitary lesions can also be observed."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-12//17092_2_1.jpg?itok=aXHVEqH3",
            "caption": "Multiple axial CT images through the lungs demonstrate multiple thick-walled pulmonary cavities predominantly in the apical and posterior segments of the upper lobes, as well as the superior segments of the lower lobes. A marginated area of consolidation containing small cavities on the left cardiophrenic angle can be recognized. There are multiple areas of nodularity and partial consolidation in a bilateral and peripheric distribution, forming a tree-in-bud pattern in some locations. Apical architectural distortion, fibrotic bronchiectasis, and upper lung volume loss can additionally be observed."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-12//17092_2_2.jpg?itok=Fwzq-dB6",
            "caption": "Multiple axial CT images through the lungs demonstrate multiple thick-walled pulmonary cavities predominantly in the apical and posterior segments of the upper lobes, as well as the superior segments of the lower lobes. A marginated area of consolidation containing small cavities on the left cardiophrenic angle can be recognized. There are multiple areas of nodularity and partial consolidation in a bilateral and peripheric distribution, forming a tree-in-bud pattern in some locations. Apical architectural distortion, fibrotic bronchiectasis, and upper lung volume loss can additionally be observed."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-12//17092_2_3.jpg?itok=4gny2ReZ",
            "caption": "Multiple axial CT images through the lungs demonstrate multiple thick-walled pulmonary cavities predominantly in the apical and posterior segments of the upper lobes, as well as the superior segments of the lower lobes. A marginated area of consolidation containing small cavities on the left cardiophrenic angle can be recognized. There are multiple areas of nodularity and partial consolidation in a bilateral and peripheric distribution, forming a tree-in-bud pattern in some locations. Apical architectural distortion, fibrotic bronchiectasis, and upper lung volume loss can additionally be observed."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-12//17092_2_4.jpg?itok=89FDrpKW",
            "caption": "Multiple axial CT images through the lungs demonstrate multiple thick-walled pulmonary cavities predominantly in the apical and posterior segments of the upper lobes, as well as the superior segments of the lower lobes. A marginated area of consolidation containing small cavities on the left cardiophrenic angle can be recognized. There are multiple areas of nodularity and partial consolidation in a bilateral and peripheric distribution, forming a tree-in-bud pattern in some locations. Apical architectural distortion, fibrotic bronchiectasis, and upper lung volume loss can additionally be observed."
          },
          {
            "number": "Figure 2e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-12//17092_2_5.jpg?itok=pgRXLLrq",
            "caption": "Multiple axial CT images through the lungs demonstrate multiple thick-walled pulmonary cavities predominantly in the apical and posterior segments of the upper lobes, as well as the superior segments of the lower lobes. A marginated area of consolidation containing small cavities on the left cardiophrenic angle can be recognized. There are multiple areas of nodularity and partial consolidation in a bilateral and peripheric distribution, forming a tree-in-bud pattern in some locations. Apical architectural distortion, fibrotic bronchiectasis, and upper lung volume loss can additionally be observed."
          },
          {
            "number": "Figure 2f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-12//17092_2_6.jpg?itok=afCWo1vu",
            "caption": "Multiple axial CT images through the lungs demonstrate multiple thick-walled pulmonary cavities predominantly in the apical and posterior segments of the upper lobes, as well as the superior segments of the lower lobes. A marginated area of consolidation containing small cavities on the left cardiophrenic angle can be recognized. There are multiple areas of nodularity and partial consolidation in a bilateral and peripheric distribution, forming a tree-in-bud pattern in some locations. Apical architectural distortion, fibrotic bronchiectasis, and upper lung volume loss can additionally be observed."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-12//17092_3_1.jpg?itok=q_qAhoqy",
            "caption": "Sagittal CT image through the right lung with MIP reconstruction better illustrates the tree-in-bud pattern (centrilobular nodularity with a linear branching pattern)."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-12//17092_4_1.jpg?itok=poo52bnp",
            "caption": "Axial venous contrasted slices through the mediastinum reveal small lymphadenopathies on the following regions: right superior paratracheal, bilateral inferior paratracheal, right hilar, and subcarinal."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-12//17092_4_2.jpg?itok=6FU-WRxc",
            "caption": "Axial venous contrasted slices through the mediastinum reveal small lymphadenopathies on the following regions: right superior paratracheal, bilateral inferior paratracheal, right hilar, and subcarinal."
          },
          {
            "number": "Figure 4c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-12//17092_4_3.jpg?itok=rSUqD_CF",
            "caption": "Axial venous contrasted slices through the mediastinum reveal small lymphadenopathies on the following regions: right superior paratracheal, bilateral inferior paratracheal, right hilar, and subcarinal."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2020-12//17092_5_1.jpg?itok=K_JKJxcm",
            "caption": "Control PA chest radiography performed seven months after treatment initiation shows resolution of the bilateral ill-defined pulmonary opacities and nodularity. Fibrotic scarring changes in the upper lung lobes can be observed. There are also some residual cavitary lesions on the left cardiophrenic angle."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/17092",
    "time": "16.12.2020"
  },
  "17122": {
    "case_id": 17122,
    "title": "Spontaneous mediastinal hematoma.",
    "section": "Chest imaging",
    "age": "46",
    "gender": "male",
    "diagnosis": "Spontaneous mediastinal haematoma",
    "history": "A 46-year-old male presents to the emergency department with an episode of oppressive, precordial pain radiating to the neck- He is diagnosed with acute myocardial infarction and treated with angioplasty and 3 farmacoactive stents. 24 hours later the patient has fever and thoracic pain that increases with deep inspiration.",
    "image_finding": "A plain X-ray was performed to exclude acute thoracic complications and it showed occupation of the anterosuperior mediastinum with enlargement of the cardiomediastinal silhouette. Patchy opacifications or pleural effusion were absent (figure 1).\nDue to the positive findings in the chest x-ray, a thoracic computed tomography (CT) was performed that showed an occupation of the anterior mediastinum by a solid hypodense homogeneous mass with polylobulated shape and ill-defined margins. The mass is in intimate contact with the great vessels and the pericardium. There was no active bleeding point or contrast extravasation (figure 2).\u00a0\nA chest magnetic resonance (MRI) was also performed and it showed a hyperintense mass in FLAIR weighted-image, but it remains with high intensity in fat suppression sequences. This helps to differentiate it from other lesions that might have a fatty component such as thymoma or germ cell carcinomas. The mass presents areas with restriction to water diffusion (C and D) which indicates the different stages of the hematoma. Highly cellular tumours such as lymphoma would show homogeneous restriction to water diffusion (figure 3).\nA chest CT performed one year later revealed an almost complete resolution of the lesion, confirming the diagnosis of mediastinal hematoma (figure 4).",
    "discussion": "Background\u00a0\nThe anterior mediastinum might be occupied by different lesions because it is composed of the thymus, lymph nodes, adipose tissue, nerves, vessels, and thoracic thyroid. However, complications of surgery/ treatment therapy can mimic a mediastinal mass such as mediastinal hematoma, aortic dissection, aneurysm rupture or arteriovenous fistula [1,2].\nMediastinal hematoma is a complication secondary to thoracic trauma or surgery complications, and, rarely, it can occur spontaneously in patients taking anticoagulants [3,4, 5].\nHowever, coughing and vomiting, among others, are predisposing factors to develop spontaneous mediastinal hematoma [3,5].\nThe consequence of the mediastinal hematoma is the compression of other structures such as the airway, a life-threatening situation [4,5, 6].\u00a0\nIt might be difficult to recognize it on x-ray, which delays its diagnosis, so it is crucial to have a compatible clinical history [5]\nClinical Perspective\u00a0\nPatients normally present with chest pain and dyspnea. Other symptoms less common are respiratory distress, tachycardia, dysphagia, dysphonia or neck wall ecchymosis [4,5]. EKC alterations might be seen [3]. A chest x-ray is primarly performed to exclude complications such as pneumothorax or bronchoaspiration, but if a vascular complication is suspected, then an angiography or angioCT should be performed.\nImaging Perspective\u00a0\nThe first imaging technique usually performed is a chest radiography, and in cases of large hematomas or aneurysms, it shows an anterior mediastinal enlargement with obscuration of the aortic arch and displacement of mediastinal structures.\nHowever, the IV contrast-enhanced CT through the chest is more precise and can detect a soft-tissue mass with areas of different attenuation that indicates haemorrhage and allows to measure the size of the hematoma, the extension, detection of active bleeding or other complications. [1,3,[4].\nThe angiography is an imaging technique used with diagnostic and therapeutic purposes that localizes the exact point of bleeding and in cases where the conservative treatment is ineffective or in hemodynamically unstable patients, it provides embolization of the bleeding vessel [5,6,7]\nFinally, to consider the diagnosis of mediastinal hematoma, it is highly important to correlate the imaging findings (mediastinal widening in a patient with a previous normal x-ray)\u00a0 with the clinical history, normally patient with chest pain and previous surgery.\nOutcome \nCT is performed to evaluate the extension of the hematoma and the presence of active bleeding or compression of other structures. In some cases, an angiography is performed to diagnose and treat active bleeding [3].\nPatients should have a follow-up chest radiograph to assess for the resolution of the hematoma[4].\nTreatment options are conservative therapy in cases of asymptomatic patients or absence of active bleeding or endovascular surgery in cases of life-threatening situations or ineffectiveness of conservative therapy. In these cases, transcatheter embolization is the preferred treatment option \u00a0[4,5,6,7].\n\u00a0\nWritten informed patient consent for publication has been obtained.\nTeaching Points\n\nSpontaneous mediastinal hematoma is an uncommon complication of cardiothoracic surgery or anticoagulation therapy.\nFollow-up chest x-ray is essential to evaluate the complete resolution of the hematoma.\nIt is highly important to compare with previous imaging studies and correlate with the clinical history.",
    "differential_diagnosis": "Spontaneous, mediastinal, haematoma, Lymphoma, Acute, aortic, syndrome, Thymoma, or, thymic, malignancies, Germ, cell, tumour",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-01//17122_1_1.JPG?itok=y1eK7I67",
            "caption": ""
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-01//17122_2_1.JPG?itok=YwfWPqUb",
            "caption": ""
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-01//17122_3_1.jpg?itok=5mRim0ZV",
            "caption": ""
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-01//17122_4_1.jpg?itok=Ve7wj6Zs",
            "caption": ""
          }
        ]
      }
    ],
    "area_of_interest": [
      "Cardiovascular system",
      "Emergency",
      "Mediastinum"
    ],
    "imaging_technique": [
      "CT",
      "MR"
    ],
    "link": "https://www.eurorad.org/case/17122",
    "time": "13.01.2021"
  },
  "17132": {
    "case_id": 17132,
    "title": "Mediastinal mass and malignant pleural effusion as an unusual manifestation of T-cell acute lymphoblastic leukaemia/lymphom",
    "section": "Chest imaging",
    "age": "1",
    "gender": "male",
    "diagnosis": "T-cell acute lymphoblastic leukaemia/lymphoma",
    "history": "A 1 \u00bd -year-old boy presented with 10-day history of breathlessness and non-productive cough. There was no history of fever. He was initially evaluated with a chest radiograph. Bone marrow study revealed blasts with granular PAS positivity. Inflow cytometry, the cells were positive for TdT, HLA-DR, CD4 and CD8.",
    "image_finding": "Initial chest radiograph (Figure 1 and 2) showed a homogeneous radio-opacity involving the left mid and lower zone obscuring the left heart border with significant cardio-mediastinal shift to the right and superior mediastinal widening. In lateral projection(b), there was absence of retrosternal clear space and retrocardiac clear space, absence of increasing lucency of vertebrae downwards and obscuration of the left diaphragmatic outline.\nSubsequent contrast-enhanced CT images (Figure 3, 4 and 5) showed an enhancing anterior mediastinal mass extending to left hemithorax causing significant mediastinal shift to the right with encasement of left brachiocephalic vein, gross left pleural effusion with subsequent collapse of lung and enhancing soft tissue masses involving the left costal pleura. All the mediastinal vessels were only mildly compressed and showed normal contrast opacification.",
    "discussion": "Precursor T cell acute lymphoblastic leukaemia/lymphoma refers to the malignant proliferation of immature lymphoid cells of T cell lineage and represent two ends of the same disease spectrum.[1][2] Patients with T cell acute lymphoblastic leukaemia usually present with haematological abnormalities like anaemia, leukocytosis and thrombocytopenia while patients with T cell lymphoblastic lymphoma usually presents with mediastinal enlargement, lymphadenopathy and have normal blood counts.[2] Pleural effusion manifests in 16% of the cases of pulmonary lymphoma and may be due to lymphatic obstruction by the mediastinal lymphadenopathy or direct pleural involvement. [3]The clinical and haematological differences between T cell lymphoblastic leukaemia and lymphoma depend on the tumour load and degree of marrow infiltration. The cut-off of 25% lymphoblasts in bone marrow to differentiate T cell lymphoblastic leukaemia and lymphoma is susceptible to sampling errors.[2] Hence, the term acute lymphoblastic leukaemia/lymphoma is used when there is a mediastinal mass with involvement of bone marrow and peripheral blood. T-cell lymphoblastic lymphoma occurs more frequently than the B-cell type which accounts for only 10%.[4] The most common site of involvement of B-cell lymphoblastic lymphoma is skin followed by bone. [4]Based on the clinical presentation of a predominantly mediastinal mass with/ without lymphadenopathy, precursor T cell lymphoblastic leukaemia/lymphoma maybe divided into thymic and non-thymic types.[3] The thymic type expresses CD8 more frequently while the expression of CD56 is more frequent in the non-thymic type.[3] Since the anatomic distribution of the disease depends on the differentiation stage of neoplastic cells, thymic and non-thymic type maybe biologically different.[3] Treatment is divided into four components \u2013 remission induction, consolidation, maintenance chemotherapy and therapy directed against the CNS.[4] 20% of children suffer relapse with a mortality of 40%.[5][6] Acute lymphoblastic leukaemia/lymphoma presenting as mediastinal mass is reported to have poor prognosis.[7] Other bad prognostic features are leukocytosis, high blast count, hepatosplenomegaly and lymphadenopathy.",
    "differential_diagnosis": "T-cell, acute, lymphoblastic, leukaemia/lymphoma, Hodgkin\u2019s, lymphoma, Thymoma, Malignant, teratoma, Germ, cell, tumour",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-02//17132_1_1.jpg?itok=gDX2MLUu",
            "caption": "Chest radiography AP projection showing homogeneous radio opacity involving left mid and lower zone with obscuration of left heart border, significant cardio-mediastinal shift to right and mediastinal widening."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-02//17132_2_1.jpg?itok=jxePgOl1",
            "caption": "Chest radiograph lateral projection showing obliteration of retrosternal and retrocardiac clear space with absence of increasing vertebral lucency downwards and obliteration of left diaphragmatic outline."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-02//17132_3_1.jpg?itok=Dx_xv2T_",
            "caption": "Axial sections of CECT thorax showing enhancing anterior mediastinal mass extending to left hemithorax which is noted encasing left brachiocephalic vein, gross left pleural effusion, soft tissue masses involving left costal pleura."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-02//17132_4_1.jpg?itok=4o1uiGLj",
            "caption": "Axial sections of CECT thorax showing enhancing anterior mediastinal mass extending to left hemithorax which is noted encasing left brachiocephalic vein, gross left pleural effusion, soft tissue masses involving left costal pleura."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-02//17132_5_1.jpg?itok=7YEyA520",
            "caption": "Axial sections of CECT thorax showing enhancing anterior mediastinal mass extending to left hemithorax which is noted encasing left brachiocephalic vein, gross left pleural effusion, soft tissue masses involving left costal pleura."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Haematologic",
      "Mediastinum",
      "Oncology",
      "Paediatric"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/17132",
    "time": "03.02.2021"
  },
  "17135": {
    "case_id": 17135,
    "title": "Prenatal Ultrasound diagnosed fetal congenital cystic adenomatoid malformations correlation with fetal MRI",
    "section": "Chest imaging",
    "age": "26",
    "gender": "female",
    "diagnosis": "Congenital cystic adenomatoid malformations type -II.",
    "history": "A primigravida with five months of amenorrhea came to G.G hospital for antenatal anomaly scans. No significant clinical complain was present. Clinical examination and routine investigations were done, all were normal. No significant family history was mentioned by the patient.",
    "image_finding": "On antenatal ultrasound in second trimester for fetal well being and to rule out any congenital abnormality. Ultrasound show multiple variable-sized intercommunicating cystic structures involving right lung parenchyma. (Figure: 1).\nOn colour Doppler studies, there was no evidence of any colour flow in the cystic structures involving right lung parenchyma. A vascular heart structure was noted adjacent to it. (Figure: 2). \nOn Magnetic Resonance Imaging (MRI), shows multiple hyperintense round to oval-shaped cystic structures involving lower lobe of right lung parenchyma. Bilateral diaphragm appears intact. Left lung parenchyma appears unremarkable, no mediastinal shift or herniation of bowel loops is noted. Stomach bubble is visualized on the left side (Figure 3 and Figure 4). \nPostnatally, the baby is under conservative management as the baby is asymptomatic and the surgery is postponed to the older age.",
    "discussion": "Fetal lung masses are rare findings in prenatal ultrasound scanning in general population, congenital cystic adenomatoid malformation (CCAM)\u00a0is multicystic lesions of segmental lung tissue with abnormal bronchial proliferation. An adenomatous overgrowth of terminal bronchioles and alveoli leads ultimately to large masses, which are communicating with the tracheobronchial tree and have feeding vascularisation from the pulmonary (bronchial) circulation [1].\nCCAM is categorized into 5 types based on its cyst diameter and cell type; type I most common with large cysts average measuring\u00a0 2-10 cm may be surrounded by smaller cysts; type II cysts are <2 cm in diameter associated with other abnormalities renal agenesis or dysgenesis or congenital cardiac anomalies; type III micro cysts\u00a0 <5 mm in size typically involves an entire lobe; type IV unlined cyst; type 0 acinar dysgenesis or dysplasia represents global arrest of lung development.\nAntenatal, the use of ultrasound with Doppler studies foetal lung lesions relies on the appearance of space-occupying lesions [2]. The appearance of fetal CCAM varies from predominantly solid to purely cystic masses. \nClassification based on ultrasound findings: - a) Microcystic lesions (< 5 mm): usually associated with fetal hydrops and has poor prognosis. b) Macrocystic lesions (> 5 mm): not usually associated with hydrops and has favourable prognosis.\n\u00a0\nFoetal MRI is helpful in improving the accuracy of diagnosis [3]. It will characterize the lesions as macro cystic or microcystic. To identify the location of the lung abnormality and determine any changes in thoracic position of other lung lobes and mediastinum [4]. It is better examination method in the cases of obese pregnant women, incorrect foetal positioning, and oligohydramnios. MRI scanning better characterizes the CCAM by determining the size of the lesion but also the total number and size of cysts. It is most helpful in distinguishing a CCAM from a diaphragmatic hernia [4]. \nPrenatal treatment methods include cystic growth aspiration or draining, thoraco-amniotic bypass, the injection of sclerosing agents, and foetal surgery. Post-natally, it is recommended to perform the lobectomy at the optimum age. If the affected part of the lung is not removed, there is a chance that it may develop into a pulmonary rhabdomyosarcoma in late childhood\nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Congenital, cystic, adenomatoid, malformations, type, -II., Bronchogenic, cyst, Congenital, cystic, bronchiectasis, Congenital, diaphragmatic, herniation, Pulmonary, sequestration",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-02//17135_1_1.JPG?itok=K_IlhM9K",
            "caption": "On ultrasound gray scale images, multiple variable sized intercommunicating anechoic cystic lesions are noted involving right lung parenchyma adjacent to another cystic structure along midline and slightly towards left side."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-02//17135_2_1.JPG?itok=0h_evwgn",
            "caption": "On colour Doppler study, intercommunicating anechoic lesions showed no evidence of any colour flow involving right lung parenchyma adjacent to vascular structure heart with colour filling is noted."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-02//17135_3_1.JPG?itok=yOEGr7YP",
            "caption": "T2WI coronal image shows multiple hyperintense round to oval shaped cystic lesions involving lower lobe of right lung parenchyma. Bilateral diaphragm appears intact. Left lung parenchyma appears unremarkable. Stomach bubble is visualized on the left side."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-02//17135_4_1.JPG?itok=akWcdy6t",
            "caption": "T2WI axial image it showed multiple hyperintense cystic lesions in right lung parenchyma. An hypoechoic round to oval structure heart is noted adjacent to it."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Foetal imaging",
      "Lung",
      "Obstetrics (Pregnancy / birth / postnatal period)"
    ],
    "imaging_technique": [
      "MR",
      "Ultrasound-Colour Doppler"
    ],
    "link": "https://www.eurorad.org/case/17135",
    "time": "03.02.2021"
  },
  "17141": {
    "case_id": 17141,
    "title": "Anti-MDA5 antibody-positive dermatomyositis associated spontaneous pneumomediastinum",
    "section": "Chest imaging",
    "age": "66",
    "gender": "female",
    "diagnosis": "Spontaneous pneumomediastinum in the context of Anti-MDA5 Antibody-positive Dermatomyositis.",
    "history": "A 66-year-old woman is admitted to our institutions\u2019 emergency department with subcutaneous emphysema in the anterior cervical region, discovered in a routine consultation. She denied any associated symptoms and did not recall recent trauma. \nThe patient had a previous medical history of Dermatomyositis (DM) with interstitial lung disease (ILD).",
    "image_finding": "A posteroanterior chest radiograph (Fig. 1) was performed and revealed pneumomediastinum associated with exuberant cervical subcutaneous emphysema. A predominantly peripheral reticulation pattern was also apparent, mainly in the middle and lower lung regions. \nChest CT was performed to exclude associated oesophagal perforation and mediastinitis. On CT (Fig 2-4) the pneumomediastinum is associated with exuberant subcutaneous emphysema. The oesophagus does not show parietal thickening and no fluid collection or pneumothorax is apparent. Features of organizing pneumonia are present with predominantly subpleural and peribronchial polygonal-shaped consolidations. Reticulation and traction bronchiectasis is also present with a basal predominance.",
    "discussion": "DM is associated ILD in 5-30%, most often NSIP and organizing pneumonia (OP), often seen in the same patient. Honeycombing is relatively rare (15%). Some patients have antisynthetase syndrome, characterized by inflammatory arthritis, myopathy, Raynaud, fever, oesophageal dysfunction and ILD (present in more than 80% of patients). Anti\u2013Jo-1 is the most common antisynthetase antibody, present in 50-70% of patients with ILD. \nThe autoimmunity evaluation did not detect Anti\u2013Jo-1 antibody, however, showed positivity for anti-melanoma differentiation-associated gene 5 (anti-MDA5) antibody, which is considered a subtype of dermatomyositis, associated with rapidly progressive ILD, higher incidence of pneumothorax and pneumomediastinum and worse prognosis[1].\nBackground\nSpontaneous pneumomediastinum (SP) is defined as the presence of free air in the mediastinum without a precipitating cause. SP can be primary or secondary to a previously known or unknown lung disease. \nThe mechanism in which the pneumomediastinum occurs in ILD is unknown. One of the theories is the \u201cMacklin Effect\u201d in which the pneumomediastinum could result from the rupture of pulmonary alveoli due to increase in intra-alveolar pressure and air bubbles posteriorly travelling along the vascular sheaths and connective tissue planes to the mediastinum[2]. \n\nClinical Perspective\nThe association between pneumomediastinum and ILD is uncommon but well established in medical literature, namely in dermatomyositis (DM) and polymyositis (PM) patients with a prevalence of 8-9% in these patients[3,4].\nSP may be the initial presentation leading to a connective tissue disease diagnosis and is considered a poor prognostic factor in patients with DM and PM[5], typically associated with a relatively benign short-term course but poorer long-term survival.\n\nImaging Perspective\nThis is a rare case in which the plain radiograph plays an important role and presents the features to make a practically definitive diagnosis. CT has the role of excluding other causes of pneumomediastinum, such as Boerhaave syndrome and complications such as mediastinitis.\n\nOutcome: SP should be treated conservatively unless a complication occurs and an invasive procedure is needed [6]. The patient was admitted for supportive therapy, being discharged after 5 days. High-resolution lung CT was performed two weeks after showing resolution of the pneumomediastinum and no aggravation of the lung disease (Fig 5).\n\nTake-Home Message / Teaching Points\nAnti-MDA5 Antibody-positive Dermatomyositis is a rare subtype of DM associated with rapidly progressive ILD, higher incidence of spontaneous pneumothorax and pneumomediastinum and worse prognosis.\n\u00a0\nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Spontaneous, pneumomediastinum, in, the, context, of, Anti-MDA5, Antibody-positive, Dermatomyositis., Spontaneous, esophageal, rupture, (Boerhaave, syndrome), Spontaneous, pneumomediastinum, caused, by, asthma, or, vigorous, exercise, Oesophagal, malignancy, with, perforation, Oesophagal, perforation, from, iatrogenic, injury",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-02//17141_1_1.jpg?itok=SPli-qly",
            "caption": "Posteroanterior plain radiograph of the thorax reveals pneumomediastinum associated with cervical subcutaneous emphysema. Peripheral reticulation pattern is present in the middle and lower lung regions"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-02//17141_2_1.jpg?itok=SzbztP6x",
            "caption": "High resolution chest CT (HRCT) shows pneumomediastinum, without associated pneumothorax. Peripheral parenchymal consolidations typical of OP can be identified"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-02//17141_3_1.jpg?itok=UCgLB-VM",
            "caption": "High resolution chest CT (HRCT) axial reconstruction at the lung basal segments shows additional fibrotic features with reticulation and bronchiectasis"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-02//17141_4_1.jpg?itok=ZEckRAnU",
            "caption": "Chest CT coronal reformation represents the exuberant cervical subcutaneous emphysema associated with the pneumomediastinum"
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-02//17141_5_1.jpg?itok=pI1fD2E-",
            "caption": "High resolution chest CT (HRCT) 2 weeks later demonstrates resolution of pneumomediastinum and no aggravation of the ILD findings."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Emergency",
      "Lung"
    ],
    "imaging_technique": [
      "CT-High Resolution"
    ],
    "link": "https://www.eurorad.org/case/17141",
    "time": "05.02.2021"
  },
  "17144": {
    "case_id": 17144,
    "title": "Pleural hemangioma masquerading as massive unilateral pleural effusion: a rare entity",
    "section": "Chest imaging",
    "age": "42",
    "gender": "female",
    "diagnosis": "Pleural hemangioma",
    "history": "A 42-year-old female patient with no significant past history presented with complaint of gradually progressive dyspnoea for two weeks. On physical examination, dull note was noted in almost entire right hemithorax.",
    "image_finding": "Plain chest radiograph revealed near-complete whiteout/opacification of right hemithorax with collapse/consolidation of right lung and mediastinal shift to opposite side suggesting Massive right pleural effusion. Pleural fluid cytology was negative for tuberculous or any other infectious and malignant aetiology.\u00a0 Plain Computed Tomography (CT) \u00a0confirmed massive right-sided pleural effusion. To demystify the underlying aetiology for such a massive effusion, Contrast-enhanced chest CT (CECT) was performed and its dynamic study revealed a broad based iso-hypodense mass measuring 5.2 X 3.3 cm in right apical region abutting the pleura posteriorly with characteristic pattern of enhancement (Fig. 3,4). In arterial phase, irregular peripheral contrast puddling (Fig 5-b) with gradual centripetal filling up on the venous phase (Fig. 5-c) and homogenous contrast opacification in delayed phase (Fig. 5-d). No calcifications were noted. Absence of features like lymphadenopathy, irregular margins, or infiltration as adjacent rib erosion, points towards benign nature. Altogether features were suggestive of pleural hemangioma.\nBiopsy /invasive investigation was thus contraindicated in strong suspicion of pleural hemangioma as it would further precipitate bleeding and thereby exacerbating the effusion or turning out to be lethal.",
    "discussion": "Background\nA hemangioma is a benign tumour which can occur externally on skin and also in internal organs. Pleural hemangioma is a rare entity with its incidence being mostly below 35 years of age with no gender predilection[5]. Pathophysiology is associated with an imbalance of proangiogenic factors and angiogenesis inhibitors\u00a0[6]\nClinical Perspective\nThey present as incidental findings or from mild symptoms of cough, chest pain, to a diagnostic dilemma with pleural effusions and become evident after the explorative CECT or thoracoscopy[2].\nImaging Perspective\nWith the advent of technology, Diagnosis mainly depends on Imaging, CECT and MRI being the investigations of choice [7,8]. \nCECT features: CT enables accurate assessment of tumour morphology, location, extent, and pattern of enhancement and can be helpful in identifying tumour tissues and types[4].\nIn the arterial phase (Fig.5b), peripheral, globular heterogeneous enhancement is seen. In the delayed phase (Fig.5c), centripetal enhancement progressing to uniform filling with a low attenuation area in the central portion can be observed.\nMRI features[9]: On T2-weighted images, hemangiomas generally appear as multiple high-signal-intensity lobules that resemble a bunch of grapes due to cavernous or cystic vascular spaces containing stagnant blood. \n\u00a0Sakurai\u00a0et al. described FDG accumulation in thoracic hemangioma as low and similar to extremity hemangioma and is not recommended[10]. However, histopathology (excision biopsy) remains gold standard for confirmation. Immunohistochemistry shows CD4 positivity for endothelial cells[11].Pleural hemangiomas are not to be confused with sclerosing pulmonary hemangiomas which have a malignant potential[12]. Sclerosing pulmonary hemangiomas can be differentiated from pleural hemangiomas by their rapid strong homogenous enhancement depending on levels of hemangiomatous/sclerosing components and being in pulmonary location rather than pleural based.[13]\nOutcome\nManagement is dependent on location, size, depth of infiltration, age of the patient. Various non-surgical options available are radiotherapy, dry ice cryotherapy, steroid treatment, sclerosing agent injection. Vascular ligation, vascular embolization, and ultimately surgical excision are considered depending on the above-mentioned factors.[14,15]. Findings are suggestive of a benign tumour and clinical features like slow growth and lack of pain support a conservative management strategy[16]. Imaging would also play a role in Follow-up to rule out any residual tumour/ recurrence.\nTake-Home Message\n\nAn extrapulmonary mass with benign features and typical centripetal enhancement pattern on contrast CT should raise a suspicion of pleural hemangioma to be added in the differential diagnoses.\nAwareness of this possibility is important to reduce the time-to-diagnose and proper management, though rare in its incidence in this location.\nWhen imaging features are suggestive of pleural hemangioma, Preoperative biopsy is not recommended as it may lead to torrential bleeding.\n\nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Pleural, hemangioma, Solitary, fibrous, tumour, Schwannoma, Sclerosing, pulmonary, hemangioma, Pleural, lipoma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-02//17144_1_1.png?itok=48g-1Ry7",
            "caption": "Scanogram showing massive right sided pleural effusion with underlying collapse/consolidation of lung and mediastinal shift to opposite side"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-02//17144_2_1.jpg?itok=SNpKF3ZG",
            "caption": "Coronal post contrast CT showing significant right pleural effusion (white arrow) with collapse consolidation of the right lung(black arrow)"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-02//17144_3_1.jpg?itok=GW3nue_v",
            "caption": "POST CONTRAST image in coronal view showing enhancing mass in right apical region"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-02//17144_4_1.jpg?itok=I0UbK1kh",
            "caption": "POST CONTRAST image in sagittal view showing enhancing mass in right apical region"
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-02//17144_5_1.jpg?itok=zFjff1XB",
            "caption": "a- Precontrast image b- A broad based iso-hypodense mass measuring 5.2 X 3.3 cm in right apical region abutting the pleura posteriorly with characteristic pattern of enhancement. In arterial phase, irregular peripheral contrast puddling c- Gradual centripetal filling up on the venous phase d-Homogenous contrast opacification in delayed phase. No calcifications were noted"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/17144",
    "time": "10.02.2021"
  },
  "17145": {
    "case_id": 17145,
    "title": "Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia: a diagnostic challenge",
    "section": "Chest imaging",
    "age": "79",
    "gender": "female",
    "diagnosis": "Diffuse Idiopathic Pulmonary Neuroendocrine Cell Hyperplasia",
    "history": "We present a case of a Caucasian 79-year-old-woman, non-smoker, with chronic dry cough for about 10 years and episodes of exertional dyspnoea and wheezing. Chronic obstructive pulmonary disease was diagnosed and medicated with corticosteroid and long-acting \u03b2-agonist inhalers.",
    "image_finding": "Due to symptomatic worsening and weight loss, a chest computed tomography (CT) was obtained and multiple bilateral pulmonary nodules and a diffuse mosaic lung pattern with air trapping raised up (figure 1). Pulmonary function tests demonstrated mixed pattern, flexible bronchoscopy with bronchoalveolar lavage showed signs of chronic bronchitis with no malignant cells and PET-CT confirmed innumerable lung nodules with discrete FGD-F18 captation (SUV max: 1.3). Surgical lung biopsy was performed and neuroendocrine cells hyperplasia was diagnosed, with Ki-67 below 5%, absence of necrosis and with homogeneous cytoplasmic chromogranin marking, corresponding to DIPNECH (figure 3). The patient repeated the chest CT one year later and the changes already described maintained the same pattern (figure 2).",
    "discussion": "Diffuse Idiopathic Pulmonary Neuroendocrine Cell Hyperplasia (DIPNECH) is a pulmonary disorder characterized by diffuse proliferation of bronchiolar and bronchial pulmonary neuroendocrine cells, initially described by Aguayo et al. in 1992 and recognized as a pre-invasive lesion for lung carcinoid tumours in 2015 by the World Health Organization.[1, 2]\nDIPNECH typically occurs in non-smoking, middle-aged women with insidious onset, usually with non-productive cough, exertional dyspnoea and wheezing.[1, 3-5] Symptomatic patients are often misdiagnosed with asthma or chronic bronchitis and the definitive diagnosis is usually established several years after the onset of symptoms, frequently after the incidental discovery of lung nodules, as demonstrated in the case reported.[6] \nLung functional tests usually show an obstructive or mixed pattern. Chest CT typically reveals a mosaic attenuation with air trapping, better appreciated on expiratory CT scans, which is due to constrictive bronchiolitis and pulmonary nodules, usually multiple, small in size and ground glass or solid in attenuation, that correspond to either tumorlets (<5 mm) or carcinoid tumours (>5 mm).[4, 5, 7-9]\nAlthough CT does not provide the diagnosis, in an appropriate clinical and demographic context the typical CT findings should raise a suspicion of DIPNECH.[5, 7, 10] The gold standard for the diagnosis remains surgical lung biopsy and recent study suggested that it can be established in the presence of 5 or more neuroendocrine cells, alone or in clusters, located within the basement membrane of the bronchiolar epithelium of at least 3 bronchioles, combined with 3 or more tumorlets.[11] The most common markers of these cells are chromogranin A, synaptophysin and CD56.[12]\nThere are no guidelines for the management of DIPNECH, however, the treatment options used include clinical observation, oral and inhaled steroids, chemotherapy, somatostatin analogues, surgical lung resection and even lung transplantation.[2-5, 13]\nMost reports described an excellent long-term prognosis, although some patients with marked constrictive bronchiolitis may progress to severe airflow obstruction and respiratory failure with worse prognosis.[2-5] Currently there are no specific guidelines, however, a close follow-up of patients is essential.[9, 14]\n\u00a0\nTake-Home Message / Teaching Points\n\nThe diagnosis of DIPNECH should be suspected when CT demonstrates diffuse mosaic perfusion and multiple lung nodules in middle-aged women with chronic cough.\nThe gold standard for the diagnosis remains surgical lung biopsy for histopathological confirmation of neuroendocrine cell proliferation.\nThere are no guidelines for the management of DIPNECH patients, although close follow-up is recommended.",
    "differential_diagnosis": "Diffuse, Idiopathic, Pulmonary, Neuroendocrine, Cell, Hyperplasia, Diffuse, pulmonary, metastasis, Hypersensitivity, pneumonitis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-02//17145_1_1.png?itok=BeqlMnOv",
            "caption": "Axial chest CT image in lung window shows scattered pulmonary nodules, the largest, well-circumscribed in the left lower lobe, measuring 5,5 mm, corresponding to the typical carcinoid"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-02//17145_1_2.png?itok=6eqgqt0J",
            "caption": "MIP axial reformation images reveals innumerable bilateral nodules randomly distributed, most measuring less than 5mm, probably corresponding to typical tumorlets."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-02//17145_1_3.png?itok=rKiCCAKe",
            "caption": "High resolution CT image acquired on expiration shows accentuation of the mosaic pattern"
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-02//17145_1_4.png?itok=OnY7FwAi",
            "caption": "High resolution CT image acquired on expiration shows accentuation of the mosaic pattern"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-02//17145_3_1.png?itok=XdtGuwmh",
            "caption": ""
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-02//17145_3_2.png?itok=odSSf2JK",
            "caption": ""
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-02//17145_3_3.png?itok=2YYKjh3a",
            "caption": ""
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Thorax"
    ],
    "imaging_technique": [
      "CT",
      "CT-High Resolution"
    ],
    "link": "https://www.eurorad.org/case/17145",
    "time": "10.02.2021"
  },
  "17153": {
    "case_id": 17153,
    "title": "Azygos vein system thrombosis due to COVID-19 pneumonia and mediastinal abscess",
    "section": "Chest imaging",
    "age": "58",
    "gender": "female",
    "diagnosis": "Azygos vein thrombosis",
    "history": "A 58-year-old female patient was transferred from another hospital to our hospital after she was previously diagnosed with bilateral pneumonia as a result of a COVID-19 (corona virus) infection and posterior mediastinal abscess. Four hours after, she developed dyspnea and chest pain, which have become progressively more severe.",
    "image_finding": "A pulmonary computed tomography angiography (CTA) and delayed venous imaging (venography) were performed, which revealed a thrombus along the azygos vein lumen, severe bilateral pneumonia with pleural effusions, and previously confirmed mediastinal abscess with adjacent vertebral body osteolysis. The\u00a0diagnosis\u00a0of\u00a0the mediastinal abscess\u00a0has been made earlier, during the previous hospitalization, as coexisting comorbidity and not directly related to the bilateral COVID-19 pneumonia. Thrombotic pulmonary embolism was not confirmed.",
    "discussion": "Background \nThe azygos venous system is composed of three vertically positioned and connected veins in the posterior thoracic wall and posterior mediastinum \u2013 azygos, hemiazygos, and hemiazygos accessoria. It collects venous blood from the posterior thoracic walls by the posterior intercostal veins and from the tributary regions of the lumbar veins. Also, the blood from some thoracic and retroperitoneal organs (lungs, esophagus, pericardium, trachea, left kidney, adrenal glands, etc.) is collected by this venous system.\nConnections between the superior and inferior vena cava by the azygos venous system have been described in detail in classic anatomy textbooks and explained by the embryological development. If the caval veins are blocked, the azygos venous system represents a collateral route for venous blood to the heart. [1,2]\nAzygos venous system thrombosis (AVST) is a rare condition scarcely described in the literature, mostly in case reports. [3,4]\nClinical Perspective \nCurrent studies have shown that the most typical finding in patients with COVID-19 and coagulopathy is an increased D-dimer level, a decrease in platelet count, and the prothrombin time prolongation. The coagulation changes associated with COVID-19 suggest the presence of a hypercoagulable state that might increase the risk of thromboembolic complications. [5] Intravascular thrombosis has been reported in the macrocirculation and microcirculation in COVID-19. Damiani et al. presented the first in vivo evaluation of the microcirculation in patients with SARS-CoV-2.\u00a0 [6,7,8] \nImaging Perspective \nRadiological imaging methods are diagnostic methods of choice. Contrast-enhanced computed tomography is a gold standard in accurate diagnostic approach. A dilatated azygos vein could be seen on chest X-ray as a right paravertebral semicircular shadow near the terminal part of the superior vena cava shadow and inseparable from it. [9]\nOutcome \nIn the data-poor context, we are consistent with other authors that AVST should be considered with more focus in patients with a history of recurrent thromboembolic events and other disorders characterized by intrathoracic masses which could cause azygos venous system obstruction due to compression and subsequently venous stasis and congestion. \nIn light of the recent findings that are consistent with the COVID-19 and high coagulopathy risk association, an explanation for sudden respiratory deterioration in the present case is probable subsegmental pulmonary thromboembolic disorder on microcirculation level considered to originate from AVST.\u00a0 \nThe patient outcome was clinically improved due to a multidisciplinary therapeutic approach (antiviral, anti-inflammatory, anticoagulant and oxygen therapy) and sufficient for surgical treatment of the mediastinal abscess.\nTake-Home Message / Teaching Points\u00a0 \nDue to its advances, the standard-protocol pulmonary CTA is established as the first-line imaging procedures for those patients.",
    "differential_diagnosis": "Azygos, vein, thrombosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-02//17153_1_1.png?itok=nCQIXokr",
            "caption": "Portal venous phase postcontrast CT coronal image demonstrates extensive thrombus alnog the lenght of the azygos vein lumen (black arrows). Distal part of the azygos vein lumen, towards the superior vena cava, is opacified by contrast with normal patency (white arrow). Paravertebral abscess of posterior left mediastinum (asterix) with drainage catheter."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-02//17153_2_1.png?itok=89GBiDCl",
            "caption": "Portal venous phase postcontrast CT axial image shows thrombus in azygos vein seen as a lumen filling defect (white arrow)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-02//17153_3_1.png?itok=8LM6SRUv",
            "caption": "Three dimensional reconstruction of postcontrast CT, lateral view. The osteolytic destruction of the vertebral body (black arrow) associated with paravertebral abscess of posterior left mediastinum. Normal patency of the azygos vein arch seen as a normal opacification (asterix) and obliterated part without contrast opacification (between lines). The thrombus extends up to arch of the azygos vein (white arrow). Superior vena cava (black circle) and right brachiocephalic vein (two black circles)."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-02//17153_4_1.png?itok=wT3Wq6_v",
            "caption": "Portal venous phase postcontrast CT sagital image demonstrate posterior mediastinal abscess (circle) and azygos vein thrombosis (white arrows)."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax",
      "Veins / Vena cava"
    ],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/17153",
    "time": "10.02.2021"
  },
  "17158": {
    "case_id": 17158,
    "title": "Case title Septic pulmonary emboli: A cause of cavitating lung nodules",
    "section": "Chest imaging",
    "age": "42",
    "gender": "female",
    "diagnosis": "Septic pulmonary emboli",
    "history": "A 42-year-old female presented with worsening cough and breathlessness of two weeks duration. She had past history of internal jugular vein thrombosis and left upper limb deep vein thrombosis. She was a known hypertensive on medication. She was afebrile at the time of examination. Laboratory investigations revealed mild leukocytosis and thrombocytosis with mildly raised D-dimer and positive Lupus anticoagulant. Echocardiography showed mild left ventricular hypertrophy with an ejection fraction of 60%.",
    "image_finding": "Chest radiograph revealed multiple nodular opacities in both lungs, few showing internal lucency, suggestive of cavitation. There was left moderate and right minimal pleural effusion with mild cardiomegaly. No peripheral or central venous line was noted. Left-sided effusion was drained with an intercostal drainage tube. A computed tomography (CT) pulmonary angiography of chest was performed. Multiple well-defined, thick-walled, cavitating and non-cavitating nodules were seen in both lungs. They did not contain air-fluid levels or enhancing soft tissue component. Bilateral pleural effusion was present. There were no features of pulmonary hypertension or thrombosis. Mediastinal and left axillary lymphadenopathy was present. There was vascular engorgement over the left anterior chest, due to collaterals formed as a result of previous left upper limb deep vein thrombosis. \n\u00a0\nThe possibility of septic emboli was considered and bronchoalveolar lavage was performed, which tested positive for Citrobacter. Intravenous antibiotics were started and the patient showed clinical improvement. Anti-neutrophil cytoplasmic antibody tests for c-ANCA and p-ANCA were negative. A CT- guided biopsy was planned to confirm the diagnosis. This revealed necroinflammatory tissue with neutrophils. There was no evidence of vasculitis or neoplasm.",
    "discussion": "A cavity is defined as a lucency within a pulmonary consolidation, mass or nodule. A combined analysis of symptoms, previous clinical history, laboratory and imaging findings is necessary to reach a diagnosis. The causes of cavitatory lesions broadly include infection, systemic diseases, neoplasm and miscellaneous causes [1]. \nSeptic emboli are usually seen in patients with infective endocarditis, indwelling catheters and a source of sepsis such as periodontal disease or deep vein thrombosis. The most frequently associated organism is Staphylococcus [2]. Clinical history can reflect rapid clinical deterioration and elevated lymphocyte counts. Imaging features include cavitating or non-cavitating nodules or peripheral wedge shape consolidations. A \u2018feeding vessel\u2019 sign which represents a pulmonary arterial branch coursing to the centre of the nodule may be seen. This was earlier considered to be highly specific to the condition [2]; however, it may be seen in other diseases such as angioinvasive pulmonary aspergillosis, pulmonary embolism, arteriovenous malformation and metastasis. Another differential is Wegener\u2019s granulomatosis, a multisystem vasculitis affecting respiratory system, kidneys and skin. Most patients have an elevated c-ANCA level. On imaging, a \u2018halo sign\u2019 may be seen due to haemorrhage, which is represented by ground-glass opacity surrounding a nodule [3]. Cavitating metastasis is another differential to be considered. A primary should be excluded. Metastases from squamous cell carcinoma, adenocarcinoma or sarcomas tend to cavitate. Spontaneous pneumothorax can occur in case of osteosarcoma metastases [4]. \nIn any suspected infection, other features should be looked for, such as consolidation with air bronchograms, \u2018split pleura sign\u2019 (empyema),\u00a0 \u2018bulging fissure sign\u2019 (Klebsiella pneumonia), tree in bud pattern nodules, air-fluid level in a cavity (abscess), halo and reverse halo signs (fungal infection) and water-lily sign (Hydatid cyst) [5]. The management in a case of septic emboli includes treating the source of infection such as drainage of abscess, removal or replacement of an infected catheter and antibiotic treatment.",
    "differential_diagnosis": "Septic, pulmonary, emboli, Granulomatosis, with, polyangiitis, Cavitating, metastases",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-02//17158_1_1.JPG?itok=p76ysRB_",
            "caption": "Posteroanterior chest radiograph shows multiple cavitating and non-cavitating nodules in both the lung fields. There is moderate left and minimal right pleural effusion with fissural extension."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-02//17158_2_1.JPG?itok=nOYXAh9o",
            "caption": "Axial chest CT (lung window) shows thick-walled cavitating nodules in both the lungs."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-02//17158_3_1.JPG?itok=seQiulNQ",
            "caption": "Axial chest CT (lung window) shows bilateral basal, peripheral consolidation and ground glass opacities. Left pleural effusion is seen extending along the oblique fissure."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-02//17158_4_1.JPG?itok=Z9TadlDj",
            "caption": "Axial CT pulmonary angiogram image in the arterial phase (mediastinal window) shows no evidence of thrombosis with multiple enlarged, non-calcified mediastinal lymph nodes."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-02//17158_5_1.JPG?itok=KlmiutDg",
            "caption": "Axial CT pulmonary angiogram image in the venous phase (mediastinal window) shows no evidence of pulmonary thrombosis. There are enlarged left axillary lymph nodes and multiple venous collaterals over the left anterior chest."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-02//17158_6_1.JPG?itok=4ib1tb-w",
            "caption": "Histopathology image shows polymorphonuclear neutrophil infiltrate with no malignant cells or vasculitis."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Thorax",
      "Vascular"
    ],
    "imaging_technique": [
      "CT-Angiography"
    ],
    "link": "https://www.eurorad.org/case/17158",
    "time": "11.02.2021"
  },
  "17166": {
    "case_id": 17166,
    "title": "Pulmonary mucormycosis: a rare and fatal complication in a young diabetic patient",
    "section": "Chest imaging",
    "age": "27",
    "gender": "female",
    "diagnosis": "Pulmonary mucormycosis",
    "history": "A 27-year-old female was admitted with diabetes decompensation secondary to severe community-acquired pneumonia. After 2 weeks in the ICU and no improvement despite broad-spectrum antibiotic treatment, a CT scan was requested. Based on the findings, bronchoscopy and biopsy were performed, which gave the diagnosis.",
    "image_finding": "The initial chest CT scan showed extensive areas of central non-enhancing consolidation in the right lung crossing the fissures, right pleural effusion, and left lung perivascular ground glass opacities. The consolidations surrounded areas of central ground glass opacity (reversed halo sign). Large halo signs were also present (Fig. 1). The pulmonary involvement encompassed all the right lung bronchi, showing amputation of the middle lobe segmental arteries (Fig. 2) and signs of mediastinal fat involvement (Fig. 3), all consistent with an invasive infection. \nIn a follow-up CT pulmonary angiogram, the consolidations showed necrosis and cavitation (Fig. 4). Left lung involvement had also worsened. Signs of vascular invasion evolved into irregularity of the interlobar and inferior lobe pulmonary arteries, with stenosis, dilation, and pseudoaneurysm formation (Fig. 5 and 6). The left pulmonary veins were also compromised (Fig. 6).",
    "discussion": "Pulmonary mucormycosis\u00a0is an uncommon opportunistic\u00a0pulmonary fungal infection\u00a0caused by Mucorales fungi belonging to the class Zygomycetes [1]. It is an angioinvasive infection often leading to pulmonary infarction and invasion of tissues by contiguity. Mucormycosis usually occurs in immunocompromised patients with haematologic malignancies, particularly after a solid organ or stem cell transplant. Nowadays, diabetes mellitus as an isolated risk factor, as in our case, is very rare [2]. \nSymptoms may comprise fever refractory to broad-spectrum antibiotics, nonproductive cough, and progressive dyspnoea. Pleuritic chest pain, haemoptysis, and pleural effusion are seen less frequently. Invasion of the major pulmonary blood vessels may lead to massive, potentially fatal haemoptysis. Invasion of adjacent organs by traversing tissue planes, including the diaphragm, chest wall, and pleura have also been described [2].\nPulmonary mucormycosis\u00a0may have a nonspecific appearance at imaging. It can manifest as a reverse halo sign on CT [2,3], consistent with a thick solid area of consolidation with central ground-glass opacity, a frequent and relatively specific sign of mucormycosis in the appropriate clinical setting. Vascular findings include arterial filling defects (fungal emboli) and pulmonary artery pseudoaneurysm formation due to direct invasion of the arterial walls. In this sense, the vascular cutoff sign [3] refers to an abrupt termination of a branch of the pulmonary artery. Some severe cases may show a pattern of multifocal pneumonia [3], which is associated with high mortality and simulates multifocal bacterial pneumonia. Identification of the hyphae in tissue by using endobronchial or percutaneous sampling can allow differentiation from invasive pulmonary aspergillosis and help confirm the diagnosis of mucormycosis [2]. \nThis opportunistic aggressive fungal infection is far less common than Aspergillus and Candida infections and has a much higher mortality rate [4,5]. Surgical treatment in conjunction with systemic antifungal therapy has been shown to significantly improve survival compared with antifungal therapy alone. Prompt and effective therapy is essential for a successful outcome [2]. Our patient, despite treatment with specific antifungals, developed severe haemoptysis with rapidly progressing clinical deterioration resulting in death.\nTake-home message\nPulmonary mucormycosis is an uncommon, usually fatal, opportunistic infection, often manifesting with the reversed halo sign on CT, which is highly specific for the disease in the appropriate clinical setting. It may also cross pleural surfaces and invade vascular structures and tissues by contiguity. Today, diabetes as the only risk factor is very uncommon.",
    "differential_diagnosis": "Pulmonary, mucormycosis, Angioinvasive, aspergillosis, Lung, cancer, Granulomatosis, with, polyangiitis, Pulmonary, infarction, Tuberculosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-02//17166_1_1.png?itok=qj1gZy20",
            "caption": "Axial contrast-enhanced chest MDCT, lung window: extensive consolidations (blue star) surrounding areas of central ground glass opacity (reversed halo sign in red arrows). Large halo sign (yellow star). Left lung ground glass opacities (pink arrows)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-02//17166_2_1.png?itok=aGpMG4rJ",
            "caption": "Coronal MPR. Amputation of the middle lobe arteries (arrow). Irregular contour of the interlobar descending artery (arrowhead)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-02//17166_3_1.png?itok=BP3gvkA2",
            "caption": "Axial contrast-enhanced chest MDCT, soft-tissue window: extensive consolidations (blue star) and mediastinal invasion (yellow arrows)."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-02//17166_4_1.png?itok=WslAK6oP",
            "caption": "Axial CT pulmonary angiogram, lung (a) and soft-tissue (b) windows. The consolidations show extensive necrosis and cavitation."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-02//17166_4_2.png?itok=JTuWbFQd",
            "caption": "Axial CT pulmonary angiogram, lung (a) and soft-tissue (b) windows. The consolidations show extensive necrosis and cavitation."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-02//17166_5_1.png?itok=I0iBTG_Q",
            "caption": "MIP reconstruction. Pseudoaneurysm (arrowhead)."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-02//17166_6_1.png?itok=WvFsR3td",
            "caption": "Volume-rendered image reconstruction showing irregularity of the interlobar and inferior lobe pulmonary arteries, with stenosis, dilation, and a pseudoaneurysm (arrowhead). The inferior left pulmonary vein is hardly visible (arrow) and the superior pulmonary vein was absent."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Emergency",
      "Lung"
    ],
    "imaging_technique": [
      "CT",
      "CT-Angiography"
    ],
    "link": "https://www.eurorad.org/case/17166",
    "time": "22.03.2021"
  },
  "17172": {
    "case_id": 17172,
    "title": "Pneumorrhachis, an underreported sign associated with pneumomediastinum",
    "section": "Chest imaging",
    "age": "19",
    "gender": "male",
    "diagnosis": "Spontaneous pneumomediastinum with pneumorrhachis",
    "history": "A 19-year-old Caucasian male with no medical or surgical history presented at the emergency department for intermittent diffuse abdominal pain since 5 days. He complained of nausea, incoercible vomiting and loss of appetite. The patient was a known user of cannabis. Physical examination showed abdominal, thoracic and dorsal widespread subcutaneous emphysema.",
    "image_finding": "Thoracic CT scan was performed because of the widespread extent of the subcutaneous emphysema. CT confirmed an extensive pneumomediastinum (Figure 1) but no pneumothorax. It also revealed a significant amount of air in the epidural space of the spinal canal from C6 to D12 (Figure 2). The patient was admitted for observation. The CT scan was repeated on the fifth day of hospitalization and showed an important decrease of the pneumomediastinum and subcutaneous emphysema. The component of air within the spinal canal had also decreased in volume. The patient was then discharged.",
    "discussion": "Background\nThe presence of air in the spinal canal is a known radiological finding. It was described for the first time in 1977 by Gordon and Hardman [1] as a traumatic pneumomyelogram in a patient with a skull base fracture. Over the years, few other cases reporting this finding have been published, dubbing it Pneumorrhachis (PR). Overall, fewer than 150 cases have been described in the literature as of 2018 [2]. A recent study by Behr et al. [2] however examined a population of 242 patients with pneumomediastinum and identified 14 patients with PR. A prevalence of 5.8% then gives rise to the notion PR may simply be underreported.\nClinical Perspective\nThe presence of air in the spinal canal is a finding that is usually associated with trauma. In absence of trauma, it is usually spontaneous and associated with pneumomediastinum as well as various conditions presenting with elevated intrathoracic pressure. When spontaneous, there exists a predilection for young illicit drug users (3,4,5). PR may be intradural or extradural. The former is associated with severe trauma, the latter being mostly spontaneous and innocuous [3]. Manoeuvres that raise intrathoracic pressure such as the Valsalva manoeuvre, create high intra-alveolar pressure. The distended alveoli may then rupture (the Macklin effect) [6]. Balachandran et al. hypothesized that due to the absence of fascial barriers between the posterior mediastinum and the retropharyngeal and epidural spaces, free air in the mediastinum and cervical soft-tissues may enter the paraspinal tissues and travel through neural foramina alongside the neurovascular bundle into the epidural space [7]. In our case, the pneumomediastinum probably occurred secondary to a Valsalva manoeuvre after forceful vomiting and/or attempts to maximize inhaled drug absorption (\u2018huffing\u2019) [8].\nImaging Perspective\nIn general, the diagnosis of pneumomediastinum can be made on plain chest radiography if PR should be associated with increased severity of pneumomediastinum [9], CT should be the preferred diagnostic method of choice to assess pneumomediastinum as conventional imaging cannot detect PR, although treatment and outcome would probably remain unaffected. \nOutcome\nPR usually resolves spontaneously without neurologic sequelae. Conservative treatment is suggested, however, the accumulation of gas may cause intracranial and intraspinal hypertension causing hypotension [3]. Rarely PR may give rise to cord compression, requiring decompressive surgery [10].\nTake-Home Message / Teaching Points\nPR is an underreported sign that is commonly associated with pneumomediastinum. In the absence of trauma, PR is often associated with illicit drug use.",
    "differential_diagnosis": "Spontaneous, pneumomediastinum, with, pneumorrhachis, Traumatic, Pneumorrhachis, Localised, epidural, gas, due, to, degenerative, disc, disease, or, synovial, cyst, degeneration, Post-operative, air, after, spine, surgery",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-02//17172_1_1.jpg?itok=MHclGSH9",
            "caption": "CT scan, axial image at the level of the upper mediastinum. Note the free mediastinal air (red asterisks)"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-02//17172_2_1.jpg?itok=JcaeY6RB",
            "caption": "CT scan, sagittal image at the level of the spine. Note the free epidural air (red arrows)"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Anatomy",
      "Emergency",
      "Mediastinum"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/17172",
    "time": "01.03.2021"
  },
  "17176": {
    "case_id": 17176,
    "title": "Out of the box",
    "section": "Chest imaging",
    "age": "72",
    "gender": "male",
    "diagnosis": "Pleural fluid collection secondary to dropped gallstones",
    "history": "A 72-year-old male ex-smoker, presented with fatigue and shortness of breath. He was referred for a CT scan due to persistent opacification in the right costophrenic angle on CXR. He had hypertension, hypercholesterolemia, hiatus hernia with Barrett\u2019s oesophagus and past history of gall stone pancreatitis a few years prior with interval cholecystectomy.",
    "image_finding": "Chest radiograph demonstrates patchy opacification and blunting of the right costophrenic angle. Additionally known hiatus hernia..\nContrast-enhanced staging CT of the thorax in arterial phase and upper abdomen in portal venous phase shows multiloculated wall enhancing pleural collection along the right costophrenic recess posterolateral to the diaphragm. It is infiltrating into the posterolateral chest wall. There is associated subsegmental atelectasis of the adjacent right lateral basal segment.\nInferiorly, there are calcific foci within the collection. No air locules within the collection. No calcified pleural plaques.\n\u00a0A subsequent USS of the right chest wall reveals calculi with posterior acoustic shadowing within the collection extending into the chest wall.",
    "discussion": "We present an unusual case of patchy right costophrenic opacification in a patient which was clinically concerning for malignancy. On staging contrast-enhanced CT this was demonstrated to be due to a right pleural fluid collection with calcific foci within. Further targeted US scan showed calcific foci with posterior acoustic shadowing in the collection consistent with appearances of calculi.\nWe also reviewed prior imaging which revealed a previous episode of gallstone associated pancreatitis four years ago seen on CT.\u00a0 Dropped gall stones within the abdomen were seen on a CT scan performed one-year post-cholecystectomy.\nThe constellation of the findings on CT and USS with review of previous imaging helped to make the diagnosis of pleural fluid collection secondary to dropped gallstones.\nIt was explained to the patient that his symptoms were related to gallstones and he opted for surveillance imaging in favour of surgical retrieval.\nDropped gallstones are an infrequent occurrence, reported in 1 to 20% of the cases following laparoscopic cholecystectomy. Amongst these, 20% of the cases may go on to have further complications, including granulomas and abscesses [1]. A dropped gallstone acts as an inflammatory nidus and incites a low-grade granulomatous response [2]. In rare instances, dropped gallstones may migrate superiorly and enter the pleural cavity, possibly as a result of diaphragmatic defects in elderly patients [2, 3]. Pleural empyema and abscesses have been reported numerous times in association with dropped gallstones [1, 2, 3].\nDiagnosis is challenging and frequently delayed because of the atypical clinical presentations, unexpected locations of dropped gallstones, and inability to visualise radiolucent calculi with conventional imaging-like radiographs [2]. Imaging is needed to rule out any sinister pathology being considered and assure the requesting physician that the pathology is benign [2]. It is crucial to keep this diagnosis in mind, as the history of surgery may be remote, and the patient may be afebrile with normal inflammatory markers [2].\nIncidental asymptomatic dropped gallstones are easily identified with CT and ultrasound when they are large and calcified [2, 3]. It is recommended to always look for prior imaging, as in this case there were dropped gallstones in the abdomen that had migrated to the pleura [3]. Figure 6 shows a contrast-enhanced CT axial image of the abdomen taken four years prior when the patient presented with acute necrotising pancreatitis associated with gallstones. In figure 7, the contrast-enhanced CT axial image of the abdomen post-interval cholecystectomy for the same patient one year after the episode of pancreatitis shows the dropped gallstones posterior to the liver.\nTake-Home Message/Teaching Points:\nDropped gallstones can cause recurrent and indolent abscesses in uncommon and extra-abdominal locations.\nPresentation is often remote from the time of the actual procedure.\nGranulomatous inflammation can mimic malignancy with infiltration into adjacent structures.\nCareful history taking and evaluation of the previous imaging helps to point towards the diagnosis.\nMultimodality imaging with CT and US or MRI is needed for making a confident diagnosis.",
    "differential_diagnosis": "Pleural, fluid, collection, secondary, to, dropped, gallstones, Mycobacterium, tuberculosis, Actinomyces, israelii, Mesothelioma, Necrotising, tumours, Simple, abscess, and, empyema",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-02//17176_1_1.jpg?itok=TRXU83yo",
            "caption": "Chest radiograph (PA) demonstrates persistent patchy opacity in the right costophrenic angle. Hiatus hernia also noted."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-02//17176_2_1.jpg?itok=XgEvgAeP",
            "caption": "Contrast enhanced arterial phase CT chest axial images (a-c) reveal multiloculated wall enhancing pleural collection with split pleura sign along the right costophrenic recess posterolateral to the diaphragm. It is infiltrating into the posterolateral chest wall. Sub segmental atelectasis of the adjacent right lateral basal segment. Inferiorly, there are calcific foci within the collection."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-02//17176_2_2.jpg?itok=4_2iazTZ",
            "caption": "Contrast enhanced arterial phase CT chest axial images (a-c) reveal multiloculated wall enhancing pleural collection with split pleura sign along the right costophrenic recess posterolateral to the diaphragm. It is infiltrating into the posterolateral chest wall. Sub segmental atelectasis of the adjacent right lateral basal segment. Inferiorly, there are calcific foci within the collection."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-02//17176_2_3.jpg?itok=XfbJ6UjJ",
            "caption": "Contrast enhanced arterial phase CT chest axial images (a-c) reveal multiloculated wall enhancing pleural collection with split pleura sign along the right costophrenic recess posterolateral to the diaphragm. It is infiltrating into the posterolateral chest wall. Sub segmental atelectasis of the adjacent right lateral basal segment. Inferiorly, there are calcific foci within the collection."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-02//17176_3_1.jpg?itok=OUkHXM9m",
            "caption": "Contrast-enhanced arterial phase CT chest sagittal image demonstrating the multiloculated wall enhancing pleural collection with split pleura sign along the right costophrenic recess posterolateral to the diaphragm. It is infiltrating into the posterolateral chest wall. Sub segmental atelectasis of the adjacent right lateral basal segment. Inferiorly, there are calcific foci within the collection."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-02//17176_4_1.jpg?itok=_GHSq9v1",
            "caption": "Contrast-enhanced axial CT image in portal phase better demonstrates the multiloculated wall enhancing pleural collection with split pleura sign along the right costophrenic recess posterolateral to the diaphragm. It is infiltrating into the posterolateral chest wall."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-02//17176_5_1.jpg?itok=zaAGgRP2",
            "caption": "Ultrasound image shows the pleural collection with calculus within."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-02//17176_6_1.jpg?itok=yvehS_Ab",
            "caption": "Contrast-enhanced axial CT image of the abdomen showing features of acute necrotising pancreatitis with non-enhancing body of pancreas and air locules within the areas of necrosis. Associated gallstones in the gallbladder."
          }
        ]
      },
      {
        "number": "Figure 7",
        "subfigures": [
          {
            "number": "Figure 7",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-02//17176_7_1.jpg?itok=z99K41V5",
            "caption": "Contrast-enhanced axial CT image of the abdomen post interval cholecystectomy one year after the episode of pancreatitis demonstrating the dropped gallstones posterior to the liver."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Thorax"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT",
      "Ultrasound"
    ],
    "link": "https://www.eurorad.org/case/17176",
    "time": "22.03.2021"
  },
  "17182": {
    "case_id": 17182,
    "title": "Recurrent respiratory papillomatosis",
    "section": "Chest imaging",
    "age": "17",
    "gender": "female",
    "diagnosis": "Recurrent respiratory papillomatosis",
    "history": "A 17-year-old female presents with 3 months progressive dysphonia, hoarseness and mild dyspnoea. Two episodes of pneumonia in the last five years were reported. The clinical examination was unremarkable. A chest radiograph and CT scan were performed, as well as laryngoscopy, which revealed a supraglottic polypoid lesion that was biopsied.",
    "image_finding": "Pathologic evaluation of the specimen revealed a squamous cell papilloma. \nThe chest radiograph revealed no significant changes. Chest CT was performed to evaluate the pulmonary parenchyma. Numerous thin-wall cystic lesions were identified in the lung parenchyma, some of which were lobulated and confluent, with bilateral distribution, predominantly on the right inferior lobe (Fig.1a-c). There was also a small number of infracentimetric and pericentimetric solid lesions (Fig. 1d-e).\nThere were no parenchymal consolidations, atelectasis, bronchiectasis, nor mucus plugging. \nA polypoid vegetant lesion was also depicted in the supraglottic space, posterior and inferior to the right aryepiglottic fold, with 11 mm (Fig. 2).",
    "discussion": "Recurrent respiratory papillomatosis (RRP) is generally a benign disease, caused by low-risk human papillomavirus (HPV) subtypes 6 and 11, and characterised by the appearance of multiple squamous cell papillomas involving the respiratory tract. Most commonly, the lesions affect the larynx and less commonly the trachea and bronchial tree. Only 1% of cases show pulmonary involvement. Focal or diffuse airway narrowing is caused by the nodular vegetant lesions, which occur on the mucosal surface, projecting into the airway lumen [1, 2]\nAlthough it is unclear how HPV infection progresses to RRP, a recent study shows the presence of pepsin inside the pharyngeal mucosal cell in 45.5% of children with RRP. Pepsin, present in laryngopharyngeal reflux, could cause or facilitate many pathologies in children, contributing to development of RRP by activating or reactivating latent HPV infection [3, 4]\nThe disease has a higher incidence in children, being the most common benign laryngeal neoplasia in this age group. The most common clinical manifestations are hoarseness, cough, stridor, dyspnea and recurrent respiratory infections [2, 5].\nChest CT is the preferred imaging technique for identification and characterization of tracheobronchial polypoid lesions and recognition of small nodules during the pulmonary dissemination phase. The characteristic CT patterns are solid nodular or polypoid lesions in the trachea, which can be single or multiple, and solid nodules scattered throughout the lung parenchyma, more numerous in the basal and posterior regions of the lungs, with a centrilobular distribution, typically confluent. These nodules may enlarge and cavitate, becoming air-filled cysts, forming large cavities with irregular internal borders, and with thick or thin walls. Less prevalent findings comprise mass, consolidation, air trapping, and pleural effusion. [2, 6, 7]\nRegular follow-up with CT is recommended due to the rare possibility of malignant transformation [6, 7].\nThe diagnosis is made after histopathological analysis of laryngeal or tracheal samples, collected by laryngoscopy or bronchoscopy [3, 5]. \nThe course of the disease is unpredictable, ranging from spontaneous remission to aggressive disease progression, spreading to the lungs, and it may require multiple surgical procedures to maintain the airway function. \nThe estimated malignancy rate of RRP is approximately 3-7% in adults and less than 1% in children [1, 5, 6]. \nNo definitive curative treatment for RRP is currently available, being surgical excision the current standard of care. Most recently, multivalent HPV vaccine has been used to manage RRP with promising outcomes; HPV vaccination is central in prophylaxis and the disease may be eliminated with universal vaccination [1, 7].\nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Recurrent, respiratory, papillomatosis, Granulomatosis, with, polyangiitis, Cystic, pulmonary, metastases, Lymphangioleiomyomatosis, Pulmonary, Langerhans, cell, histiocytosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-02//17182_1_1.jpg?itok=RPv9KVDJ",
            "caption": "Chest CT images in lung parenchymal window, showing multiple cavitated nodules in the right lower lobe. The nodules show thin walls, some with faint peripheral ground-glass opacities (A and B - axial; C - coronal); In the same lobe, note the few solid nodular lesions scattered (D and E)"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-02//17182_1_2.jpg?itok=KiSZO-WH",
            "caption": "Chest CT images in lung parenchymal window, showing multiple cavitated nodules in the right lower lobe. The nodules show thin walls, some with faint peripheral ground-glass opacities (A and B - axial; C - coronal); In the same lobe, note the few solid nodular lesions scattered (D and E)"
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-02//17182_1_3.jpg?itok=1kAUooPX",
            "caption": "Chest CT images in lung parenchymal window, showing multiple cavitated nodules in the right lower lobe. The nodules show thin walls, some with faint peripheral ground-glass opacities (A and B - axial; C - coronal); In the same lobe, note the few solid nodular lesions scattered (D and E)"
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-02//17182_1_4.jpg?itok=6sTXPuhq",
            "caption": "Chest CT images in lung parenchymal window, showing multiple cavitated nodules in the right lower lobe. The nodules show thin walls, some with faint peripheral ground-glass opacities (A and B - axial; C - coronal); In the same lobe, note the few solid nodular lesions scattered (D and E)"
          },
          {
            "number": "Figure 1e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-02//17182_1_5.jpg?itok=-OOHJrOL",
            "caption": "Chest CT images in lung parenchymal window, showing multiple cavitated nodules in the right lower lobe. The nodules show thin walls, some with faint peripheral ground-glass opacities (A and B - axial; C - coronal); In the same lobe, note the few solid nodular lesions scattered (D and E)"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-02//17182_2_1.jpg?itok=dNbCC5wv",
            "caption": "Axial (A) and coronal (B) contrast-enhanced CT images showing a supraglottic polypoid lesion, arisen from the inferior and posterior margin of the right aryepiglottic fold."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-02//17182_2_2.jpg?itok=_EVH06ec",
            "caption": "Axial (A) and coronal (B) contrast-enhanced CT images showing a supraglottic polypoid lesion, arisen from the inferior and posterior margin of the right aryepiglottic fold."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/17182",
    "time": "22.03.2021"
  },
  "17188": {
    "case_id": 17188,
    "title": "ndobronchial lipom",
    "section": "Chest imaging",
    "age": "68",
    "gender": "male",
    "diagnosis": "Endobronchial lipoma",
    "history": "A 68-year-old male patient consulted the emergency department referring to dyspnoea and fever. Patient had a smoking history but did not refer to constitutional syndrome. Blood analysis showed leukocytosis and other inflammatory parameters elevation. Antibiotic treatment was given and the patient was sent to the respiratory medicine department for further study and control.",
    "image_finding": "Chest x-ray showed a segmental consolidation on the anterior right lobe upper segment and a doubtful increased in size of the right hilum (Fig. 1).\nPersistence of the consolidation was evidenced on the control chest x-ray performed 4 weeks later (Fig. 2).\nThoracic computed tomography (CT) with intravenous contrast was performed and the presence of an increased attenuation with consolidation density and volume loss in the right upper lobe anterior segment was confirmed (Fig. 3).\nEndoluminal lesion with fat attenuation causing occlusion of the segmental anterior bronchus of the right upper lobe was seen (Fig. 4, Fig 5).\nThe patient underwent flexible bronchoscopy with biopsy (Fig. 6).\nHistopathology result showed fatty mature cells with no signs of atypia nor mitosis, being confirmed the diagnosis of endobronchial lipoma (Fig. 7).",
    "discussion": "Endobronchial lipoma is a benign tumour of fatty lineage, with an incidence of approximately 0,1 \u2013 0,5% around all pulmonary tumours. [1] Endobronchial lipoma comes along with repeated pneumonia, breathing difficulty, cough and other symptoms due to bronchial obstruction\u00a0 [2] Due to the obstruction produced by the tumours, on chest X-ray is usually observed segmental atelectasis or certain volume loss,\u00a0 consolidation, mass-like image or certain pleural effusion. [3,4]\nDiagnosis based on image techniques is difficult and for its certain diagnosis, it is mandatory to demonstrate airway obstruction caused by a fat attenuation material without calcification,[5,6] usually nodular or\u00a0polyploid.\nCT is mandatory for the correct assessment of the level of the obstruction and distinguishes the potential cause of atelectasis. Also, CT must demonstrate a fat attenuating lesion (usually - 80UH) for its presumptive diagnosis. When evaluating an endobronchial lipoma or any other endobronchial lesion CT radiologist must highlight the shape, location (endobronchial tree, segment, lobe and if there is extraluminal extension) \u00a0in order to guide the management of the lesion. As in all endobronchial tumours, final diagnosis is provided by flexible bronchoscopy and histopathology.\nFor the correct management of endobronchial lipoma, every case must be individualised. Treatment possibilities should always be planned with the presence of the radiologist for a better understanding of the tumour anatomic factors and the condition of the affected lung and, as a part of a multidisciplinary team. Nowadays, treatment for endobronchial benign lesions can vary from surgical resection with endobronchial treatment with cryotherapy or YAG laser (neodymium-doped yttrium aluminium garnet).[7,8]\nPrognosis is good when completed resected. \u00a0When it cannot leads to repeatedly pneumonia and atelectasis of the affected lobe [9].\nAs teaching point always remember:\n1. Demonstration of an endobronchial lesion with totality or high-fat content with a homogenous attenuation and the absence of calcification is highly suggestive of endobronchial lipoma.\n2. Endobronchial lesions are rare, the most frequent is pulmonary hamartoma always look up the features and lookup for the most accurate diagnosis.\n3. When describing an endobronchial lesion always define the location, length, shape and extraluminal parts if had any.\n4. Endobronchial lesions can cause cough and pneumonia due to bronchial obstruction.\n5. Radiologist presence and his opinion must be taken into consideration when deciding the best treatment option. Written informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Endobronchial, lipoma, Hamartoma, Foreign, body, with, low-fat, attenuation, (vegetable), Bronchogenic, carcinoma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-03//17188_1_1.png?itok=CeWIchBs",
            "caption": "Chest X-ray (posteroanterior and lateral projection) performed at diagnosis in the ED. Increase in density with consolidation characteristics in the anterior segment of right upper and doubtful increase in the size of the right hilum."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-03//17188_2_1.png?itok=gB9joq-j",
            "caption": "Thoracic X-ray (posteroanterior and lateral projection) performed at the end of the antibiotic treatment. The lesion persists, without significant modification."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-03//17188_3_1.png?itok=d0gcOnEK",
            "caption": "Contrast enhanced coronal reconstruction CT with lung window. Consolidation versus atelectasis in the anterior segment of the RUL."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-03//17188_4_1.png?itok=Tsqa5sgV",
            "caption": "Contrast enhanced axial and sagittal reconstruction, CT thorax with mediastinal window. There is a low density lesion (approx-90 UH), compatible with fat density in the anterior segmental bronchus of right upper lobe (Red arrow)."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-03//17188_5_1.JPG?itok=B6MBwmXO",
            "caption": "Magnified view of axial CT showing the endobronchial lipoma, showing low attenuation in the anterior segmental bronchus."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-03//17188_6_1.png?itok=I7gbe_fA",
            "caption": "Images of bronchoscopy, appreciate total occlusion of the segmental bronchus, caused by a polypoid, shiny, pediculated and benign aspect image, compatible with lipoma."
          }
        ]
      },
      {
        "number": "Figure 7",
        "subfigures": [
          {
            "number": "Figure 7",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-03//17188_7_1.png?itok=bk2pKfFU",
            "caption": "Pathological study. Respiratory epithelium and mature adipose cells that showed no atypia nor mitosis."
          }
        ]
      },
      {
        "number": "Figure 8",
        "subfigures": [
          {
            "number": "Figure 8",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-03//17188_8_1.png?itok=RJKPhk7Y",
            "caption": "Thoracic X-ray (posteroanterior projection) performed as a part of protocol when the patient returned referring low back pain. Persistence of atelectasis of the right upper lobe."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/17188",
    "time": "01.03.2021"
  },
  "17197": {
    "case_id": 17197,
    "title": "Acute fibrinous and organizing pneumonia (AFOP)",
    "section": "Chest imaging",
    "age": "36",
    "gender": "female",
    "diagnosis": "Acute fibrinous and organizing pneumonia (AFOP)",
    "history": "A 36-year-old woman with history of hypertrophic cardiomyopathy, awaiting heart transplant, developed a 2-month clinical condition of progressive low-grade fever and dry cough, refractory to multiple cycles of antibiotics. Laboratory exams presented leukocytosis (17.000x109/mL) with neutrophilia and pronounced C-reactive protein elevation (260mg/dL). The remaining laboratory investigations were unremarkable.",
    "image_finding": "Initial chest radiographs showed bilateral ill-defined opacities with basal predominance, more conspicuous on the right hemithorax (Fig. 1a,b). \nAn initial chest computed tomography (CT) scan was performed, which showed multifocal ground-glass opacities associated with septal thickening (crazy-paving pattern), mainly with peripheral distribution and lower lobe predominance, with scattered small foci of consolidation (Fig. 2a-c).\nA follow-up CT, ten days later, showed more extensive opacities, which also increased in density, while maintaining basal and peripheral predominance. A small right pleural effusion was also seen (Fig. 3a,b), probably related to the underlying cardiac dysfunction.\nThe patient underwent a lung biopsy with histological evaluation, which showed enlarged alveolar septa caused by early fibrosis, inflammatory infiltrate and alveoli filled with blood and fibrin. These morphological aspects were compatible with acute fibrinous and organising pneumonia (AFOP). Therapy with methylprednisolone was started, with symptomatic, laboratory and imaging improvement in the following two months.",
    "discussion": "Background \nAFOP is a rare form of idiopathic interstitial pneumonia, which courses with pulmonary parenchymal inflammation and fibrosis. [1]\nThe dominant histopathological aspects are the presence of intra-alveolar fibrin, with formation of \"fibrin balls\", and concomitant foci of organising pneumonia. Thickening of alveolar septa can be seen as a result of inflammatory cell infiltration. [2]\n\u00a0\nClinical Perspective \nClinical manifestations include dyspnoea, fever and cough. [3]\nThere are two forms of the disease: 1) the acute and fulminant form, with rapid respiratory failure, associated with significant intra-alveolar fibrinous component; 2) the subacute form, with slower progression and good response to therapy, in which the organising component predominates. [3]\n\u00a0\nImaging Perspective \nThe definitive diagnostic of AFOP relies on pathology and requires the presence of the two dominant histological findings described above (refer to \"Background\" section). [2]\nImaging findings are nonspecific and demonstrate the severity of lung involvement. Chest radiography may show disperse segmental opacities and diffuse interstitial infiltrates. Chest CT scans demonstrate two types of findings: 1) the fibrotic component of the disease, with diffuse, basal predominant, ground-glass opacities and simultaneous reticular thickening (which often produces a crazy-paving pattern); 2) the organising pneumonia foci, with multifocal consolidations, with variable distribution. [3]\nAlthough histologically both components co-exist, the first imaging findings are predominantly seen in the acute form of the disease, while the second ones are more common in the subacute form. [4]\nThe main imaging differential diagnoses are acute pulmonary oedema, acute respiratory distress syndrome and some atypical types of pneumonia. [3]\nOutcome (therapeutic options, prognosis, impact of imaging on therapy planning)\nTherapy involves high-dose corticosteroids for several weeks. As such, the exclusion of infectious entities is essential. [3]\nShort term prognosis is variable, with a high morbidity and mortality rate in the acute form and an average recovery rate in the subacute form. [3]\nIn the long term, the prognosis is poor, with frequent recurrence and high mortality rate in the following three years, usually caused by pneumonia. [5]\nResidual peribronchial fibrosis and architectural distortion are frequently found on CT scan reassessments. [5]\nThis case report describes a histologically proven case of AFOP in the subacute form, with a slow and progressive evolution and a good response to corticosteroids. The patient died one year later, during the post-operative period following heart transplantation, from pneumonia (Mycoplasma pneumoniae).\n\u00a0\nTake-Home Message / Teaching Points\nAFOP is a rare idiopathic interstitial pneumonia with variable prognosis.\nImaging findings are nonspecific and include ground-glass opacities and foci of organising pneumonia. \nThe definitive diagnostic is histological, with identification of \"fibrin balls\" inside the alveoli and foci of organising pneumonia.",
    "differential_diagnosis": "Acute, fibrinous, and, organizing, pneumonia, (AFOP), Acute, respiratory, distress, syndrome, Acute, pulmonary, oedema, Viral, pneumonia, Pneumocystis, jirovecii, pneumonia",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-03//17197_1_1.png?itok=FFFEBptJ",
            "caption": "Chest radiographs in posteroanterior (a) and lateral (b) incidences, showing bilateral ill-defined opacities with basal predominance, more conspicuous on the right hemithorax (arrowheads)."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-03//17197_1_2.png?itok=pd4TEZ3c",
            "caption": "Chest radiographs in posteroanterior (a) and lateral (b) incidences, showing bilateral ill-defined opacities with basal predominance, more conspicuous on the right hemithorax (arrowheads)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-03//17197_2_1.png?itok=7imJbVER",
            "caption": "Initial chest CT scan in axial (a,b) and coronal (c) planes, showing multifocal ground glass opacities associated with septal thickening (crazy-paving pattern), with peripheral distribution and lower lobe predominance, with scattered small foci of consolidation (arrows)."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-03//17197_2_2.png?itok=CAUFVH9Y",
            "caption": "Initial chest CT scan in axial (a,b) and coronal (c) planes, showing multifocal ground glass opacities associated with septal thickening (crazy-paving pattern), with peripheral distribution and lower lobe predominance, with scattered small foci of consolidation (arrows)."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-03//17197_2_3.png?itok=vjLFeIbZ",
            "caption": "Initial chest CT scan in axial (a,b) and coronal (c) planes, showing multifocal ground glass opacities associated with septal thickening (crazy-paving pattern), with peripheral distribution and lower lobe predominance, with scattered small foci of consolidation (arrows)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-03//17197_3_1.png?itok=IHnDm2mt",
            "caption": "Follow-up chest CT scan, ten days later, in axial (a) and coronal (b) planes, showing more extensive bilateral basal and peripheral opacities, which also increased in density, associated with more pronounced intralobular septal thickening."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-03//17197_3_2.png?itok=i3i-KFXB",
            "caption": "Follow-up chest CT scan, ten days later, in axial (a) and coronal (b) planes, showing more extensive bilateral basal and peripheral opacities, which also increased in density, associated with more pronounced intralobular septal thickening."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/17197",
    "time": "03.03.2021"
  },
  "17221": {
    "case_id": 17221,
    "title": "Case of multiple pulmonary metastasis from a benign intercranial meningiom",
    "section": "Chest imaging",
    "age": "59",
    "gender": "male",
    "diagnosis": "WHO Grade-2 meningioma metastasis",
    "history": "A 59-year-old Caucasian male presented to our institution following a witnessed seizure with a background history of a previously excised WHO grade-2 frontal meningioma and stereotactic radiation therapy. Other previous history included further debulking surgery in due to significant growth with suspicion of focal brain invasion.",
    "image_finding": "A CT brain performed on presentation to our Emergency Department, demonstrated no interval change from multiple prior surveillance studies.\nSurprisingly, a routine chest radiograph performed to investigate anterior chest wall pain (Figure 1), demonstrated multiple, well-circumscribed non-cavitating round opacities (cannonball lesions) in the lungs bilaterally measuring up to 60 mm. Importantly, the clinical history was devoid of respiratory symptoms such as cough and dyspnoea.\nCT Thorax (Figure 2a, b) subsequently revealed multiple pulmonary metastases. Of note, the patient last chest imaging was from 2013, which showed no evidence of metastatic disease.\u00a0 CT Abdomen and Pelvis imaging showed no synchronous neoplastic pathologies to account for the metastatic disease in the lungs and further investigation with sigmoidoscopy and endoscopy were reported as normal. Furthermore, biopsy from one of the lung lesions confirmed the diagnosis of metastatic meningioma and treatment with Sumatinib, a Tyrosine kinase inhibitor, was commenced.",
    "discussion": "Mostly benign with slow growth rate, accounting for 94% of cases, and rare tendency to metastasise (<1%) meningiomas are the most common primary intracranial tumours. [1]. Broadly divided into three histologic grades, meningioma can be typical/benign (WHO grade-1), atypical (WHO grade-2) or anaplastic (WHO grade-3).\nMetastasis from Grade-2 and Grade-3 have been reported in up to 5% and 30% of the cases respectively. Review of the literature shows that the lung is the most common organ for metastasis (61%) followed by the pleura, liver, abdominal viscera, lymph nodes and bones. [2]\nRisk factors for metastasis include previous craniotomy, venous sinus invasion, local recurrence, and aggressive histological subtypes. Hematogenous metastasis may be the most likely mechanism for extracranial spread with 70% of patients reporting to have had metastatic disease following a craniotomy. [3]\nA second route believed to lead to the development of distant metastasis may be via the cerebrospinal fluid pathway [4]. It is hypothesised that surgical interference may release the tumour cells from their cohesive state into the cerebrospinal fluid. The local recurrence rates even after complete resection vary from 9 to 32%. Despite relatively large number of surgical resections performed each year, metastasis remains rare at less than 1%.[4]\nThere is no standard treatment with curative intent for metastatic meningioma. Complete surgical resection for accessible intracranial meningiomas is the mainstay of treatment for WHO grade-1 meningiomas, whereas grade-2 and 3 tumours often require adjuvant treatment, either radiotherapy or stereotactic radiosurgery. Postoperative radiotherapy has been recommended for prevention of local recurrence, especially when resection is subtotal or when the histology is suggestive of aggressive histology.[5] \nSurgical resection of pulmonary lesions is restricted to those patients who have no extra-thoracic metastatic disease and only if all metastatic lesions could be excised without affecting residual pulmonary function. New approaches which combine the use of chemotherapy and targeted treatments are currently ongoing in clinical trials. [6]\nMeningioma metastasis to the lung should be suspected if there is history of treated meningioma and multiple pulmonary lesions on chest imaging, particularly if the patient is asymptomatic. Biopsy of the pulmonary lesions is ultimately the only way to confirm. FDG PET/CT is helpful to exclude an occult alternative pathology.",
    "differential_diagnosis": "WHO, Grade-2, meningioma, metastasis, Renal, cell, carcinoma, Giant, cell, tumour, of, the, bone, Prostate, cancer, Thyroid, carcinoma, Sarcoma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-03//17221_1_1.jpg?itok=m5dSXzM_",
            "caption": "Multiple cannon ball opacities in the lungs bilaterally measuring up to 60 mm in keeping with metastatic disease."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-03//17221_2_1.jpg?itok=tekzsnAx",
            "caption": "A selective slice on coronal plane CT image depicting multiple pulmonary lesions."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-03//17221_2_2.jpg?itok=ELPwMqPk",
            "caption": "A selective slice on axial plane CT image depicting multiple pulmonary lesions."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Oncology",
      "Respiratory system",
      "Thorax"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/17221",
    "time": "25.03.2021"
  },
  "17250": {
    "case_id": 17250,
    "title": "A case of traumatic oesophageal pleural fistul",
    "section": "Chest imaging",
    "age": "27",
    "gender": "male",
    "diagnosis": "A case of traumatic oesophageal pleural fistula.",
    "history": "A 27-year-old male presented to emergency department with history of stab injury to left side of chest. At the time of presentation, the patient was breathless and complained of pain in left side of chest. His vitals were stable.",
    "image_finding": "An initial evaluation with supine chest radiograph (CXR) showed homogenous diffuse opacity in left hemithorax. Ultrasound evaluation confirmed presence of fluid within the left pleural cavity and subsequently intercostal drainage tube was inserted. He was further evaluated with plain Computed tomography (CT) of thorax which revealed left-sided hydropneumothorax with multiple high-density contents within the left pleural cavity and air space opacities in left basal segments, suggesting underlying lung contusion. A suspicious abnormal communication between left lateral wall of upper thoracic oesophagus and the left pleural cavity prompted the radiologist to perform. Dynamic and static fluoroscopic imaging, which confirmed oesophageal fistula communicating with left pleural cavity. The findings were confirmed by oesophageal endoscopy, and oesophageal stent was deployed.\nThe patient was further taken up for CT thorax with positive orally administered contrast to delineate the fistula prior to definitive surgical management, which revealed accumulation of orally administered contrast into the left pleural cavity via a fistulous communication between oesophagus and pleura.",
    "discussion": "Background \nAn abnormal communication between oesophagus and the pleural cavity called as esophago-pleural fistula (EPF) is a rare entity[1]. The common predisposing factors leading to this condition are iatrogenic injury due to oesophageal instrumentation, malignancy of oesophagus, irradiation or rarely as a complication of pneumonectomy[2].\nClinical Perspective \nThe signs and symptoms are non-specific, hence clinical diagnosis of esophagopleural fistula(EPF) becomes difficult. The diagnosis of EPF can be suspected clinically when a patient presents with retrosternal chest pain, fever, dysphagia, and dyspnea in the background of antecedent history of instrumentation or surgery.; however, for confirmation, imaging is required [3]. \nImaging Perspective \nThe imaging modalities include chest radiograph, ultrasound, barium swallow, contrast-enhanced computed tomography (CT), and magnetic resonance imaging (MRI) with each modality having its advantages, and chest CT is a very useful modality.\nRadiographic findings in EPF include pneumothorax, hydropneumothorax and localized pneumonitis[4]. Ultrasound is helpful in detecting the hydro- or hydropneumothorax.\nA thoracic CT with oesophageal contrast will demonstrate oesophageal pleural fistulas [5].\u00a0CT also plays a role in the management of the EPF as its prognosis depends upon the extent of the mediastinal involvement. EPF without mediastinal involvement usually carries good prognosis and may respond to percutaneous pleural drainage[1]. \nSingle contrast esophagogram with barium or water-soluble contrast media can show leakage of contrast from the oesophagus into pleural cavity, although rarely indicated in this era of CT.[6].\nOutcome \nManagement of the EPF depends on site, size, duration, and severity of perforation. Another important prognostic factor is extent of mediastinal involvement, which is better evaluated by chest CT. Conservative therapy includes drainage of the empyema, local irrigation, tube feeding, surgery which includes repair or direct reconstruction of the esophagus. Early diagnosis and management of the EPF are important as it carries poor prognosis.\nTreatment of EPF depends on the site and size of defect in the oesophagus. Conservative management includes drainage of pleural cavity, with local irrigation and feeding by means of gastrostomy, or jejunostomy[1]. Systemic antibiotics should be administered for at least 4-6 weeks for sterilization of the empyema cavity. Definitive management is by closing with self-expanding metal stents or by surgical exploration with a muscle flap[7]. \nTake-Home Message/Teaching Points\nEsophageal-pleural fistula (EPF) is a rare clinical entity with a high degree of morbidity and mortality. The lack of familiarity, along with non-specific clinical manifestation and subtle findings in routine imaging modality, warrants specific imaging protocols, making it a diagnostic challenge.\u00a0High index of suspicion is needed to detect this potentially fatal entity.",
    "differential_diagnosis": "A, case, of, traumatic, oesophageal, pleural, fistula., Oesophagal, perforation, Hydropneumothorax, Infected, hydropneumothorax",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-04//17250_1_1.png?itok=oCgT6M1G",
            "caption": "Axial Computed Tomography of chest in lung window settings showing external lacerated wound over the left anterior thorax (white arrow)"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-04//17250_2_1.png?itok=cKOSaDbW",
            "caption": "Coronal Computed Tomography section of thorax in lung window setting showing left sided hydropneumothorax (white arrow) and intercoastal drainage tube within left pleural cavity (yellow arrow)"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-04//17250_3_1.jpg?itok=zSZouQeZ",
            "caption": "Axial computed tomography image of thorax showing abnormal communication (white arrow) between oesophagus and left pleural cavity at  third dorsal (D3) vertebral level"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-04//17250_4_1.jpg?itok=1az2Z8MN",
            "caption": "Spot fluoroscopy barium swallow image showing contrast within the pharynx"
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-04//17250_4_2.jpg?itok=wfN9KYmZ",
            "caption": "Spot fluoroscopy barium swallow image showing barium flowing into the left pleural cavity through a fistulous communication between esophagus and pleural cavity"
          },
          {
            "number": "Figure 4c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-04//17250_4_3.png?itok=ngjmf3W3",
            "caption": "Spot fluoroscopy barium swallow image showing barium accumulating in left pleural cavity(green arrows) due through a fistulous communication between esophagus and pleural cavity. Intercostal drainage tube (yellow arrow) is seen draining the accumulated barium"
          },
          {
            "number": "Figure 4d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-04//17250_4_4.png?itok=ex-gg67v",
            "caption": "Spot fluoroscopy barium swallow image showing barium flowing into the left pleural cavity through a fistulous (yellow arrow) communication between oesophagus and pleural cavity"
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-04//17250_5_1.jpg?itok=fvlZP2nD",
            "caption": "Coronal reformatted images of Computed tomography of thorax shows fistulous communication between the thoracic oesophagus and left pleural cavity (yellow arrow)"
          },
          {
            "number": "Figure 5b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-04//17250_5_2.jpg?itok=b5_o6SnG",
            "caption": "Axial oblique reformatted images of Computed tomography of thorax shows fistulous communication between the ballooned and thinned out thoracic oesophagus and left pleural cavity(green arrow)"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Contrast agents",
      "Gastrointestinal tract",
      "Mediastinum",
      "Trauma"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT",
      "Fluoroscopy"
    ],
    "link": "https://www.eurorad.org/case/17250",
    "time": "22.04.2021"
  },
  "17251": {
    "case_id": 17251,
    "title": "Pulmonary talcosis due to intravenous drug abuse",
    "section": "Chest imaging",
    "age": "44",
    "gender": "male",
    "diagnosis": "Pulmonary talcosis",
    "history": "A 44-year-old male presented to the cardiologist complaining of long-lasting progressive dyspnoea, worsening on exertion. In the last 10 days, he experienced mild fever and was treated with antibiotics for pneumonia, without significant improvement. He reported illicit drug use and had been on substitutional methadone therapy.",
    "image_finding": "PA chest x-ray showed non-homogenous opacities in the periphery of the right upper lobe with signs of significant volume loss. \nPost-contrast high-resolution chest CT was performed showing patchy, confluent consolidation in the right upper and middle lobe that were predominantly peribronchial and subpleural in distribution, associated with thickening and mild distortion of the airways and significant volume loss of the right upper lobe. In the apical segment, several rounded and polygonal perilobular opacities were noted.\u00a0 A small amount of pleural fluid was present. \nAt the level of the right lower lobe images revealed patchy ground-glass opacities with some reticulations and interlobular septal thickening. Few random nodules were present as well. There was more subtle involvement of the left upper pulmonary lobe.\nDue to the prolonged clinical course and unspecific imaging findings, transbronchial forceps biopsy was performed.",
    "discussion": "Talc has been widely used in different industries. Talc induced granulomatous lung disease may occur as a result of talc inhalation in patients with occupational exposure. However, it is most commonly seen in the setting of intravenous drug abusers when talc-containing oral tablets are being crushed and administered intravenously.[1,2] Consequently, whether inhaled or injected, talc accumulates in the pulmonary vessels leading to migration of small particles into the pulmonary interstitium and finally to granulomatous foreign-body reaction. [3,4]\nPatients usually present with non-specific symptoms including long term, progressive dyspnea, dry cough, fever and weight loss or conditions related to emphysema, pulmonary hypertension and fibrosis in more severe cases. Physical examination and laboratory test findings are often unremarkable.\nA wide range of CT findings has been described including diffuse nodular pattern consisting of tree-in-bud pattern or multiple centrilobular nodules which may merge forming larger conglomerate masses containing areas of high attenuation, ground-glass opacities and emphysema. [1-5]Studies describe bilateral lung changes and we did not find literature reports on predominately one-sided lung involvement. We can hypothesize that uneven severity of parenchymal changes may be due to the non-uniform distribution of crystals entering the pulmonary arterial bed in specific lung region leading to different intensity of granulomatous reaction on one side. This may represent one possible underlying cause for significant asymmetry of infiltrations between both lungs, that have been presented in our case. \nPulmonary talcosis may be difficult to distinguish from pulmonary infections or other granulomatoses by CT appearance alone.\u00a0 History of talc exposure greatly contributes to differential diagnosis and lung biopsy is usually required for final confirmation. \nCharacteristic histopathologic feature consists of inflammatory reaction composed of macrophages, foreign body multinuclear giant cells and bi-fringent needle-shaped crystals inside or outside macrophages being visualised under polarised light.\u00a0[6](Figure 5)\nThere is no definite consensus regarding the treatment of talc granulomatosis. [1]This patient was treated with corticosteroids and reported significant clinical improvement, although only minimal improvement was noted on the follow-up chest X-rays.\nIn conclusion, pulmonary talcosis is not commonly suspected in many patients and may remain underdiagnosed even in known intravenous drug abusers. Considering unspecific CT findings, taking thorough medical history may raise suspicion and indicate further clinical evaluation. As clinical manifestations and CT appearance range from mild to severe and may resemble pulmonary infections or other pneumoconioses, the final diagnosis is usually made after lung biopsy. CT remains modality of choice to depict distribution and severity of parenchymal changes and to assess response to treatment.",
    "differential_diagnosis": "Pulmonary, talcosis, Silicosis, Seacoidosis, Organizing, pneumonia, Pulmonary, infections, (mycobacterial,, PCP), Septic, embolism",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-04//17251_1_1.jpg?itok=oESJXAGj",
            "caption": "PA chest X-ray showsnon-homogenous opacities in the periphery of the right upper lobe with signs of significant volume loss"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-04//17251_2_1.jpg?itok=k--7LVRT",
            "caption": "Axial thin-section CT scan (lung window, 1 mmsection thickness) obtained at the level of the right upper lobe shows patchy, peribronchial and subpleural consolidations, thickening and mild distortion of the airways and more subtle ground glass opacities at the level of the left upper lobe (a). Perilobular consolidationsat the level of the apical segment.(b)Significant volume loss is noted Indicating fibrosis due to prolonged disease"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-04//17251_2_2.jpg?itok=6qSlot92",
            "caption": "Axial thin-section CT scan (lung window, 1 mmsection thickness) obtained at the level of the right upper lobe shows patchy, peribronchial and subpleural consolidations, thickening and mild distortion of the airways and more subtle ground glass opacities at the level of the left upper lobe (a). Perilobular consolidationsat the level of the apical segment.(b)Significant volume loss is noted Indicating fibrosis due to prolonged disease"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-04//17251_3_1.jpg?itok=iJxnyhTR",
            "caption": "Axial thin section CT scan (soft tissue window, 2 mm section thickness) at the level of aortic arch (a) and right pulmonary artery (b) indicates peripheral consolidations and small amount of pleural fluid in the right lung"
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-04//17251_3_2.jpg?itok=EA5vEl5U",
            "caption": "Axial thin section CT scan (soft tissue window, 2 mm section thickness) at the level of aortic arch (a) and right pulmonary artery (b) indicates peripheral consolidations and small amount of pleural fluid in the right lung"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-04//17251_4_1.jpg?itok=iRGyuEmQ",
            "caption": "Axial thin-section CT scan (lung window, 1 mmsection thickness) obtained at the level of the right lower lobe showspredominantly ground-glass attenuation associated with some reticulations and random small nodules<3 mm in diameter"
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-04//17251_5_1.jpg?itok=Rho2Tq6e",
            "caption": "A. Lung  tissue with the granulomatous inflammatory reaction in alveolar septal walls  (arrow). B. A needle-like particles can be seen in the cytoplasm of  multinuclear  giant cells  (arrows).  HE, magnification  x100 (A) and x400 (B)"
          },
          {
            "number": "Figure 5b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-04//17251_5_2.jpg?itok=doKpCC-U",
            "caption": "A. Lung  tissue with the granulomatous inflammatory reaction in alveolar septal walls  (arrow). B. A needle-like particles can be seen in the cytoplasm of  multinuclear  giant cells  (arrows).  HE, magnification  x100 (A) and x400 (B)."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Respiratory system"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/17251",
    "time": "22.04.2021"
  },
  "17273": {
    "case_id": 17273,
    "title": "As(pea)ration",
    "section": "Chest imaging",
    "age": "73",
    "gender": "female",
    "diagnosis": "Foreign body aspiration",
    "history": "A 73-year-old woman, without relevant background history, was admitted to the emergency department two hours after a chocking event at lunch, followed by persistent dry coughing, dyspnea and right pleuritic pain. At physical examination, inspiratory wheezing was evident, without any oropharynx changes. Computed tomography (CT) scan was then performed.",
    "image_finding": "Chest CT revealed an endoluminal round structure in the right intermediate bronchus, with 10 mm in diameter. The pulmonary parenchyma was normal. (Fig. 1a-1c)\nThe radiological findings in this case, along with the clinical history, were highly suggestive of foreign body aspiration. The final diagnosis was confirmed with flexible bronchoscopy procedure, and a pea was retrieved from the right intermediate bronchus. (Fig. 2a-2b)",
    "discussion": "Foreign body aspiration is a rare entity in adults, and children account for the vast majority of foreign body aspirations cases. In adulthood, there is a higher prevalence among geriatric patients with predisposing factors, such as neurological diseases. However, aspiration can occur without any obvious known risk factors. [1, 2]\nThe symptoms are determined by the size of the inhaled body and the location in which it becomes lodged. In adults, a silent presentation may be present, due to the distal impaction of the foreign body in the lower lobe bronchi, particularly in the right lower lobe, due to its more vertical orientation. A detailed patient history is a powerful tool in the evaluation of such patients. [2, 3]\nClinically, patients may present either with asphyxiation and acute respiratory failure particularly when impaction occurs in the trachea, or with recent onset of respiratory symptoms, including stridor, dyspnea, wheezing, cough, and absence of breath sounds on the side of the impaction. [1, 4]\nChest radiography and mainly CT examination can aid in the diagnosis, by correctly localizing and characterizing the foreign body and eventual complications. Radiopaque foreign bodies can be depicted on radiographic studies. However, most of the foreign bodies, such as food, are radiolucent and, therefore, not directly visible on chest radiograph. In such cases, chest CT is more sensitive in the identification of the foreign body. The indirect signs of airway obstruction include lobar consolidation, atelectasis, hyperinflation/air-trapping, lung abscesses, bronchiectasis or ipsilateral pleural effusion. [1, 3] The differential diagnosis of endobronchial lesions includes endobronchial tumors, namely carcinoid tumor or metastases, which usually enhance after contrast administration.\nBronchoscopy remains the gold standard for diagnosis and management of foreign body aspiration and it should be performed as soon as possible, to prevent granulation tissue formation or bacterial superinfection. [1]\nWhen foreign body aspiration is suspected, chest CT is the main imaging tool for diagnosis work-up, providing valuable information for bronchoscopy planning, which is fundamental for a successful removal proceeding.",
    "differential_diagnosis": "Foreign, body, aspiration, Anaphylaxis, Asthma, Bronchial, carcinoid, tumor",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-05//17273_1_1.jpg?itok=kgHdg2_7",
            "caption": "Axial chest CT image showed an endoluminal round image in the right lower bronchus; along with the clinical history, this suggests foreign body aspiration"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-05//17273_1_2.jpg?itok=4O8Q3dzn",
            "caption": "Coronal chest CT image shows the rounded foreign body in the right lower bronchus, without atelectasis"
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-05//17273_1_3.jpg?itok=S_-fPpzd",
            "caption": "Coronal chest CT image shows the rounded foreign body in the right lower bronchus,"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-05//17273_2_1.jpg?itok=NxcYUejM",
            "caption": "During bronchoscopy, a green foreign body was seen in the right intermediate bronchus: a green pea was removed"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-05//17273_2_2.jpg?itok=KKnKzxAU",
            "caption": "During bronchoscopy, a green foreign body was seen in the right intermediate bronchus: a green pea was removed"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/17273",
    "time": "25.05.2021"
  },
  "17297": {
    "case_id": 17297,
    "title": "Thoracic ganglioneurom",
    "section": "Chest imaging",
    "age": "4",
    "gender": "female",
    "diagnosis": "Thoracic ganglioneuroma",
    "history": "A 4-year-old girl was admitted for fever and vomiting. Because of persisting fever and inflammation in the blood tests, a thoracic-abdominal X-ray was taken in another hospital, illustrating a retrocardiac mass with pleural fluid at the right lung base. Diagnostic refinement was obtained with CT and complementary 123 I-mIBG and MRI.",
    "image_finding": "On CT there was a large solid hypo-attenuating mass (compared to muscle) containing peripheral calcifications, situated on the right side in the posterior paraspinal mediastinum (Figure 1). The mass showed enhancement of the wall with mural proliferations and internal septations (Figure 2).\u00a0 In addition, a pleural effusion and secondary atelectasis were present. No adenopathies were seen.\nAdditional 123 I-mIBG scintigraphy didn\u2019t show detectable mIBG uptake of the tumour (Figure 3) whereby additional MRI was obtained.\nOn MRI the mass demonstrated a heterogeneous hyperintense signal on T2 (Figure 4) with a slight decrease of the signal on longer TE (Figure 5), a homogeneous iso-intense signal on T1 with enhancing strands and mural proliferations upon the injection of contrast (Figure 6). On DWI the mass demonstrated no restricted diffusion with a high signal on B1000 and with a high signal on ADC (T2-shine-through; Figure 7).",
    "discussion": "A ganglioneuroma (GN) is a rare benign tumour of the neural crest, arising wherever sympathetic tissue is present: the neck, pelvis, retroperitoneum, the adrenal medulla gland but most commonly the posterior paraspinal mediastinum. Together with neuroblastoma (NB) and ganglioneuroblastoma (GNB), these are known as neuroblastic tumours [1]. A ganglioneuroma is typically made of ganglion cells and Schwannian stroma without any neuroblast, intermediate cells or mitotic figures [2]. They can occur primarily or secondary to radiotherapy (mostly from NB therapy) [3]. The incidence of ganglioneuromas is estimated between 0,1 to 0,5% of the total central nervous system tumours [4] and are 6 times less frequent than NB. In young patients, however, it is the most common tumour arising in the paravertebral mediastinum [5].\nGanglioneuroma most commonly presents without clinical signs and is often an incidental finding on X-ray. Some patients do show symptoms like dysphagia, dyspnea, back pain, chest pain, stridor, cough or Horner\u2019s syndrome [6]. GN occur in older patients than NB with a median age of 7 years and with a slight female predominance[1]. Although elevated production of catecholamines is more typically with NB or GNB, 37% of the patients with ganglioneuroma also show some elevation of catecholamines [1]. The intensity of 123 I-mIBG-scintigraphy correlates with the number of catecholamines and their metabolites. In contrary to NB, ganglioneuroma only shows uptake in 57%, giving this test a poor sensitivity [2].\nOn CT a ganglioneuroma typically shows a homogeneous low signal containing speckled or coarse calcifications in up to 60%. The lesions have the tendency to show moderate contrast enhancement, sometimes only in the delayed phase, in a homogeneous or heterogeneous way depending on the number of nerve fibres or ganglion cells [1,7]. On MR, there is a homogeneous low signal on T1, with the same enhancement pattern as on CECT. The mass is heterogeneous hyperintense on T2 and on DWI T2-shine-through is common[1,7].\nGanglioneuromas are treated with complete surgical resection and should be followed up radiologically as local recurrences have been reported [8].\nA ganglioneuroma mostly presents in the posterior paraspinal mediastinum as a hypoattenuating mass on CT and as a T2 heterogeneous, hyperintense and T1 homogeneous hypointense mass on MRI with a heterogeneous mural or strand-like enhancement pattern on contrast-enhanced images. Calcifications can be present. \u00a0\nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Thoracic, ganglioneuroma, Neuroblastoma, and, ganglioneuroblastoma, Cystic, teratoma, Schwannoma, Lymphangioma, cysticum, Pleural, endothelioma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-05//17297_1_1.PNG?itok=bswvfhWU",
            "caption": "A large hypodense mass posteriorly at the right side of the paravertebral mediastinum with an inlaying focal calcification (dashed-line arrow), adjacent pleural effusion (star), compression atelectasis (arrow) and compression on the right atrium"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-05//17297_2_1.PNG?itok=eYHiqu5M",
            "caption": "After the submission of contrast, the lesion showed enhancement of the wall with mural proliferation and internal strands (dashed-line arrow). The inlaying focal calcification, adjacent pleural effusion (star) and compression atelectasis (arrow) are also present"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-05//17297_3_1.PNG?itok=_UHCXcxm",
            "caption": "Physiological uptake at the salivary glands, myocardium, lungs, spleen and liver without noticeable uptake at the mediastinal mass"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-05//17297_4_1.PNG?itok=L_LNBdQU",
            "caption": "Heterogeneous T2-hyperintense mass at the right paravertebral mediastinum (small arrows) with adjacent compression atelectasis (arrow)"
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-05//17297_5_1.png?itok=ylQWpbjP",
            "caption": "(a) TE= 80 TR= 601 (b) TE= 363 TR= 995. Hyperintense signal on HASTE imaging with short echo time (a) and a mild decrease in signal with longer echo time (b) is seen at the mass at the right paravertebral mediastinum (small arrows) with adjacent compression atelectasis (arrow)"
          },
          {
            "number": "Figure 5b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-05//17297_5_2.png?itok=tm1XS1lW",
            "caption": "(a) TE= 80 TR= 601 (b) TE= 363 TR= 995. Hyperintense signal on HASTE imaging with short echo time (a) and a mild decrease in signal with longer echo time (b) is seen at the mass at the right paravertebral mediastinum (small arrows) with adjacent compression atelectasis (arrow)"
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-05//17297_6_1.png?itok=B2icUnlS",
            "caption": "(a) before and (b) after contrast administration, TE= 2372, TR= 4861. A rather homogeneous signal iso-intense to the signal of muscle (a) with inhomogeneous enhancing strands (dashed-line arrow) after contrast administration (b) within the mass at the right paravertebral mediastinum (small arrows) with adjacent compression atelectasis (arrow)"
          },
          {
            "number": "Figure 6b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-05//17297_6_2.png?itok=vyVE4Lfv",
            "caption": "(a) before and (b) after contrast administration, TE= 2372, TR= 4861. A rather homogeneous signal iso-intense to the signal of muscle (a) with inhomogeneous enhancing strands (dashed-line arrow) after contrast administration (b) within the mass at the right paravertebral mediastinum (small arrows) with adjacent compression atelectasis (arrow)"
          }
        ]
      },
      {
        "number": "Figure 7",
        "subfigures": [
          {
            "number": "Figure 7a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-05//17297_7_1.png?itok=NT445y7k",
            "caption": "(a) B 1000 and (b) ADC. The mass shows a high signal on B1000 without a drop in signal on ADC (T2-shine-through)"
          },
          {
            "number": "Figure 7b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-05//17297_7_2.png?itok=Up1xS2xR",
            "caption": "(a) B 1000 and (b) ADC. The mass shows a high signal on B1000 without a drop in signal on ADC (T2-shine-through)"
          }
        ]
      },
      {
        "number": "Figure 8",
        "subfigures": [
          {
            "number": "Figure 8a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-05//17297_8_1.png?itok=h60Penr9",
            "caption": "A capsulated mass of 6 x 5 x 3 cm with homogeneous white to yellow tissue (a). Spindle-shaped (neural) elements with in-between several ganglion cells occurring as large cells consisting of abundant eosinophilic cytoplasm with an eccentric nucleus, sometimes with an inlaying nucleolus (b)"
          },
          {
            "number": "Figure 8b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-05//17297_8_2.png?itok=5pqtNmiN",
            "caption": "A capsulated mass of 6 x 5 x 3 cm with homogeneous white to yellow tissue (a). Spindle-shaped (neural) elements with in-between several ganglion cells occurring as large cells consisting of abundant eosinophilic cytoplasm with an eccentric nucleus, sometimes with an inlaying nucleolus (b)"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Neuroradiology spine",
      "Thorax"
    ],
    "imaging_technique": [
      "CT",
      "MR"
    ],
    "link": "https://www.eurorad.org/case/17297",
    "time": "27.05.2021"
  },
  "17298": {
    "case_id": 17298,
    "title": "Pulmonary sequestration in fetal magnetic resonance imaging (MRI)",
    "section": "Chest imaging",
    "age": "31",
    "gender": "female",
    "diagnosis": "Bronchopulmonary sequestration",
    "history": "Female, 31 years old, 25 weeks pregnant in her first pregnancy. She has no significant clinical history. An ultrasound was performed by a general practitioner raising the suspicion for a diaphragmatic hernia in the left fetal hemithorax. The patient was forwarded to a specialized centre to perform a fetal MRI.",
    "image_finding": "MRI revealed a mass with T2-weighted hypersignal occupying the left hemithorax (Figure1), promoting dislocation of the mediastinum to the right side \u2013 configuring heart dextroposition \u2013 compressing both lungs, defined in MRI by usual signal intensity. The left lung is more compressed than the right one, in the superior region (Figure2). The left diaphragm is flattened, which confirms the mass effect caused by the abnormal tissue, but no discontinuity or hernia was associated (Figure3).\nTwo structures compatible with vessels were seen inside this tissue, one originating from the descending thoracic aorta, presumably systemic arteries (Figure4-A), and the second oriented to the heart (most probably the left atrium), suggesting pulmonary vein (Figure5-A).\nMRI features are consistent with supra-diaphragmatic bronchopulmonary sequestration. The distinction between intralobar and extralobar types is not accurate in this case as the own pleura covering could not be defined and the extralobar type can also have systemic venous drainage. Although this case presents hypertensive signals, like diaphragm flattening and lung compression, no fetal hydrops was evident, usually related to esophagus and thoracic vein compressions.\nThese findings are also schematically presented in Figure6.",
    "discussion": "Background\u00a0 \nBronchopulmonary sequestration is the presence of lung tissue that does not present communication with the bronchial tree by a normally located bronchus and receives its blood supply from anomalous systemic arteries [1-3].Most cases are described in the left lower lobe, and about 90% of them are supradiaphragmatic [1].\nIt\u2019s divided in two types: Intralobar pulmonary sequestrations (IPS) do not present pleural covering, are contiguous with the normal lung and their drainage is usually through the pulmonary veins [1,2]. In extralobar pulmonary sequestration (EPS), the abnormal lung tissue is completely separated from the normal lung by its distinct pleural covering [2]. Unlike in IPS, its drainage is usually through systemic drainage [1], although in 25% of the cases it may also drain to pulmonary veins [4].\nThe differences between IPS and EPS are illustrated in Figure7.\n\u00a0\nClinical Perspective\u00a0\nMost patients with ILS present in adolescence or early adulthood with recurrent bacterial pneumonia and rarely with hemothorax and high-output heart failure. On the other hand, ELS is often diagnosed on prenatal ultrasound or MRI and is frequently associated with other congenital anomalies. Infants with ELS may be asymptomatic or may suffer from respiratory distress owing to lung hypoplasia or mass effect. ELS rarely becomes infected, as its pleural investment prevents contact with inhaled air [5].\n\u00a0\nImaging Perspective\u00a0\nCT and MRI are the reliable imaging modalities for demonstrating the anomalous artery supplying, with CT allowing better evaluation of the parenchyma changes [6]. However, in fetal evaluation, ultrasonography and MRI are the methods of choice. Although fetal ultrasound is the primary modality for imaging the chest and detecting masses [7], MRI can be helpful in limiting conditions such as maternal obesity and oligohydramnios.\u00a0\nBPS appears as a solid hyperintense lesion on T2-weighted images, frequently in the left lower lobe. Identification of the systemic vascular supply, especially with balanced sequences, facilitates the diagnosis [1]. These sequences are ultrafast and have robust imagery with a liquid/tissue contrast and excellent signal-to-noise ratio.\n\u00a0\nOutcome\u00a0\nWhen no other malformations are associated, it has an excellent prognosis \u2013 most of it will disappear before birth. However, larger lesions can compress mediastinum structures, causing hydrops. In those cases, fetal intervention and early delivery can be indicated [1]. When complications occur in the postnatal period, some of the treatment options include embolization and/or surgical resection [1]. Since MRI can detect associated anomalies and complications, it is of great value in therapy planning.\n\u00a0\nTake-Home Message/Teaching Points\nIn fetal MRI, when facing a T2-weighted hyperintense mass in the fetal thorax - especially in the lower left pulmonary lobe - the diagnosis of BPS must be remembered, and an active search for anomalous vessels may support this diagnosis.\u00a0\n\u00a0\nWritten informed consent for publication has been obtained.",
    "differential_diagnosis": "Bronchopulmonary, sequestration, Hypogenetic, lung, syndrome, (scimitar, syndrome, and, pulmonary, venolobar, syndrome), Anomalous, systemic, arterial, supply, to, normal, lung, Bronchogenic, Cyst, Congenital, Cystic, Adenomatoid, Malformation, Congenital, Diaphragmatic, Hernia, Neuroblastoma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-05//17298_1_1.jpeg?itok=8z5abQox",
            "caption": "Coronal T2-weighted sequence image shows hyperintense mass in the left hemithorax"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-05//17298_2_1.jpeg?itok=0DrYMXDC",
            "caption": "Coronal T2-weighted sequence image shows that this mass is located in the lower left pulmonary lobe and compressing the mediastinum to the right side"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-05//17298_3_1.jpeg?itok=8zdn10ZA",
            "caption": "Sagittal-T2 weighted sequence image shows flattened diaphragm by compression of the hyperintense mass in the lower left lobe"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-05//17298_4_1.jpeg?itok=xsJtZuf_",
            "caption": "Axial-T2 weighted sequence image shows anomalous vessel originating from the thoracic aorta"
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-05//17298_4_2.jpeg?itok=JADRfz_l",
            "caption": "Schematic representation of the anatomic structures described in Figure 4-A"
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-05//17298_5_1.jpeg?itok=7Xo-rYt6",
            "caption": "Axial-T2 weighted sequence image shows venous drainage to the topography of the left atrium"
          },
          {
            "number": "Figure 5b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-05//17298_5_2.jpeg?itok=KHlquYfp",
            "caption": "Schematic representation of the anatomic structures described in Figure 5-A"
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-05//17298_6_1.jpeg?itok=6c6lJcTj",
            "caption": "Schematic illustration of the main findings described in the case"
          }
        ]
      },
      {
        "number": "Figure 7",
        "subfigures": [
          {
            "number": "Figure 7",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-05//17298_7_1.jpeg?itok=owzcjKUa",
            "caption": "Schematic illustration of the main differences between intralobar and extralobar pulmonary sequestration"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Cardiovascular system",
      "Lung",
      "Obstetrics (Pregnancy / birth / postnatal period)"
    ],
    "imaging_technique": [
      "MR"
    ],
    "link": "https://www.eurorad.org/case/17298",
    "time": "27.05.2021"
  },
  "17322": {
    "case_id": 17322,
    "title": "Myxoinflammatory fibroblastic sarcoma of the lung: an unexpected aetiology of a solitary pulmonary mass",
    "section": "Chest imaging",
    "age": "53",
    "gender": ",male",
    "diagnosis": "Myxoinflammatory fibroblastic sarcoma",
    "history": "A 53-year-old man, who refers to left shoulder pain with a few weeks of evolution. The pain irradiates to the thorax, is not incapacitant, but occurs even in at rest, persisting along time, with some increase in the last few days. No pain on physical examination nor other changes. No other relevant clinical information.",
    "image_finding": "The patient had done first a chest x-ray (Figure 1), and the only relevant change was a nodular formation with soft tissue density in the right lung base, measuring about 5 cm, with mass criteria, suggesting a better characterization by computed tomography.\nA CT study without intravenous contrast agent injection was then carried out (Figure 2), which revealed a mass with soft tissue density, with well-defined contours, about 45 mm in diameter in the lateral segment of the right middle lobe, suspected of lung cancer. The lesion contacts the pleura and the fissure, not overcoming it, but displacing the right major fissure.\nRegarding the results of the CT study, the patient has undergone a biopsy of the mass, guided by CT, with an unclear result. The report was: The fragment collected by needle biopsy represents a tissue with exuberant neocapillary proliferation, associated with a component of inflammatory cells, where plasmocytes predominate. The vast panel of antibodies performed did not allow a conclusive diagnosis, pointing to an inflammatory process in organization / vascular neoplasia (benign) / inflammatory pseudotumor. A malignant neoplastic lesion of epithelial or mesothelial nature was not evident. (Figure 3).\nAfter the result obtained with the CT-guided biopsy, it was decided to perform a PET-CT, in order to better characterize the lesion and try to understand whether it was malignant or benign, as well as if there were lesions in other anatomical locations. PET-CT was carried out outside our institution and we only had access to the written report, which was as follows: The study carried out reveals a mass in the middle lobe of the right lung, showing heterogeneously increased uptake of FDG-18, bringing together anatomic-functional characteristics suspected of malignancy. No other significant areas of FDG-18 uptake were evident.\nSteps induced by Imaging Findings, Treatment and Follow-up\nWith this information from PET-CT, it was decided to excise the lung mass by VATS. The surgeon\u2019s report described the excision of a mass of the right middle lobe, adjacent to the right parietal pleura, with no other changes found in the pulmonary exploration performed. The excised mass was analyzed histo-pathologically, the result being the following: The excised nodular lesion shows histomorphological and immunohistochemical characteristics that fit into myxo-inflammatory fibroblastic sarcoma (Figure 4).\nIt was decided in a multidisciplinary team meeting that, considering the histological diagnosis, there was no indication for radiotherapy or chemotherapy. The follow-up of the patient will go through a phase of initial tight control, to find any aspect suggestive of recurrence early. A follow-up CT exam one year after surgery has already been performed, which did not reveal any changes associated with recurrence. Only a slight sub-pleural thickening was found in the middle lobe, suggestive of fibro-scarring resulting from the surgical procedure.",
    "discussion": "Myxoinflammatory fibroblastic sarcoma is a very rare soft tissue tumour, first reported in 1998, having been initially assigned the name myeloid inflammatory tumour of the distal extremities with Reed-Sternberg-like cells [1,2]. Most of these tumours are in the soft tissues and can grow as a single lobulated nodule or as multiple ill-defined nodules, along the fibrous connective tissue, adipose tissue, fascia or tendon fibres [3]. It generally presents itself as a slow-growing and painless mass, which affects mainly the acral and dorsal soft tissues, namely: fingers, hands, feet, wrists and ankles. However, there are cases in proximal extremities, trunk, head and neck [3,4]. This tumour is typically described as locally aggressive, but with a very low metastatic potential [1,2]. The percentage of distant metastasis is very low, generally involving the regional lymph nodes and in a much smaller percentage the lung [3,4].\nHistological and immunohistochemical confirmation is necessary for a definitive diagnosis [5].\nImaging characteristics most often are those of a soft tissue mass which can vary from well to poorly defined, with distal predominance, without bone involvement, mainly with hypersignal in T2 and hyposignal in T1 (unspecific characteristics) [6,7]. With contrast administration, most well-differentiated tumours have a diffuse enhancement pattern, without peripheral enhancement, in contrast to poorly differentiated tumours, which exhibit a peripheral enhancement pattern, with small areas of invasion into the surrounding soft tissues [7]. \nIn this case, CT was performed without contrast enhancement, which reduces the diagnostic accuracy, and in the suspicion of a malignant lung injury, contrast should have been used, because it allows a better characterization of the lesion; enhancement after injection is in favour of malignancy. The multidisciplinary team decided not to perform magnetic resonance imaging because it was considered unnecessary given the available information.\nThe open question of this case is related to the origin of this tumour. On the one hand, we know that these types of tumours are typical of the acral extremities and that only rare cases of pulmonary metastases are reported. There is no reference in the literature for tumours of this type originating from the lung or pleura. \nOne might consider that this was a sarcoma of pulmonary origin but there is no definite answer to this question.\nIt is also important to clarify that the pain referred by the patient in his left shoulder, which originated his visit to the doctor and the performance of several exams, which ended up discovering this lung injury, was not mentioned again during the treatments at our hospital. But even so, the patient performed an x-ray and an ultrasound on his left shoulder, with no significant alteration being evident.\nThis case demonstrates very well that sometimes the imaging methods point us to a possibility of diagnosis that is not the correct one, emphasizing the importance of pathological anatomy in the final diagnosis. Radiologists also assume an important role in the follow-up, trying to find evidence of local recurrence, another primary tumour in other locations or distant metastases from this tumour. We have to be aware that such rare cases exist, even though they do not have specific radiological characteristics that allow their diagnosis.",
    "differential_diagnosis": "Myxoinflammatory, fibroblastic, sarcoma, Granuloma, Pulmonary, hamartoma, Bronchogenic, carcinoma, Pulmonary, metastases, Carcinoid, tumors",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-06/figure_1a.jpg?itok=G_U1sy6_",
            "caption": "A \u2013 left profile incidence\r\nThe chest x-ray showed a nodular formation with soft tissue density in the right lung base, measuring about 5 cm, with mass criteria. No other significant findings were found"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-06/figure_1b.jpg?itok=M52mKAVa",
            "caption": "B \u2013 posteroanterior incidence. The chest x-ray showed a nodular formation with soft tissue density in the right lung base, measuring about 5 cm, with mass criteria. No other significant findings were found"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-06/figure_2a.jpg?itok=0GhoWpEz",
            "caption": "A \u2013 axial plane at lung window\r\nThe chest CT performed without intravenous contrast agent, revealed a homogeneous mass with soft tissue density (mean density of 30 HU), with well-defined contours, about 45 mm in diameter in the lateral segment of the right middle lobe, suspected of lung cancer. The lesion contacts the pleura and the fissure, not overcoming it, displacing the right major fissure. In the pulmonary parenchyma, a small area with densification in \"ground glass\" of a non-specific nature was also observed in the right para-vertebral region (paravertebral dystelectasis), without the presence of other changes"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-06/figue_2b.jpg?itok=DwB5f_3C",
            "caption": "B \u2013 coronal plane at lung window\r\nThe chest CT performed without intravenous contrast agent, revealed a homogeneous mass with soft tissue density (mean density of 30 HU), with well-defined contours, about 45 mm in diameter in the lateral segment of the right middle lobe, suspected of lung cancer. The lesion contacts the pleura and the fissure, not overcoming it, displacing the right major fissure. In the pulmonary parenchyma, a small area with densification in \"ground glass\" of a non-specific nature was also observed in the right para-vertebral region (paravertebral dystelectasis), without the presence of other changes"
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-06/figure_2c.jpg?itok=I2WHFaqr",
            "caption": "C \u2013 sagittal plane at lung window\r\nThe chest CT performed without intravenous contrast agent, revealed a homogeneous mass with soft tissue density (mean density of 30 HU), with well-defined contours, about 45 mm in diameter in the lateral segment of the right middle lobe, suspected of lung cancer. The lesion contacts the pleura and the fissure, not overcoming it, displacing the right major fissure. In the pulmonary parenchyma, a small area with densification in \"ground glass\" of a non-specific nature was also observed in the right para-vertebral region (paravertebral dystelectasis), without the presence of other changes"
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-06/figure_2d.jpg?itok=P7n4KoJw",
            "caption": "D \u2013 axial plane at soft tissue window.\r\nThe chest CT performed without intravenous contrast agent, revealed a homogeneous mass with soft tissue density (mean density of 30 HU), with well-defined contours, about 45 mm in diameter in the lateral segment of the right middle lobe, suspected of lung cancer. The lesion contacts the pleura and the fissure, not overcoming it, displacing the right major fissure. In the pulmonary parenchyma, a small area with densification in \"ground glass\" of a non-specific nature was also observed in the right para-vertebral region (paravertebral dystelectasis), without the presence of other changes"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-06/figure_3a.jpg?itok=gG1dE7pT",
            "caption": "A and B \u2013 Histological images of the biopsy guided by CT, with the presence of an extensive inflammatory infiltrate, with abundant vascularization and without aspects suggestive of malignancy (A), and a magnification (B) of the rectangular area seen in (A), with the typical inflammatory infiltrate, in a hematoxylin-eosin staining."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-06/figure_3b.jpg?itok=qOuBMtNv",
            "caption": "A and B \u2013 Histological images of the biopsy guided by CT, with the presence of an extensive inflammatory infiltrate, with abundant vascularization and without aspects suggestive of malignancy (A), and a magnification (B) of the rectangular area seen in (A), with the typical inflammatory infiltrate, in a hematoxylin-eosin staining."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-06/figure_4a.jpg?itok=zJCToOOI",
            "caption": "A and B \u2013 Histological images of the surgical specimen, with the typical myxo-inflammatory pattern (A), and a magnification (B) of the rectangular area seen in (A), with the characteristic Reed-Sternberg like cells (arrow), in a hematoxylin-eosin staining."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-06/figure_4b.jpg?itok=dhdFpPfm",
            "caption": "A and B \u2013 Histological images of the surgical specimen, with the typical myxo-inflammatory pattern (A), and a magnification (B) of the rectangular area seen in (A), with the characteristic Reed-Sternberg like cells (arrow), in a hematoxylin-eosin staining."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Thorax"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/17322",
    "time": "24.06.2021"
  },
  "17350": {
    "case_id": 17350,
    "title": "Bilateral multifocal and multilobar mucinous adenocarcinoma of the lung",
    "section": "Chest imaging",
    "age": "62",
    "gender": "female",
    "diagnosis": "Bilateral multifocal and multilobar mucinous adenocarcinoma of the lung",
    "history": "A 62-year-old non-smoker woman presented with cough and progressive dyspnoea. The patient was referred for asthenia, anorexia, and weight loss for the past 3 months. She denied fever for the same period. \nAt the time of presentation, the patient had a type 1 respiratory failure (hypoxemia and hypocapnia) with negative inflammatory markers.",
    "image_finding": "On chest radiography (Fig 1), uncountable patchy opacities, some of which confluent, were diffusely seen distributed on both lungs, without a preferential location. Pleural effusion or hilar enlargement were not documented.\nSubsequently, the patient performed a Computed Tomography (CT) Angiography, to exclude pulmonary embolism due to a very high level of D-dimers. There weren\u2019t any filling defects seen in the branches of the pulmonary arterial system. CT (Fig 2) showed multiple solid nodules, randomly distributed throughout both lungs. Some of these nodules were centrally cavitated. Consolidation areas with air bronchograms were seen on both basal lung segments. No pleural effusion or hilar adenopathies were shown.\nDuring the inpatient treatment, a bronchofibroscopy was performed with no definite result. The diagnosis was obtained by CT-guided transthoracic core needle lung biopsy (Fig 3), showing showed goblet cells with abundant cytoplasmic mucin and small basally oriented nuclei with minimal atypia and predominantly lepidic growth.",
    "discussion": "Background\nInvasive mucinous adenocarcinoma, once called mucinous bronchioloalveolar carcinoma, is a rare variant form of lung invasive adenocarcinoma. This type of adenocarcinoma is distinguished from non-mucinous adenocarcinoma and it has been re-classified in the international association for the Lung Cancer / American Thoracic Society / European Respiratory Society [1] because of its clinical, radiological pathological, and genetic idiosyncrasies.\nClinical perspective\nInvasive mucinous adenocarcinoma has a high frequency in non-smoker women [2], with younger age at presentation, compared to other lung cancer types [1]. Patients may show no symptoms or display non-specific symptoms, such as dyspnoea, cough, sputum, or haemoptysis.\nImaging Perspective\nImaging features may be variable. Both multifocal and solitary forms of invasive mucinous adenocarcinomas tend to be found at the lower lobes [3].\nTypical computed tomography findings are characterized by lobar or segmental consolidations, ground-glass opacities, and nodules. A focal nodule or mass is less frequent.\u00a0 Thin-wall cysts can be present although being rare [4].\u00a0 \nPositron Emission Tomography-CT (PET-CT) may show only mild fluorodeoxyglucose (FDG) uptake because of the abundant mucin component [5].\u00a0 \nInvasive mucinous adenocarcinoma tends to be multifocal and multilobar. [3, 6] Histology consists of tall columnar cells with abundant cytoplasm that contains apical mucin and small basal nuclei.\nAlthough being predominantly invasive, these lesions also usually have a lepidic pattern. They are often peripheral with desmoplastic reaction and mucin production. They are usually multifocal in up to 25% of cases [7].\nOutcome\nInvasive mucinous adenocarcinoma is an aggressive lung tumour, with a much poorer prognosis compared to other lung adenocarcinomas [1]. Early diagnosis is challenging but essential to treat this malignancy.\nTake home message / Teaching Point\n\nRadiologists should be aware of the spectrum of imaging findings in lung adenocarcinoma lesions.\nInvasive mucinous adenocarcinoma is a rare adenocarcinoma of the lung, but important to consider as a differential diagnosis of lower lobe consolidations, cavitations, and small multifocal metastasis.\nLung biopsy is fundamental to obtain a final diagnosis",
    "differential_diagnosis": "Bilateral, multifocal, and, multilobar, mucinous, adenocarcinoma, of, the, lung, Tuberculosis, Granulomatosis, with, poliangiitis, Metastases, from, head, and, neck, carcinoma, Metastases, from, gastrointestinal, adenocarcinoma, Metastases, from, Sarcoma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-07//17350_1_1.jpg?itok=iX8eQy3W",
            "caption": "Chest radiography with bilateral diffuse nodular pattern"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-07//17350_2_1.png?itok=L0063HX3",
            "caption": "Angio-CT shows randomly distributed solid nodules (A-C); some are cavitated. There are also bilateral basal consolidations with air bronchogram (C)"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-07//17350_2_2.png?itok=sYeSXtLD",
            "caption": "Angio-CT shows randomly distributed solid nodules (A-C); some are cavitated. There are also bilateral basal consolidations with air bronchogram (C)"
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-07//17350_2_3.png?itok=tmS3Pntd",
            "caption": "Angio-CT shows randomly distributed solid nodules (A-C); some are cavitated. There are also bilateral basal consolidations with air bronchogram (C)"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-07//17350_3_1.png?itok=3qKIP1uy",
            "caption": "Lung Biopsy: A) Goblet cells with abundant cytoplasmic mucin and predominantly lepidic growth (HE, 100x); B) Basally oriented nuclei with minimal atypia (HE, 400X)"
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-07//17350_3_2.png?itok=1C2iFpqo",
            "caption": "Lung Biopsy: A) Goblet cells with abundant cytoplasmic mucin and predominantly lepidic growth (HE, 100x); B) Basally oriented nuclei with minimal atypia (HE, 400X)"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/17350",
    "time": "15.07.2021"
  },
  "17351": {
    "case_id": 17351,
    "title": "Desmoid tumour of ple",
    "section": "Chest imaging",
    "age": "46",
    "gender": "male",
    "diagnosis": "Desmoid tumour of pleura",
    "history": "A 46-year-old male patient with no known comorbidities presented with complaints of hoarseness of voice and right sided chest pain for a duration of 1 month. He had developed dyspnoea on exertion in the last 2 weeks. Blood investigations were found to be normal.",
    "image_finding": "Chest radiograph frontal projection shows an opacity in the right hemithorax with a shift of mediastinum to the left. Lateral chest radiograph shows the opacity in the posterior aspect of hemithorax. CT images show a large soft tissue density lesion which is broad-based to the costal pleura in the posterior aspect of the right hemithorax and the adjacent mediastinal pleura with an attenuation similar to muscle and a mild homogenous enhancement. The lesion showed a displacement of the mediastinum to the left with compression of the superior vena cava. No evidence of any bony erosions or widening of neural foramen was noted.",
    "discussion": "CT guided biopsy was done from the lesion, following which surgical resection was done. A large tumour that weighed over 2 kg was operated out from our patient which was reported as a spindle cell neoplasm with morphology and immune profile consistent with a desmoid tumour on histopathology.\nDesmoid tumours, also referred to as aggressive fibromatosis are locally aggressive tumours with potential for local recurrence and adjacent organ involvement (1).\u00a0 They are rare mesenchymal neoplasms with a female predilection and a peak incidence in the third and fourth decades (2). There is a strong association between desmoid tumours and familial adenomatous polyposis (3). Pathologically they consist of fascicles of spindle cells and fibroblasts in dense collagen stroma (2). \nDesmoid tumours are commonly intraabdominal but may also be extra-abdominal. Extra abdominal desmoids have been commonly reported from the shoulder and upper extremity, the gluteal region, chest wall, back and head and neck (2). Pleural desmoid tumours are extremely rare (4).\u00a0 Due to the locally aggressive nature, adjacent organ involvement is often responsible for the clinical presentation. Hence intrathoracic desmoid tumours tend to show features like cardiac arrhythmias, superior vena cava syndrome, cardiac failure and pulmonary manifestations (5).\u00a0 \nOn ultrasonography, desmoid tumours appear hypoechoic with variable vascularity. CT shows a soft tissue density lesion with attenuation similar to that of muscle. Margins may be indistinct and enhancement varies from mild to moderate. Mesenteric desmoid may show radiating spicules extending into the adjacent fat (6). MRI shows a heterogeneous pattern of lesion which appears isointense or hyperintense to skeletal muscle on T2WI. With dense collagen and decreased cellularity, signal intensity on T2 decreases while higher content of spindle cells show increased T2 signal intensity (7). Avid enhancement may be seen in highly cellular regions. Desmoid fibroids are not very metabolically active on PET imaging. \nDefinitive diagnosis is given by a histopathological examination and immunohistochemistry. Spindle cells stain positive for beta-catenin (8). \nThe main goal of treatment is local control and surgical resection, if possible. Recurrence is seen in 20 \u2013 68% of the patients with a higher potential in syndromic patients (9). Systemic therapy can be used as an alternative or as neoadjuvant therapy. Despite the rarity of disease, it is important not to overlook desmoid tumours while considering the differentials for pleural and mediastinal tumours. An early diagnosis and treatment can prevent life-threatening complications of this locally aggressive neoplasm.",
    "differential_diagnosis": "Desmoid, tumour, of, pleura, Solitary, fibrous, tumour, of, pleura, Metastatic, disease, Neurogenic, tumour",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-07//17351_1_1.jpg?itok=WuTM7DEJ",
            "caption": "X ray frontal and lateral projection showing opacity in the right hemithorax, more towards the posterior aspect with shift of mediastinum to left"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-07//17351_2_1.jpg?itok=gY3T9TIz",
            "caption": "Plain axial CT section of thorax showing large mixed density lesion broad based to posterior costal pleura and adjacent mediastinal pleura with attenuation similar to muscle"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-07//17351_3_1.jpg?itok=Sn0c28ip",
            "caption": "Contrast enhanced coronal section of thorax showing pleural based lesion in right hemithorax lesion mild homogenous enhancement"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-07//17351_4_1.jpg?itok=sg7BrpkC",
            "caption": "Axial contrast enhanced CT section of thorax showing pleural based lesion in right hemithorax causing displacement of mediastinum to left"
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-07//17351_5_1.jpg?itok=nOUD6C2y",
            "caption": "Coronal contrast enhanced CT section of thorax showing large pleural based mass lesion in right hemithorax causing compression of superior vena cava"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/17351",
    "time": "15.07.2021"
  },
  "17362": {
    "case_id": 17362,
    "title": "Multimodality imaging of incidental pleural fibroma: usefulness for surgical planning",
    "section": "Chest imaging",
    "age": "46",
    "gender": "female",
    "diagnosis": "Solitary fibrous tumor (SFT)-Pleural fibroma",
    "history": "A routine chest X-ray performed in an asymptomatic 46-year-old woman showed an extrapulmonary lesion. Careful assessment of the lesion by the chest radiology team provided useful preoperative information for surgical planning.",
    "image_finding": "The chest x-ray showed a small well-defined opacity in the upper left hemithorax. The mass abutted the chest wall and formed an obtuse angle (Figure 1, A-B), suggesting an extrapulmonary origin of the lesion.\nChest CT revealed a well-circumscribed and relatively homogeneous intense background enhancing mass (rich vascularization) arising from the left chest wall. Obtuse angles with the chest wall with tapered margins and mild displacement of pulmonary vasculature adjacent to the lesion suggested a pleural origin (Figure 2, A-D). The fat plane of the intercostal muscles was preserved. No bony destruction of the thoracic cage was detected. \n\u00a0\nPET-CT showed low metabolic activity (SUV max=2.5) of the pleural-based lesion (Figure 3). The mass was surgically removed by robot-assisted procedure (da Vinci\u00ae surgical system) (Figure 4). Histological images showed spindle cells with prominent stromal collagen and hemangiopericytoma-like vessels (Figure 5, A-B). Immunohistochemical analysis revealed a negative staining for CD34 and nuclear expression of STAT6 with positive staining for BCL2 (Figure 6, A-C). These findings confirmed the diagnosis of pleural fibroma.",
    "discussion": "Solitary fibrous tumors (SFT), also known as pleural fibromas, are rare mesenchymal tumors which arise from the pleura [1]. Most of them (80%) originate from the visceral pleural (SFTPs) [2,3]. SFTs generally occur during the fifth and sixth decades of life without significant sex predilection. They are usually benign and slow growing tumors. In 20% of the cases, SFTs can be malignant.\nMost patients with SFTs are asymptomatic. The tumor is usually discovered as an incidental finding on a routine chest radiograph. Other patients can present non-specific pulmonary symptoms such as: chest pain (more common in those tumors originated from the parietal pleura), cough or shortness of breath [4]. Digital clubbing and hypertrophic pulmonary osteoarthropathy can be associated in 20% of pleuropulmonary SFT.\nRadiologists must be aware of the imaging characteristics of these tumors to determine the lesion origin and thus contribute to surgical planning. CT imaging features of SFTs are not specific. They usually appear as well-defined and peripheral soft-tissue masses showing an obtuse angle with the chest wall [6]. Larger lesions are heterogeneous and may present calcification (seen in up to 26% of cases) [7,8]. \nOn imaging, the tumor is attached to the lung by a narrow pedicle when originates from the visceral pleura (2/3 of the cases), while it presents a broad-based attachment when arises from the parietal pleura. The origin of the tumor provides important information for the ulterior surgical management: the small and pedunculated SFTs can be removed by minimally invasively surgery (robot-assisted procedure), while the larger ones, usually arising from the parietal pleura, require thoracotomy [5]. Uncommonly, a tumor arising from the parietal pleura can be \"inverted\" and appear to grow within the lung parenchyma [9]. \nOn MRI, SFTs typically show low T1 signal intensity, variable T2 signal, and avid contrast enhancement [10]. \nBased on FDG uptake, PET-CT can sometimes help to differentiate benign from malignant SFT (mean SUVmax of 3.02\u00b11.02 for benign SFTs vs 4.89\u00b12.12 for malignant SFTs). Nevertheless, if unclear, the size, presence of necrosis and hilar lymphadenopathy on CT images are key findings indicating malignancy [11, 12]. Both CT and PET-CT can be helpful to exclude other malignant tumors of the pleura. \nSurgical excision is the treatment of choice. Recurrence is rare [1, 2].\nThe immunohistochemical (IHC) profile of the lesion markers of SFT include a negative expression of CD34 (endothelial marker) and positive staining for BCL2 (B-cell lymphoma 2). Although these markers have been historically useful to distinguish SFT from histologic mimics, they are not specific for SFT. STAT-6 positive nuclear immunoreactivity is essential for distinguish solitary fibrous pleural tumor from sarcomatoid mesothelioma and synovial sarcoma, relatively frequent lesions in this location, which entail different treatment and prognosis[13].",
    "differential_diagnosis": "Solitary, fibrous, tumor, (SFT)-Pleural, fibroma, Intercostal, Schwannoma, Loculated, pleural, effusion, Pleural, metastases, Pleural, lipoma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-07//17362_1_1.PNG?itok=GhKtdHpo",
            "caption": "A. Chest X-ray showing a peripheral mass in the upper left hemithorax"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-07//17362_1_2.PNG?itok=sJiFlCKS",
            "caption": "B. The lesion forms obtuse angles with the chest wall (opposite to pulmonary lesions), suggesting a pleural origin (black star)"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-07//17362_2_1.PNG?itok=VNJmXH12",
            "caption": "A. Axial unenhanced CT image. Lung window. Maximum intensity projection (MIP) image showing a pleural-based lesion. The centering along the chest wall (black star), tapering obtuse margins and mild displacement of the pulmonary vasculature surrounding the lesion suggest a pleural origin (dashed grey circle)"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-07//17362_2_2.PNG?itok=qnL37X2x",
            "caption": "B, C and D. Unenhanced axial CT reconstruction and axial with coronal reconstruction obtained after the intravenous administration of iodine contrast material. Mediastinal window. Small well-defined pleural-based mass on the left chest wall.  Well-circumscribed and relatively homogeneously intense background enhancing mass (rich vascularization) arising from the left chest wall better seen on axial view"
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-07//17362_2_3.PNG?itok=7CA--epd",
            "caption": "B, C and D. Unenhanced axial CT reconstruction and axial with coronal reconstruction obtained after the intravenous administration of iodine contrast material. Mediastinal window. Small well-defined pleural-based mass on the left chest wall.  Well-circumscribed and relatively homogeneously intense background enhancing mass (rich vascularization) arising from the left chest wall better seen on axial view"
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-07//17362_2_4.PNG?itok=AqyJCfPe",
            "caption": "B, C and D. Unenhanced axial CT reconstruction and axial with coronal reconstruction obtained after the intravenous administration of iodine contrast material. Mediastinal window. Small well-defined pleural-based mass on the left chest wall.  Well-circumscribed and relatively homogeneously intense background enhancing mass (rich vascularization) arising from the left chest wall better seen on axial view"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-07//17362_3_1.PNG?itok=nJ2hdhu8",
            "caption": "PET-CT image. Mediastinal window. The study showed low metabolic activity of the pleural-based lesion (SUV max= 2.5)"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-07//17362_4_1.PNG?itok=kmDyWkD2",
            "caption": "A-D. Robotic-assisted procedure using the da Vinci surgical system. Surgical removal of the tumor. E. Macroscopic surgical piece"
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-07//17362_5_1.PNG?itok=zuIFTlp0",
            "caption": "A-B. Hematoxylin and eosin-stained images of the pleural lesion showing spindle cells with prominent stromal collagen and hemangiopericytoma-like vessels"
          },
          {
            "number": "Figure 5b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-07//17362_5_2.PNG?itok=99u4nbVA",
            "caption": "A-B. Hematoxylin and eosin-stained images of the pleural lesion showing spindle cells with prominent stromal collagen and hemangiopericytoma-like vessels"
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-07//17362_6_1.PNG?itok=s03_GC1M",
            "caption": "Immunohistochemical images. A. Positive staining for BCL2. B. Negative staining for CD34. C. Nuclear expression of STAT6"
          },
          {
            "number": "Figure 6b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-07//17362_6_2.PNG?itok=TU5rFISD",
            "caption": "Immunohistochemical images. A. Positive staining for BCL2. B. Negative staining for CD34. C. Nuclear expression of STAT6"
          },
          {
            "number": "Figure 6c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-07//17362_6_3.PNG?itok=ZGT-kkBk",
            "caption": "Immunohistochemical images. A. Positive staining for BCL2. B. Negative staining for CD34. C. Nuclear expression of STAT6"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT",
      "CT-High Resolution",
      "Digital radiography",
      "PET-CT"
    ],
    "link": "https://www.eurorad.org/case/17362",
    "time": "04.08.2021"
  },
  "17369": {
    "case_id": 17369,
    "title": "Cystic lung destruction distal to pulmonary emboli/immunothrombosis in COVID-19",
    "section": "Chest imaging",
    "age": "53",
    "gender": "male",
    "diagnosis": "Cystic lung destruction secondary to COVID-19 associated pulmonary emboli",
    "history": "A 53-year-old male with a heavy smoking history presented following 8 days of feeling generally unwell with fever and worsening dyspnoea. He had oxygen saturations of 90% on 15L of oxygen via a non-rebreather mask. He tested positive for SARS-Cov-2 on RT-PCR, and was intubated and treated with IV steroids and antibiotics on intensive care.",
    "image_finding": "An initial CT pulmonary angiogram on admission revealed features in keeping with severe COVID-19 pneumonitis but no pulmonary emboli. The patient had repeat imaging one week into his admission following a further increase in oxygen requirement and a D-Dimer of >20000, which revealed pulmonary thrombi in the lingular artery and right lower lobe lateral segmental artery (Figure 1(a)). Although there was evidence of worsening COVID-19 pneumonitis, there were no bullae or cysts seen within the lungs (Figure 1(b)). Further high resolution CT 18 days later showed two new, large thin walled, air-filled cysts in the lung segments distal to the pulmonary thrombi demonstrated on the previous images (Figure 2).",
    "discussion": "Patients with COVID-19 are at increased risk of developing pulmonary thrombosis, with various studies revealing incidences of between 20 and 30% of thrombotic complications in critically ill COVID-19 patients [1,2]. Patients being treated in intensive care already have a high risk of developing pulmonary thrombosis [3], but in addition to this, increased hypercoagulability in patients with COVID-19 can lead to immunothrombosis, which has a different pathophysiological mechanism to conventional pulmonary emboli [4]. Although not yet fully understood, immunothrombosis is a result of increased production of immunologically mediated thrombi that predominantly form within the microvasculature [5]. \u00a0There is emphasis on prompt initiation of prophylactic dose anticoagulation in order to decrease mortality in patients with severe COVID-19, with an argument for therapeutic anticoagulation for high risk patients [6]. It is not possible to determine whether the thrombi were secondary to pulmonary emboli or immunothrombosis on imaging alone, but nonetheless cystic lung destruction as a sequelae of these events should be an important consideration when imaging patients with COVID-19 due to potential complications such as pneumothorax. Pulmonary infarction is a possible mechanism of cystic lung destruction in this case. Another theory published in a previous case report by Caviezel et al is that the cysts formed as a result of air leak secondary to severe vascular inflammation and focal endolethitis [7]. \nThe patient received treatment dose clexane following confirmation of PEs on CT. Despite treatment with broad spectrum antibiotics, antifungals, pulsed steroids and mechanical ventilation, the patient continued to deteriorate, becoming increasingly hypoxic and acidotic. Unfortunately the patient passed away about 5 weeks after admission. The reversibility of these changes could therefore not be assessed on follow-up imaging.\nLearning points:\n\nCOVID-19 patients being treated in critical care are proven to be at increased risk of not only conventional pulmonary emboli, but also immunothrombosis.\nThe potential for pulmonary emboli/immunothrombosis to lead to cystic lung destruction should be an essential consideration when imaging patients with COVID-19.",
    "differential_diagnosis": "Cystic, lung, destruction, secondary, to, COVID-19, associated, pulmonary, emboli, Air, leak, secondary, to, vascular, inflammation, and, focal, endolethitis, Fungal, pneumonia, Primary, bullous, lung, disease",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-07//17369_1_1.jpg?itok=_gLU6akE",
            "caption": "CT pulmonary angiogram demonstrating pulmonary thrombi in the lingular artery and right lower lobe lateral segmental"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-07//17369_1_2.jpg?itok=-hzan3O3",
            "caption": "High resolution CT taken at the same time as the CT pulmonary angiogram, showing severe COVID-19 pneumonitis"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-07//17369_2_1.jpg?itok=ZdUhKzIV",
            "caption": "High resolution CT showing two new, large thin walled, air-filled cysts in the lung segments distal to the known pulmonary thrombi"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/17369",
    "time": "04.08.2021"
  },
  "17370": {
    "case_id": 17370,
    "title": "Lung hernia: a strange condition",
    "section": "Chest imaging",
    "age": "55",
    "gender": "male",
    "diagnosis": "Noncomplicated lung hernia",
    "history": "A 55-year-old man with a history of chronic alcohol intake, smoking, obesity, and obstructive sleep apnea syndrome. Right rib pain after trauma a few months ago, suspected rib fracture. A cleft is palpated between the last right ribs.",
    "image_finding": "Chest X-ray (figure 1): Soft tissue enlargement in the right inferolateral region with well-defined and air-density structure at the ipsilateral base, which seems to be continued with the lung.\nChest CT: Mediastinal and lung windows (figures 2a and 2b): rupture of the intercostal muscles located between the 8th and 9th right costal arches, with herniation of lung tissue through them. \nFindings are consistent with pulmonary hernia.",
    "discussion": "Background\nPulmonary hernia is an abnormal protrusion of the lung parenchyma through a defect in the thoracic cavity. It is a rare condition, about 300 cases have been described in the literature[1]. Its pathophysiology is related to the sudden increase in intrathoracic pressure, such as coughing, sneezing, vomiting or weight lifting[2]. Risk factors are rib fracture, trauma, thoracic surgery, COPD, infections, neoplasms, obesity and taking steroids[3].\nClinical Perspective\nIt can be asymptomatic, manifests as acute pain or a soft mass that increases with Valsalva manoeuvres [2]. It can be complicated by incarceration, hemoptysis, or infection[4].\nImaging Perspective\nIts diagnosis is mainly clinical and is complemented with chest radiography and CT. An expiratory and oblique chest X-ray is recommended[3]. It is described based on the Morel-Lavallee classification and is based on the location and aetiology of pulmonary hernias: location (diaphragmatic, intercostal, or cervical) and aetiology (congenital or acquired)[1].\nOutcome\nObservation or surgery are the treatment options. Surgical intervention is performed when it is large, symptomatic or becomes incarcerated. CT helps to determine the location, size and herniated parenchyma, prior to surgical treatment[2].\nTake-Home Message/Teaching Points\nPulmonary hernias are protrusions of the lungs. They are classified according to their location and aetiology. They are associated with rib fractures and increases in intrathoracic pressure.\u00a0Helps to characterize it prior to surgery.\n\u2018Written informed patient consent for publication has been obtained.\u2019",
    "differential_diagnosis": "Noncomplicated, lung, hernia, Lipoma, Subcutaneous, emphysema, Bronchopleural, fistula",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-07//17370_1_1.jpg?itok=tiIKnRVy",
            "caption": "Chest X-ray. Soft tissue enlargement in the right inferolateral region with well-defined and air-density structure at the ipsilateral base, which seems to be continued with the lung"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-07//17370_2_1.jpg?itok=2D24WUVA",
            "caption": "Chest CT with mediastinal (a) and lung windows (b). Rupture of the intercostal muscles located between the 8th and 9th right costal arches, with herniation of lung tissue through them"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-07//17370_2_2.jpg?itok=Q7U8pf4L",
            "caption": "Chest CT with mediastinal (a) and lung windows (b). Rupture of the intercostal muscles located between the 8th and 9th right costal arches, with herniation of lung tissue through them"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/17370",
    "time": "04.08.2021"
  },
  "17402": {
    "case_id": 17402,
    "title": "All that seems is not COVID:\u00a0a Weil\u2019s syndrome in a global COVID-19 pandemic context",
    "section": "Chest imaging",
    "age": "34",
    "gender": "male",
    "diagnosis": "Weil Syndrome complicated with alveolar haemorrhage",
    "history": "A 34-year-old male patient, a cocaine consumer (who had recently started a job as a bricklayer on a rural farm), was discharged from the emergency department with flu-like symptoms. 4 days later, he was readmitted as suspicious for COVID-19 infection. However, he presented jaundice, acute renal failure, and hemoptysis.",
    "image_finding": "Initially, the chest X-ray (Figure 1) showed bilateral, peripheral, alveolar-interstitial opacities, predominantly in the lung bases and right lung, which given the current epidemiological situation, were compatible with COVID-19 infection. However, RT-PCR for SARS-COV2 was negative. \nA contrast-enhanced CT (Figures 2 and 3) scan showed multiple rounded, patchy, peripheral, and confluent ground-glass opacities, predominantly in both lower pulmonary lobes, associated with areas of confluent air space consolidation.\nA second chest X-ray (Figure 4) was performed (6 hours after the first one) before his admission in the intensive care unit, showing a bilateral increase in alveolar opacities predominantly in the right lung, presenting at present clear areas of bilateral consolidations which given its rapid evolution and the appearance of hemoptysis were compatible with alveolar haemorrhage. Successive controls with chest X-rays showed complete resolution of the areas of alveolar consolidations (Figures 5a and 5b).",
    "discussion": "Weil syndrome is a severe form of presentation of Leptospira infection in humans [1].\nLeptospirosis is a zoonosis with a worldwide distribution and a notably higher incidence in tropical and subtropical countries, where the incidence varies between 10 and 100 cases per 100,000 inhabitants [2]. Only 783 cases were reported in the European Union countries by 2016, with an incidence of between 0.1-0.2 cases per 100,000 inhabitants [3]. This pathology was first recognised as an occupational disease associated with agriculture, sewage maintenance and animal farming due to its transmission through contact with urine, water or soil contaminated by the urine of animals such as rodents, dogs and livestock. These constitute the main vectors of the infection and one of the critical antecedents for its diagnosis. In recent years, climate change, the increase in ecotourism and, in general, the more significant interaction between humans and animals has led to a rise in its incidence, and it is now considered an emerging zoonosis [2].\nThe clinical course is typically biphasic, with the first stage of flu-like symptoms representing the blood circulation of the bacteria. This stage is followed by an immune phase, in which the leptospiral toxins and the body's immune reaction produce the complications of infection, such as liver failure, kidney failure, and massive pulmonary haemorrhages [1], The classic triad of Weil's disease is characterised by jaundice, acute kidney failure, and haemorrhages [3].\nThe diagnosis of leptospirosis is determined by the modified Faine criteria proposed by the WHO, which include three pillars: clinical findings, epidemiological factors, and laboratory and bacteriological results [4].\nThe radiological manifestations of the disease are unspecific, being the radiological findings caused by the appearance of petechiae and areas of multifocal pulmonary haemorrhage. The most frequently reported radiological manifestations are ground-glass opacities, airspace nodules, \"crazy paving\" pattern, and confluent areas of airspace consolidation, with resolution within two weeks in most patients [5\u20138].\nOur patient presented a typical biphasic clinical course with a prior visit to the emergency department four days before with flu-like symptoms and the later appearance of jaundice, acute kidney failure, and hemoptysis. However, the early diagnosis was limited by the current global pandemic context of COVID-19 since the clinical and radiological findings of the first phase of leptospirosis are practically superimposable to SARS-COV2 infection. In addition, the history of cocaine consumption in this patient also suggested the differential diagnosis with crack lung due to the CT scan findings.\nFinally, the appearance of jaundice, acute kidney failure and, especially, the hemoptysis, the rapid progression of the opacities to consolidations, and the recent epidemiological background of the patient (who reported at that time had started 15 days ago a job as a bricklayer in a rural farm with contact with the ground, in an unhygienic environment) was the keys to the final presumptive diagnosis. The final diagnosis was confirmed by IgM serology positive for Leptospira.\n\u00a0\nTake-home message\nFor diseases such as this one, where radiological findings are non-specific, correlation with the clinical course, epidemiological history, and clinical-radiological evolution is crucial in the differential diagnosis, even more in the current context of a global pandemic of COVID-19.\nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Weil, Syndrome, complicated, with, alveolar, haemorrhage, COVID-19, infection, Goodpasture, Syndrome, Crack, lung",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-09//17402_1_1.jpeg?itok=MWlH9lav",
            "caption": "First posteroanterior (PA) chest X-ray. Bilateral, peripheral alveolar-interstitial opacities, predominantly in both lung bases and right lung, which given the current epidemiological situation were compatible with COVID-19 infection"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-09//17402_2_1.jpeg?itok=Wqpm97zo",
            "caption": "A thoracic contrast-enhanced CT scan. Multiple rounded, patchy, peripheral, and confluent ground-glass opacities, predominantly in both lower pulmonary lobes, associated with confluent areas of consolidation compatible with alveolar hemorrhage"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-09//17402_3_1.jpeg?itok=rIDZRtT_",
            "caption": "A thoracic contrast-enhanced CT scan. Multiple rounded, patchy, peripheral, and confluent ground-glass opacities, predominantly in both lower pulmonary lobes, associated with confluent areas of consolidation compatible with alveolar hemorrhage"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-09//17402_4_1.jpeg?itok=TBvJcKNe",
            "caption": "Second anteroposterior chest X-ray (6 hours after the first one), before patient admission in the intensive care unit. Bilateral increase of alveolar opacities predominantly in the right lung, presenting at present areas of bilateral consolidations with border effacement of the right diaphragm, compatible with alveolar hemorrhage"
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-09//17402_5_1.jpeg?itok=F1ycMbpO",
            "caption": "A PA and lateral chest X-ray performed 15 days after the first one. Resolution of previous bilateral alveolar consolidations"
          },
          {
            "number": "Figure 5b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-09//17402_5_2.jpeg?itok=iyyQfBI_",
            "caption": "A PA and lateral chest X-ray performed 15 days after the first one. Resolution of previous bilateral alveolar consolidations"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Emergency",
      "Thorax"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/17402",
    "time": "22.09.2021"
  },
  "17417": {
    "case_id": 17417,
    "title": "Systemic hydatid disease: pulmonary, hepatic and musculoskeletal involvement and its complications",
    "section": "Chest imaging",
    "age": "66",
    "gender": "male",
    "diagnosis": "Systemic hydatid disease",
    "history": "A 66-year-old man consulted the emergency department for dyspnea, dry cough and weight loss.\nAt arrival, his blood oxygen saturation was 85%. And biochemical analytics showed increased bilirubin and acute phase reactants.",
    "image_finding": "Chest X ray with bilateral low density homogeneous pulmonary masses and right diaphragmatic elevation (Figure 1).\nIn order to complete the study, an enhanced CT was performed.\nSagittal and coronal image reconstruction in the mediastinal and lung windows present bilateral and multiples cysts with well-defined borders (asterisk). On the right upper lobe one of the cysts shows air crescent and air bubble sign (arrowheads).\u00a0 Compression of the right diaphragm by hepatic hydatic cysts can also be seen. (Figure 2).\nThoracic axial and coronal MIP reconstruction revealed cystic nodules (arrowhead) that caused luminal widening in apical segmental artery of the right upper lobe, anterior and apical segmental arteries of the left upper lobe consistent with emboli. (Figure 3) Ground glass area in the left upper lobe probably related to incipient infarction (arrow). (Figure 2b)\nOn abdominal CT in the portal venous phase multiples liver cysts with peritoneal dissemination can be seen (asterisk). The one on the right hepatic lobe (arrow) presents daughter vesicles inside (type II) and biliary dilatation (arrowhead) as an indirect sign of intrabiliary rupture of hepatic hydatic cyst (Figure 4).\nMusculoskeletal involvement was also manifested with a low-density lesion next to left scapula with bone erosion. (Figure 5).",
    "discussion": "Background\nHydatidosis is a parasitic disease caused by the larvae of the tapeworm Echinococcus. There are two main forms of the disease in humans: cystic echinococcosis caused by E. granulosis which is the most common and alveolar echinococcosis due to E. multilocularis. [1]\nEchinococcus granulosis, has carnivores (e.g. dogs, cats\u2026) as definitive hosts. E. granulosis can be transmitted to humans by ingestion of food or water contaminated by the faeces of parasitized carnivores.\n\u00a0\nClinical and Imaging Perspective\nLiver and lungs are the organs most commonly affected and show characteristic imaging findings. Bones, kidneys, spleen, muscles and central nervous system involvement may be seen due to hematogenous dissemination. [3,8,9] \nRadiography is the initial imaging modality but multimodality imaging approach can be used including US, MRI or CT\u00a0[9]. CT allows to classified cysts depending on the stage of the disease ( useful for the detection of intralesional calcifications) and to identify complications. [4, 8]\nCysts could be asymptomatic for many years, and become painful when they reach a larger volume. Most of their complications are related to their rupture to adjacent structures such as the biliary tree, the pleura or the peritoneum that may be silent clinically or cause anaphylaxis. [2,4]\nUncomplicated hydatid cysts of the lung are usually asymptomatic, while complicated cysts present with nonspecific clinical features like coughing, chest pain, an hemoptysis.\u00a0[3]\nRuptures may be classified in: \n\ncontained (detachment of the pericyst from the endocyst)\ncommunicating (with the bronchus)\ndirect (rupture of all membranes with spillage of contents) [3]\n\n\u00a0\nSome imaging signs of contained rupture hydatic cyst are: \n\nair crescent sign ( a thin crescent of air seen between the pericyst and endocyst caused by bronchial erosion) \nair bubble sign (small intracyst air blebs are seen at the periphery of the cyst between the pericyst and endocyst). [3-8]\n\nHepatic hydatic cysts may also present complications like infection or rupture. Rupture occurs in 35% of the cases and the most common type is the communicating rupture(15%). Communicating rupture within the biliary tree can be detected by indirect signs such as the presence of fat, air or airfluids levels within the cysts, deformation of the cysts, focal defect on the cystic wall or biliary tree dilatation [5,6].\nPulmonary or systemic embolism caused by hydatic cysts are rare complications. Hepatic echinocci may open to the inferior vena cava and daughter vesicles may cause embolisms in the pulmonary arteries. [7]\nMuskuloskeltal involvement is also very rare and may cause bone erosion.[10]\n\nOutcome\nMedical treatment with albendazol and surgical intervention (Lagrot cyst perichystectomy) were performed in this case.",
    "differential_diagnosis": "Systemic, hydatid, disease, Pulmonary, metastases, Pulmonary, abscess, Tuberculosis, Polycystic, disease, Pulmonary, aspergillosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-09//17417_1_1.png?itok=2D9MSitz",
            "caption": "PA Chest X-ray with bilateral low density pulmonary masses and right diaphragmatic elevation"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-09//17417_2_1.png?itok=85PJe_cA",
            "caption": "Sagittal (a) and coronal (b) thoracic CT, with lung window and sagittal(c) and coronal(d) thoracic CT with mediastinal window, present bilateral multiples cysts with well-defined borders (astherisk). Some of them with signs of contained rupture: the air crescent sign and bubble sign (arrowheads). Ground glass area in the left upper lobe probably related to incipient infarction (arrow)"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-09//17417_2_2.png?itok=zAd7gr-H",
            "caption": "Sagittal (a) and coronal (b) thoracic CT, with lung window and sagittal(c) and coronal(d) thoracic CT with mediastinal window, present bilateral multiples cysts with well-defined borders (astherisk). Some of them with signs of contained rupture: the air crescent sign and bubble sign (arrowheads). Ground glass area in the left upper lobe probably related to incipient infarction (arrow)"
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-09//17417_2_3.png?itok=QXpx9Usg",
            "caption": "Sagittal (a) and coronal (b) thoracic CT, with lung window and sagittal(c) and coronal(d) thoracic CT with mediastinal window, present bilateral multiples cysts with well-defined borders (astherisk). Some of them with signs of contained rupture: the air crescent sign and bubble sign (arrowheads). Ground glass area in the left upper lobe probably related to incipient infarction (arrow)"
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-09//17417_2_4.png?itok=5IfkBHEo",
            "caption": "Sagittal (a) and coronal (b) thoracic CT, with lung window and sagittal(c) and coronal(d) thoracic CT with mediastinal window, present bilateral multiples cysts with well-defined borders (astherisk). Some of them with signs of contained rupture: the air crescent sign and bubble sign (arrowheads). Ground glass area in the left upper lobe probably related to incipient infarction (arrow)"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-09//17417_3_1.png?itok=J5BU7JsC",
            "caption": "Axial (a) and coronal (b) thoracic MIP reconstruction revealed cystic nodules (arrowhead) that caused luminal widening in apical segmental artery of the right upper lobe, anterior and apical segmental arteries of the left upper lobe consistent with emboli"
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-09//17417_3_2.png?itok=eIpAka7f",
            "caption": "Axial (a) and coronal (b) thoracic MIP reconstruction revealed cystic nodules (arrowhead) that caused luminal widening in apical segmental artery of the right upper lobe, anterior and apical segmental arteries of the left upper lobe consistent with emboli"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-09//17417_4_1.png?itok=kc-DrQz-",
            "caption": "Coronal (a) and axial (b , c) abdominal CT in the portal venous phase with multiples liver cysts with peritoneal dissemination (asterisk). The one on the right hepatic lobe (arrow) presents daughter vesicles inside (type II) and biliary dilatation (arrowhead) as an indirect sign of intrabiliary rupture of hepatic hydatic cyst"
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-09//17417_4_2.png?itok=7_g4A3r8",
            "caption": "Coronal (a) and axial (b , c) abdominal CT in the portal venous phase with multiples liver cysts with peritoneal dissemination (asterisk). The one on the right hepatic lobe (arrow) presents daughter vesicles inside (type II) and biliary dilatation (arrowhead) as an indirect sign of intrabiliary rupture of hepatic hydatic cyst"
          },
          {
            "number": "Figure 4c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-09//17417_4_3.png?itok=6nEce2mr",
            "caption": "Coronal (a) and axial (b , c) abdominal CT in the portal venous phase with multiples liver cysts with peritoneal dissemination (asterisk). The one on the right hepatic lobe (arrow) presents daughter vesicles inside (type II) and biliary dilatation (arrowhead) as an indirect sign of intrabiliary rupture of hepatic hydatic cyst"
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-09//17417_5_1.png?itok=kxbnkw5v",
            "caption": "Axial CT with low density lesion next to left scapula with bone erosion"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Abdomen",
      "Emergency",
      "Thorax"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/17417",
    "time": "24.09.2021"
  },
  "17421": {
    "case_id": 17421,
    "title": "Recurrent Pleuromediastinal Dedifferentiated Liposarcom",
    "section": "Chest imaging",
    "age": "75",
    "gender": "female",
    "diagnosis": "Recurrent Pleuromediastinal Dedifferentiated Liposarcoma",
    "history": "A 75-year-old patient presented with a 3-week course of progressive dyspnea. Chest X-ray and chest CT were performed.",
    "image_finding": "Initial Chest X-ray (figure 1) showed a nearly complete white-out of the right hemithorax with contralateral mediastinal shift, so subsequent chest CT was performed (figure 2). A large heterogeneous soft-tissue intrathoracic mass was seen, probably arising from the pleural surface and also invading the prevascular mediastinum. No macroscopic fat could be appreciated in the described lesion. Secondary right lung collapse and left mediastinal shift could also be noted. There was an associated moderate amount of right pleural effusion.\nOne year later, a new CT scan denoted the presence of a new right basal pleuromediastinal mass (figure 3), along with an infradiafragmatic mass in the falciform ligament (figure 4). This second mass was extending into the anterior segments of the right hepatic lobe, and some calcifications could be appreciated inside.",
    "discussion": "After the initial CT, upper right lobectomy was performed resecting the mass (figure 5). The anatomopathological result showed a grade 2 dedifferentiated pleuromediastinal liposarcoma. After two new episodes of dyspnea and respiratory failure, the radiological images showed new intrathoracic and intrabdominal masses. The histology showed a grade 3 dedifferentiated liposarcoma. These findings suggested metastatic recurrence of her disease and the patient died a few days later.\nLiposarcoma commonly arises from the retroperitoneum and the extremities, although it can also affect other anatomic locations. However, primary intrathoracic liposarcoma is extremely uncommon [1,2]. In general, sarcomatous lesions in the thorax are most commonly due to metastases from extrathoracic musculoskeletal tumours [3].\nDedifferentiated liposarcoma has a well-differentiated component and a non-adipose cellular sarcoma component. Affects men and women in similar proportions, with a peak prevalence in the 7th decade [1]. These neoplasms typically have an expansile slow-growing and silent behaviour, until they produce symptoms due to mass effect presenting as large or even massive tumours [1,2].\nOverall, imaging features of thoracic primary sarcomas are very limited in the literature and they are often based on other more prevalent locations [3]. They tend to be large masses with well-defined contours and heterogeneous density on CT. It is often difficult or either impossible to determine if the tumour is arising from the chest wall, the pleura, the mediastinum or the lungs [2]. Pleural effusion is commonly associated but lymphadenopathies are exceptional [3]. Dedifferentiated liposarcomas share radiological features with well-differentiated liposarcomas, presenting as soft-tissue masses with fat components and nodular nonlipomatous components with thick septa [1]. They occasionally show calcification or metaplastic parts [1]. However, dedifferentiation is based on the non-fatty component, which can be quite large and occasionally dominant, not being able to differentiate fat density on CT on poorly differentiated subtypes [1,2]. These nonadipose foci demonstrate similar attenuation or slightly lower than that of skeletal muscle on CT [1].\nThe treatment approach of dedifferentiated liposarcomas consists of wide surgical excision, usually with adjuvant radiation therapy. Despite the treatment, these kinds of tumours have a high tendency to local recurrence and metastases are seen in 15-20% of cases, predominantly affecting the lungs, liver and bone [1].\u00a0 \nIn conclusion, the diagnosis of intrathoracic liposarcoma may be difficult when only based on radiological features, particularly if macroscopic fat is absent. Further research needs to be done to better characterize this kind of neoplasms in this unusual location.\n\u00a0\nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Recurrent, Pleuromediastinal, Dedifferentiated, Liposarcoma, Malignant, Mesothelioma, Solitary, Fibrous, Tumour, of, the, Pleura, Malignant, Fibrous, Histiocytoma, Other, Sarcoma-like, Malignances",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-09//17421_1_1.png?itok=pYgyViH2",
            "caption": "Initial PA chest radiography. Nearly complete white-out of the right hemithorax with contralateral mediastinal shift can be observed"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-09//17421_2_1.png?itok=Fz0G21-R",
            "caption": "(a-b). Initial axial and coronal contrast-enhanced chest CT in venous phase. CT shows a large heterogeneous soft-tissue intrathoracic mass, probably arising from the pleural surface and also invading the prevascular mediastinum. Secondary right lung collapse and left mediastinal shift can be noted. There is an associated moderate amount of right pleural effusion. The coronal plane better illustrates the extension of the soft-tissue mass, occupating all the right hemithorax. No macroscopic fat can be appreciated"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-09//17421_2_2.png?itok=OOS2zei3",
            "caption": "(a-b). Initial axial and coronal contrast-enhanced chest CT in venous phase. CT shows a large heterogeneous soft-tissue intrathoracic mass, probably arising from the pleural surface and also invading the prevascular mediastinum. Secondary right lung collapse and left mediastinal shift can be noted. There is an associated moderate amount of right pleural effusion. The coronal plane better illustrates the extension of the soft-tissue mass, occupating all the right hemithorax. No macroscopic fat can be appreciated"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-09//17421_3_1.png?itok=5BVl1bq7",
            "caption": "Axial contrast-enhanced chest CT in venous phase performed one year after. CT shows a soft-tissue intrathoracic mass arising from the middle mediastinum and protruding into the right lung. This mass is also in contact with the right diaphragm and the liver dome. Post-surgical changes can be appreciated in the right lung and the sternum"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-09//17421_4_1.png?itok=Rbdz734R",
            "caption": "Axial contrast-enhanced abdominal CT in venous phase performed one year after. Abdominal CT demonstrates an infradiafragmatic soft-tissue mass in the falciform ligament, extending into the anterior segments of the right hepatic lobe. Some thin calcifications can be seen on its periphery"
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-09//17421_5_1.png?itok=g86lsglV",
            "caption": "Macroscopic appearance of the right intrathoracic mass. Large multilobed mass, brownish-white in color, with some yellowish necrotic-looking areas. It has a trabecular cut and some area that seems to infiltrate lung parenchyma"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/17421",
    "time": "04.10.2021"
  },
  "17428": {
    "case_id": 17428,
    "title": "Beyond pleura: fluid collection with extrapleural fat sign",
    "section": "Chest imaging",
    "age": "82",
    "gender": "male",
    "diagnosis": "Left spontaneous extrapleural hematoma in a patient with coagulopathy",
    "history": "An 82-year-old man with diabetes, hypertension, dyslipidaemia \u00a0and ischemic heart disease was admitted to the intensive care unit for cholangitis and type 2 myocardial infarction. He received a loading dose of antiplatelet therapy. At admission, he had significant hepatic/cholestatic changes, with international normalized ratio (INR) of 1.5. No history of trauma.",
    "image_finding": "An abdominal CT was performed to re-evaluate cholangitis. Included inferior thoracic tomograms showed bilateral pleural effusion and de novo small, slightly convex fluid collection that pushed the extrapleural fat layer centrally within the hemithorax, away from the ribs (Figures 1a and 2) and had higher spontaneous attenuation than pleural fluid (Figure 1b). All ribs were regular, without fracture.\nCT scan performed two days earlier showed no convex fluid collection, only a thin pleural effusion.",
    "discussion": "Background\nThe extrapleural space (EPS) is located between the thoracic cage and the parietal pleura and contains the extrapleural fat, the endothoracic fascia, and the musculi intercostales intimi. The extrapleural fat includes the intercostal nerve and vessels and separates the pleura from the endothoracic fascia and is located more posterolaterally, from the 4th to the 8th rib. The lymphatic drainage of the parietal pleura is through the EPS. \nImaging Perspective\nOn CT assessment, the EPS is poorly defined, but when it is displaced away from the inner rib contours, it is useful in distinguishing between intrathoracic or extrathoracic location of a lesion. An extrapleural collection or mass produces the appearance of a fatty streak (low-attenuating layer) that reflects inward displacement of the extrapleural fat and parietal pleura, known as \"extrapleural fat sign.\" [1-4]\nThe most common cause of this sign is an extrapleural hematoma, usually due to blunt chest trauma, and it can mimic a hemothorax. However, spontaneous hematoma may also occur in cases of coagulopathy [2]. \nTwo cases of spontaneous extrapleural hematoma have been reported in the literature - one in a hemodialysis patient [5] and another in an anticoagulated patient with valvular heart disease [6]. In both cases, the hematoma had an arterial origin and caused larger biconvex collections. In contrast, venous hematomas tend to be non-convex and smaller [7]. \nHematoma bleeding can be rapid and cause haemodynamic or respiratory instability, especially if it has an arterial origin, secondary to chest trauma. \nIdentifying the location of a fluid collection in the extrapleural space is extremely important to differentiate between hematoma and hemothorax, considering they have different management, to avoid incorrect treatment with a chest tube.\nOutcome\nManagement of an extrapleural hematoma depends on its location, size, origin, and impact on laboratory parameters or cardiorespiratory compromise. Biconvex hematomas tend to be larger and require surgery; nonconvex hematomas generally do not require specific treatment [7].\nIn the present case, based on the presence of the extrapleural fat sign, the features of fluid collection, and its shape, a venous spontaneous extrapleural hematoma was assumed in an ICU patient with coagulopathy, with no effect on blood haemoglobin. He was treated with phytomenadione for INR stabilization. No invasive procedure was required and the hematoma regressed spontaneously with conservative treatment.",
    "differential_diagnosis": "Left, spontaneous, extrapleural, hematoma, in, a, patient, with, coagulopathy, Hemothorax, Extrapleural, tumour, Chest, wall, infection, Extrapleural, lymph, node, involvement",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-10//17428_1_1.JPG?itok=oBCUzwoB",
            "caption": "Axial non-contrasted Computed Tomography of the chest in mediastinal window setting showing bilateral pleural effusion and a left-sided dorsolateral de novo small slightly convex collection of fluid pushing the extrapleural fat layer forward and medially (white arrow) \u2013 extrapleural fat sign"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-10//17428_1_2.JPG?itok=3upvCbv_",
            "caption": "Same scan as 1a with densitometry, showing a higher attenuation of the extrapleural fluid (24 HU) as compared to the pleural effusion (10 HU)"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-10//17428_2_1.JPG?itok=rHnB3zVa",
            "caption": "Axial Computed Tomography of the chest in mediastinal window setting with contrast showing the extrapleural fat sign (white arrow) and aneurysmal dilation of the left ventricle with  a scar (black arrow) in the context of myocardial infarction"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Respiratory system",
      "Thorax"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/17428",
    "time": "08.10.2021"
  },
  "17450": {
    "case_id": 17450,
    "title": "Better out than in: Spontaneous pneumomediastinum as a result of a stifled sneeze",
    "section": "Chest imaging",
    "age": "25",
    "gender": "male",
    "diagnosis": "Spontaneous pneumomediastinum following alveolar rupture",
    "history": "A 25-year-old male presented with sudden onset neck and chest pain after a single episode of dry heaving followed by stifling a forceful sneeze. Examination revealed a reduced range of motion at the neck in all planes and odynophagia. Vital signs were unremarkable, and blood tests revealed raised inflammatory markers.",
    "image_finding": "Initial Chest Radiograph PA view demonstrated linear lucencies along bilateral hilar and paratracheal regions with extension into the subcutaneous tissues of the neck, more evident on the left side. Appearances are suspicious for pneumomediastinum with associated subcutaneous emphysema (Figure 1).\nSelected axial CT images confirm pneumomediastinum and associated surgical emphysema. (Figure 2a, 2b).\nTo rule out oesophageal rupture, CT chest with oral gastrografin contrast was conducted. 6 hours after the initial study, the subsequent CT does not display any extravasation of contrast into the mediastinum to suggest an active leak. The pneumomediastinum and surgical emphysema remain unchanged (Figure 3a, 3b).\nThe source of the pneumomediastinum was unclear and was eventually attributed to alveolar rupture; however, due to clinical uncertainty, the patient was admitted, kept nil by mouth, and received broad-spectrum antibiotics to cover an oesophageal source.\nPre-discharge chest radiograph shows interval resolution of the pneumomediastinum after five days (Figure 4).",
    "discussion": "Pneumomediastinum is defined as free air within the mediastinum and was first described by Laennec in 1829 [1]. Spontaneous pneumomediastinum (SPM) is used to describe pneumomediastinum with no apparent cause such as trauma, infection or iatrogenesis. It is commonly linked to sudden increases in intrathoracic pressure such as through coughing and vomiting or Valsalva manoeuvre [2]. SPM is a relatively rare presentation, with one study noting an incidence of 1 in 44511 patients that presented to an emergency department [3].\nCommon symptoms of a pneumomediastinum include chest pain and dyspnoea [4]. Given the overlap with numerous pathologies, pneumomediastinum must remain a differential in patients presenting with cardiopulmonary complaints. In the case of our patient, the initial assessing clinician decided on discharge with a diagnosis of muscle spasm in the neck following the internalised sneeze. It was only after the patient sought a second opinion that a chest radiograph was organised, drawing attention to the extraluminal gas. This emphasises the importance of early imaging in detecting pneumomediastinum, especially in instances of diagnostic uncertainty.\nChest radiography may demonstrate subcutaneous emphysema and lucencies outlining mediastinal structures such as the pulmonary artery and major aortic branches which may prompt further imaging [4,5]. In our case, the patient experienced some chest discomfort following an initial dry heave which was then significantly worsened by the sneeze. As such, there was clinical suspicion that the gas may have originated from the oesophagus. In such instances, imaging with oral contrast agents becomes prudent [2]. Contrast extravasation into the mediastinum may demonstrate oesophageal perforation, a potential source of mediastinitis, which has been associated with mortality rates of approximately 30% [6]. In the absence of any oesophageal leak being identified, SPM commonly originates from the lungs through alveolar rupture, usually dissecting surrounding peribronchial/perivascular sheaths, and is treated conservatively as a benign and self-limiting condition. Other potential sources may include bowel and airways [4]. If however, an active oesophageal breach is identified, the patient in question will likely require emergency surgical repair [2].\nTeaching points\n\nSPM is a rare but important differential to consider for patients presenting with chest pain or respiratory symptoms, especially when there is diagnostic uncertainty.\nChest radiograph may demonstrate streaky lucencies. This should prompt CT imaging to further evaluate the extent of gas within the mediastinum, and consideration of oral contrast to assess oesophageal involvement.\n\nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Spontaneous, pneumomediastinum, following, alveolar, rupture, Spontaneous, pneumomediastinum, following, oesophageal, rupture",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-10//17450_1_1.jpg?itok=IkRgsnIK",
            "caption": "Linear lucencies along bilateral hilar and paratracheal regions with extension into the subcutaneous tissues of the neck, more evident on the left side. Appearances are suspicious for pneumomediastinum with associated subcutaneous emphysema"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-10//17450_2_1.jpg?itok=c5E0VGPC",
            "caption": "Selected axial CT image confirms pneumomediastinum (a) and associated surgical emphysema (b)"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-10//17450_2_2.jpg?itok=5dIT92IM",
            "caption": "Selected axial CT image confirms pneumomediastinum (a) and associated surgical emphysema (b)"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-10//17450_3_1.jpg?itok=X3URc9SE",
            "caption": "The pneumomediastinum remains unchanged (a). There is no extravasation of contrast into the mediastinum to suggest an active oesophageal tear (b)"
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-10//17450_3_2.jpg?itok=G-UVU_TP",
            "caption": "The pneumomediastinum remains unchanged (a). There is no extravasation of contrast into the mediastinum to suggest an active oesophageal tear (b)"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-10//17450_4_1.jpg?itok=MuTxBpm7",
            "caption": "Interval resolution of the pneumomediastinum is noted"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Mediastinum"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/17450",
    "time": "18.10.2021"
  },
  "17464": {
    "case_id": 17464,
    "title": "Tracheobronchopathia Osteochondroplastica: An Underdiagnosed Non-Neoplastic Airway Disease",
    "section": "Chest imaging",
    "age": "65",
    "gender": "female",
    "diagnosis": "Tracheobronchopathia Osteochondroplastica",
    "history": "A 65-year-old female with severe persistent asthmatic bronchitis, seasonal allergy, gastroesophageal reflux disease (GERD) presented to her pulmonologist with shortness of breath for a year. She smoked 1 pack per day for 7 years and quit 41 years ago. A recent chest x-ray was negative for acute cardiopulmonary findings. A non-contrast CT was ordered for further evaluation.",
    "image_finding": "Non-contrast CT images showed scalloping of the tracheal wall with multiple small nodular, non-calcified lesions in the trachea and the proximal left main bronchus sparing the posterior membranous portion of the trachea (Figure 1-4).",
    "discussion": "Tracheobronchopathia osteochondroplastica (TO) is one of the diffuse non-neoplastic diseases of the central airway.\u00a0 TO affects the anterior tracheal wall and the major bronchi, characterised by multiple submucosal osteocartilaginous nodules. The most commonly affected locations are the lower trachea and the proximal portions of the primary bronchi [1]. The nodules consist of hyaline cartilage with sparing of the posterior membranous tracheal wall, in contrast to tracheobronchial amyloidosis, tracheobronchial papillomatosis, and granulomatosis with polyangiitis (GPA) in which the posterior wall is affected [2]. TO is frequently found in patients in their mid-50s, and affects more men than women with a ratio of 3:1 [1]. A study in which 2180 people underwent bronchoscopy showed 9 patients had TO, making the prevalence among this population 0.37%. These findings were consistent with other researchers which showed it to be 0.02- 0.7% [1].\u00a0 \nThe aetiology of TO is unknown. One proposed mechanism by Tajima et al was the involvement of bone morphogenic protein-2(BMP-2) and transforming growth factor-beta 1 (TGF-1) in causing formation of cartilaginous nodules [3]. It does not have relation with smoking or other systemic disorders [4]. \nAlthough most patients are asymptomatic, the symptomatic patients can present with nonspecific respiratory symptoms such as cough, dyspnea on exertion, recurrent infection, wheezing and sometimes hemoptysis. Hemoptysis occurs secondary to mucosal breakage from the rubbing between the opposing nodules [1]. In even more rare occasions, airway obstruction can be found in one or more parts of the trachea and bronchi in patients with severe disease [2]. TO is frequently misdiagnosed as asthma since the presentations can be very similar [4]. In 8/9 of the patients diagnosed with TO, spirometry showed an obstructive lung pattern, further showing how TO can be misdiagnosed as asthma [5].\u00a0 \nRadiological appearance of TO ranges from tracheal scalloping, nodular irregularity to varying degree of asymmetric stenosis. On CT, irregular calcifications in the thickened tracheal cartilage can be seen (Figure 1-4). The posterior membrane of the trachea is spared from the nodules [1]. During bronchoscopy, multiple smooth, raised, white, osteocartilaginous nodules can be found (Figure 5). The hard density of those nodules makes biopsy difficult, although biopsy has shown osteocartilaginous tissue [6].\u00a0 \nMost patients with TO are asymptomatic and treatment is not necessary. Currently, there is no specific treatment to remove the existing nodules or to prevent the development of new nodules [1]. One study showed tracheoplasty successfully alleviated symptoms of a few patients with severe and symptomatic disease with follow up to 12 years [2]. The mainstay for management of TO is bronchodilators. Although treatment of pulmonary infections and bronchoscopic dilation can also be used if clinically indicated [4]. \nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Tracheobronchopathia, Osteochondroplastica, Relapsing, polychondritis, Tracheobronchial, amyloidosis, Tracheolaryngeal, papillomatosis, Granulomatosis, with, polyangiitis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-10//17464_1_1.PNG?itok=4_mKVpAv",
            "caption": "Axial CT images through the upper trachea in the soft tissue (a), lung (b) and bone (c) windows show multiple non-calcified nodular lesions sparing the posterior trachea"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-10//17464_1_2.PNG?itok=r54WbftP",
            "caption": "Axial CT images through the upper trachea in the soft tissue (a), lung (b) and bone (c) windows show multiple non-calcified nodular lesions sparing the posterior trachea"
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-10//17464_1_3.PNG?itok=5cmWiPqI",
            "caption": "Axial CT images through the upper trachea in the soft tissue (a), lung (b) and bone (c) windows show multiple non-calcified nodular lesions sparing the posterior trachea"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-10//17464_2_1.PNG?itok=AGWQUxuh",
            "caption": "Axial CT images at the level of main bronchi in the soft tissue (a), lung (b) and bone (c) windows show multiple non-calcified nodular lesions in the proximal left main bronchus"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-10//17464_2_2.PNG?itok=LNYwMmA7",
            "caption": "Axial CT images at the level of main bronchi in the soft tissue (a), lung (b) and bone (c) windows show multiple non-calcified nodular lesions in the proximal left main bronchus"
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-10//17464_2_3.PNG?itok=VFT5cWOO",
            "caption": "Axial CT images at the level of main bronchi in the soft tissue (a), lung (b) and bone (c) windows show multiple non-calcified nodular lesions in the proximal left main bronchus"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-10//17464_3_1.PNG?itok=LyE2e0Lz",
            "caption": "Coronal CT images through the upper trachea in the soft tissue (a), lung (b) and bone (c) windows show multiple non-calcified nodular lesions scalloping the airway without significant obstruction"
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-10//17464_3_2.PNG?itok=2L4cz8pH",
            "caption": "Coronal CT images through the upper trachea in the soft tissue (a), lung (b) and bone (c) windows show multiple non-calcified nodular lesions scalloping the airway without significant obstruction"
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-10//17464_3_3.PNG?itok=5GQPHeIc",
            "caption": "Coronal CT images through the upper trachea in the soft tissue (a), lung (b) and bone (c) windows show multiple non-calcified nodular lesions scalloping the airway without significant obstruction"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-10//17464_4_1.PNG?itok=SlDwy_vb",
            "caption": "Sagittal CT images through the trachea in the soft tissue (a), lung (b) and bone (c) windows show multiple non-calcified nodular lesions scalloping the airway without significant obstruction"
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-10//17464_4_2.PNG?itok=y7Y0o6M-",
            "caption": "Sagittal CT images through the trachea in the soft tissue (a), lung (b) and bone (c) windows show multiple non-calcified nodular lesions scalloping the airway without significant obstruction"
          },
          {
            "number": "Figure 4c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-10//17464_4_3.PNG?itok=MFNRBopy",
            "caption": "Sagittal CT images through the trachea in the soft tissue (a), lung (b) and bone (c) windows show multiple non-calcified nodular lesions scalloping the airway without significant obstruction"
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-10//17464_5_1.png?itok=YCHNQ3T-",
            "caption": "Direct bronchoscopy was performed at the level of the upper trachea (a), mid trachea (b and c), above the carina (d and e) and left main bronchus (f) showed multiple smooth, raised bony/cartilaginous protuberances throughout the anterolateral trachea and to a lesser degree the proximal left main bronchus"
          },
          {
            "number": "Figure 5b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-10//17464_5_2.png?itok=y6J6x9K0",
            "caption": "Direct bronchoscopy was performed at the level of the upper trachea (a), mid trachea (b and c), above the carina (d and e) and left main bronchus (f) showed multiple smooth, raised bony/cartilaginous protuberances throughout the anterolateral trachea and to a lesser degree the proximal left main bronchus"
          },
          {
            "number": "Figure 5c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-10//17464_5_3.png?itok=0UTwta7U",
            "caption": "Direct bronchoscopy was performed at the level of the upper trachea (a), mid trachea (b and c), above the carina (d and e) and left main bronchus (f) showed multiple smooth, raised bony/cartilaginous protuberances throughout the anterolateral trachea and to a lesser degree the proximal left main bronchus"
          },
          {
            "number": "Figure 5d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-10//17464_5_4.png?itok=Q2sRfQHi",
            "caption": "Direct bronchoscopy was performed at the level of the upper trachea (a), mid trachea (b and c), above the carina (d and e) and left main bronchus (f) showed multiple smooth, raised bony/cartilaginous protuberances throughout the anterolateral trachea and to a lesser degree the proximal left main bronchus"
          },
          {
            "number": "Figure 5e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-10//17464_5_5.png?itok=iznm-MtS",
            "caption": "Direct bronchoscopy was performed at the level of the upper trachea (a), mid trachea (b and c), above the carina (d and e) and left main bronchus (f) showed multiple smooth, raised bony/cartilaginous protuberances throughout the anterolateral trachea and to a lesser degree the proximal left main bronchus"
          },
          {
            "number": "Figure 5f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-10//17464_5_6.png?itok=9Jf_vT_k",
            "caption": "Direct bronchoscopy was performed at the level of the upper trachea (a), mid trachea (b and c), above the carina (d and e) and left main bronchus (f) showed multiple smooth, raised bony/cartilaginous protuberances throughout the anterolateral trachea and to a lesser degree the proximal left main bronchus"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Respiratory system",
      "Thorax"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/17464",
    "time": "22.10.2021"
  },
  "17474": {
    "case_id": 17474,
    "title": "Unusual presentation of congenital pulmonary underdevelopment of left lung: A rare case report",
    "section": "Chest imaging",
    "age": "60",
    "gender": "male",
    "diagnosis": "Left upper lobar agenesis of lung in adult male",
    "history": "A 60-year-old male presented with breathlessness on exertion for one year. He was referred to the radiology department for a chest radiograph. He had no co-morbidities. On chest auscultation absence of breath sounds in the left hemithorax noted. He gives the history of blunt trauma to the chest 10 years back.",
    "image_finding": "Chest radiograph showed opaque hemithorax on the left side with the cardio-mediastinal shift to the ipsilateral side. The left main bronchus was not seen. The right lung appears radiolucent due to compensatory over-inflation. The patient underwent contrast-enhanced CT which showed the absence of the left upper lobe with the complete collapse of the left lower lobe and cardio-mediastinal shift to the left side. The main pulmonary artery was normal with hypoplasia of the left pulmonary artery which continued as left lower lobe pulmonary artery without any upper lobe branch. Left main bronchus was absent. This is a very unusual case as there is no left lower lobe bronchus, however, left lower lobe collapse lung tissue supplied by left lower pulmonary artery branches seen. Pulmonary sequestration is ruled out as there is no systemic arterial supply to collapsed lung tissue. Our findings were confirmed with fiberoptic bronchoscopy which showed abrupt cutoff at the left main bronchus. No other congenital anomalies were detected.",
    "discussion": "Pulmonary agenesis is an uncommon congenital anomaly that belongs to a spectrum of pulmonary underdevelopment. It can present either as an isolated entity or can be associated with anomalies involving the cardiovascular, gastrointestinal, genitourinary, or skeletal system [1]. It can present with variable respiratory symptoms and recurrent respiratory tract infections. Pulmonary agenesis presents as a unilateral condition as bilateral agenesis of the lung is not compatible with life [1]. \u00a0Agenesis is more commonly seen on the left side and these individuals have a longer life expectancy. \u00a0The right-sided form carries a poor prognosis due to associated anomalies, mainly cardiovascular [2]. \nPulmonary agenesis and aplasia result from complete arrested lung development of primitive lung during embryonic life, whereas pulmonary hypoplasia results from incomplete development of lung during prenatal development. It has been hypothesized that abnormal blood flow in the dorsal aortic arch during the embryonic phase causes pulmonary agenesis [4]. Other causes attributed to lack of vitamin A during pregnancy, viral agents, genetic factors,\u00a0 as well as iatrogenic factors.\nPulmonary agenesis is the complete absence of lung parenchyma, bronchial tree, and supporting vasculature. Although pulmonary aplasia is similar to agenesis, the main difference being the presence of blind-ending bronchus in aplasia, whereas in pulmonary hypoplasia there is an incomplete development of lung resulting in abnormally low number/size of bronchopulmonary segments or alveoli.\nDepending upon the stage of development of the primitive lung bud, pulmonary agenesis is classified into three categories initially described by Schneider later modified by Boyden [3] \nType 1 (Agenesis) \u2013 Complete absence of lung parenchyma, bronchus, and its vasculature. \nType 2 (Aplasia) \u2013 Rudimentary bronchus with complete absence of pulmonary parenchyma. \nType 3 (Hypoplasia) \u2013 Presence of variable amounts of the bronchial tree, pulmonary parenchyma, and its vasculature.\n\u00a0Pulmonary agenesis can be diagnosed with different imaging techniques. A plain chest radiograph shows opaque hemithorax with mediastinal shift and compensatory hyperinflation of contralateral lung. Contrast-enhanced CT is a standard imaging technique for the diagnosis of lung agenesis, however other modalities as bronchography, bronchoscopy, and pulmonary angiography can also be used.\nIn our case, the diagnosis was made with chest radiograph, CECT thorax and fiberoptic bronchoscopy which showed,\na) Complete absence of left main bronchus and its bronchial segments.\nb)Collapsed residual lung parenchyma in left lower hemithorax.\nc)Hypoplastic left pulmonary artery with its branches supplying residual lung parenchyma.\nPulmonary agenesis is diagnosed prenatally only in few cases, as there are technical difficulties in differentiating from other lung malformations. Isolated pulmonary agenesis shows considerable time delay in diagnosis as the symptoms are nonspecific.\nTreatment depends on the severity of symptoms. In most cases, surgical resection of the nonfunctioning lobe is performed with implantation of tissue expanders to place the mediastinum in its normal anatomical position. Survival prognosis depends on the functioning capacity of the contralateral lung.",
    "differential_diagnosis": "Left, upper, lobar, agenesis, of, lung, in, adult, male, Left, lung, collapse, Left, endobronchial, tumor, Left, post, pneumonectomy",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-10//17474_1_1.jpg?itok=QpZwnMEV",
            "caption": "Frontal chest radiograph shows left opaque hemithorax with cardiomediastinal shift to left. Compensatory hyperinflation of right lung seen. Incidental fracture second and third rib and body of scapula on left side seen"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-10//17474_2_1.png?itok=4Jq4Jc3n",
            "caption": "Coronal CT lung window shows absent lung parenchyma on the left side with complete absence of left main bronchus (arrow)"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-10//17474_2_2.jpg?itok=7fv9kWHk",
            "caption": "Coronal contrast-enhanced CT chest shows absent left lung parenchyma with a shift of cardia to the left side"
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-10//17474_2_3.jpg?itok=u7IFAE3O",
            "caption": "Axial contrast-enhanced CT chest shows collapse left lower lobe supplied by left lower lobe pulmonary artery branches. There is a complete shift of mediastinal structure to the left side"
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-10//17474_2_4.png?itok=RLORfL3u",
            "caption": "Coronal contrast enhanced CT image in anterior aspect of thorax shows complete volume loss of left lung with normal main pulmonary artery and right main pulmonary branch"
          },
          {
            "number": "Figure 2e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-10//17474_2_5.png?itok=9lJcfVPn",
            "caption": "Coronal contrast enhanced CT image in posterior aspect of thorax shows complete collapse of left lower lobe with left lower segmental branches of pulmonary artery supplying residual lung tissue"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-10//17474_3_1.png?itok=zpZQwD9w",
            "caption": "Maximum intensity projection image of pulmonary angiogram shows normal main pulmonary artery and right main pulmonary artery. Hypoplastic left main pulmonary artery with absent left upper lobar segmental branches. Left lower segmental branches seen supplying residual lung tissue"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Anatomy",
      "Cardiac",
      "Mediastinum"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/17474",
    "time": "27.10.2021"
  },
  "17492": {
    "case_id": 17492,
    "title": "Unusual presentation of a mediastinal cystic hygrom",
    "section": "Chest imaging",
    "age": "24",
    "gender": "female",
    "diagnosis": "Mediastinal cystic hygroma",
    "history": "A 24-year-old woman who is normally fit presented to A&E with a three-week history of shortness of breath as well as chest pain. Pain was sharp and pleuritic in nature. This was preceded by a one-week history of a viral upper respiratory tract infection. She had no prior medical history.",
    "image_finding": "Initial computed tomography pulmonary angiogram (CT PA) showed a soft tissue density in the anterior mediastinum with irregular margins and calcifications. Positron emission tomography - fluorodeoxyglucose (PET- FDG) highlighted an atypical soft tissue density of low grade activity. Latest CT chest showed significant reduction in the soft tissue density after surgical resection.",
    "discussion": "Cystic hygromas, a type of lymphatic malformation, are fluid-filled sacs that arise from a lymphatic system blockage. They are benign malformations and the vast majority are discovered during early childhood though some can be seen on ultrasound foetal scans. There have been links with congenital syndromes such as Down\u2019s syndrome, and other aneuploidic anomalies, as well as congenital cardiac anomalies e.g. aortic coarctation. The individual in this report did not have any of the above-mentioned conditions nor any other lymphatic/vascular malformations. \u00a0\nThe usual location of cystic hygromas are in the neck with mediastinal cystic hygromas usually being resultant from the extension of the neck tumour [1]. Of all cystic hygromas, approximately 1% are primarily mediastinal [2].\nClinical picture is usually from a parent or guardian concerned about a painless soft mass. Although, when symptomatic the presentation largely depends on location and results from compression of nearby structures. It can range from serious, such as airway compromise, to mild discomfort over the affected region as well as purely cosmetic. Symptoms such as discomfort, chest pain, cough and dyspnoea can be associated with mediastinal involvement; however, patients can also be asymptomatic [3].\nImaging alone cannot offer a definitive diagnosis of hygroma as most cystic mediastinal masses often look similar. Imaging does verify the cystic nature, give further information on relation to other nearby structures and guide treatment. Computed tomography (CT) normally shows well-delineated cystic lesions without any calcifications. On magnetic resonance imaging (MRI) the lesions are typically low signal on T1-weighted images and high on T2-weighted images. \nManagement is largely surgical with complete resection through a thoracotomy being the preferred option. Sclerotherapy - using OK-432 agents - has been used in cervical cystic hygromas; however, it is not the preferred method of treatment in solitary mediastinal lesions. Radiotherapy is another therapeutic option, though due to the possibility of damage to neighbouring structures, it is of little use [4].\nLearning Points\nIn this case the radiological findings were not in keeping with those typically seen in cystic hygromas but instead seemed like a soft tissue mass. Histology showed irregular vascular-like spaces with occasional endothelial lined lumens with some focal thrombi. The endothelial lesions stain positive with actin and desmin within the wall and positive with CD31 in the lumen. Findings in keeping with cystic hygromas. Due to the lack of D240 staining of the endothelial cells the lesion could be a vascular hamartoma.\nThis goes to show that the classical presentation is not always present and to keep a wide index of suspicion.\nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Mediastinal, cystic, hygroma, Vascular, hamartoma, Mediastinal, haemangioma, Pericardial, cysts, Pulmonary, sequestration, Thymus, cyst",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-10//17492_1_1.png?itok=gQJ1Qhjw",
            "caption": "Pre-operative CT PA axial. CT PA showing right paracardiac anterior mediastinal soft tissue density with calcifications"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-10//17492_1_2.png?itok=KQZqhKFj",
            "caption": "Pre-operative CT PA sagittal. CT PA showing anterior mediastinal soft tissue density with irregular margins"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-10//17492_2_1.png?itok=xgB78iTU",
            "caption": "Pre-operative PET FDG axial. PET FDG showing soft tissue density with low grade activity"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-10//17492_3_1.png?itok=01Qmi2v_",
            "caption": "Post-operative CT chest axial. CT chest showing significant reduction in the soft tissue mass after surgical resection"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Mediastinum",
      "Thorax"
    ],
    "imaging_technique": [
      "CT",
      "CT-Angiography",
      "PET"
    ],
    "link": "https://www.eurorad.org/case/17492",
    "time": "27.10.2021"
  },
  "17505": {
    "case_id": 17505,
    "title": "Luftsichel sign in upper lobe collapse",
    "section": "Chest imaging",
    "age": "65",
    "gender": "female",
    "diagnosis": "Left upper lobe collapse secondary to a left hilar carcinoma",
    "history": "A 65-year-old woman, without relevant background history, was admitted to the emergency department due to recent onset of dyspnea and pleuritic pain. Physical examination was normal. Chest radiograph and computed tomography (CT) scan was then performed.",
    "image_finding": "The chest radiograph (Figure 1) revealed a left para-aortic crescent of hyperlucency outlining the aortic arch, with sharp margins, extending from the apical lobe to the superior pulmonary vein, suggestive of left upper lobe collapse. This appearance is known as the Luftsichel sign. Also, an additional density in the left hilum can be defined and the left hilum and hemidiaphragm are mildly elevated. These findings are compatible with left upper lobe collapse secondary to left hilar mass.\nContrast-enhanced CT of the chest (Figure 2a and 2b) confirms the presence of left upper lobe collapse secondary to a left hilar enhancing soft tissue mass, causing complete obstruction of the left upper lobe bronchus.\nEndobronchial biopsy of this lesion confirmed the diagnosis of squamous cell carcinoma.",
    "discussion": "The left upper lobe collapses in the anterosuperior direction, displacing the major fissure anteromedially. \u00a0In the majority of cases of left upper lobe collapse, the aortic arch is abutted by the collapsed lung and hence the normal silhouette is lost. \nHowever, in some cases, the hyperinflated superior segment of the left lower lobe interposes between the collapsed left upper lobe and the superior mediastinum, giving the posterior margin of the collapsed lobe a V shape. On chest radiographs, this finding is called the Luftsichel sign.\nSome direct signs of collapse include displacement of fissures and crowding of vessels. Indirect signs such as hilar displacement, elevation of the hemidiaphragm, rib crowding, tented appearance of hemidiaphragm (juxtaphrenic peak sign), compensatory hyperinflation of the remaining lung and shift of the mediastinum to the left may also be seen.\nLeft upper lobe collapse has some characteristic features in a chest radiograph that allows its prompt identification, which may indicate endobronchial pathology and the need for further study.",
    "differential_diagnosis": "Left, upper, lobe, collapse, secondary, to, a, left, hilar, carcinoma, Lung, cancer, Right, lung, herniation, Pneumomediastinum",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-11//17505_1_1.png?itok=VQI3a42B",
            "caption": "The hyperinflated superior segment of the left lower lobe between the superior mediastinum and the collapsed left upper lobe, known as the Luftsichel sign (arrows)"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-11//17505_2_1.png?itok=auZ4hTKf",
            "caption": "Contrast-enhanced CT chest mediastinal window shows a left hilar enhancing soft tissue mass causing collapse of left upper lobe and complete occlusion of the left upper lobe bronchus"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-11//17505_2_2.png?itok=dwj_C949",
            "caption": "Contrast-enhanced CT chest mediastinal window shows a left hilar enhancing soft tissue mass causing collapse of left upper lobe and complete occlusion of the left upper lobe bronchus"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Thorax"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/17505",
    "time": "04.11.2021"
  },
  "17506": {
    "case_id": 17506,
    "title": "A rare cause of haemoptysis: Anomalous systemic arterial supply to lung without sequestration.",
    "section": "Chest imaging",
    "age": "26",
    "gender": "male",
    "diagnosis": "Systemic arterialization of lung without sequestration",
    "history": "A 26-year-old man admitted with complaints of three episodes of haemoptysis. No history of fever, chest pain, dyspnoea or syncope.",
    "image_finding": "Chest radiograph showed prominent vessels in the right lower zone. Contrast-enhanced computed tomography (CT) of thorax showed prominent vessels in the right lower lobe which were branches of an anomalous branch of descending thoracic aorta. In addition to these vessels, normal pulmonary vasculature was also supplying the lower lobe. There was no evidence of lung sequestration. Selective angiography revealed distal aneurysmal dilatation of the artery without evidence of early venous drainage. Obliteration of the anomalous artery was achieved by embolization of the distal branches using multiple coils and proximal segment with Amplatzer Vascular Plug.",
    "discussion": "Bronchopulmonary sequestration includes a spectrum of abnormalities of lung parenchyma characterized by abnormal systemic vascular supply to lung. In 1946, Pryce proposed a classification system encompassing pulmonary sequestration and anomalous systemic arterial supply to lung. It included Pryce type I \u2013 normal lung with anomalous systemic arterial supply, type II \u2013 anomalous artery supplying sequestered lung and adjacent normal lung, type III \u2013 anomalous artery to sequestered lung [1]. Systemic arterialization of lung without pulmonary sequestration (Pryce type I), also referred to as \u201cpseudosequestration\u201d, is the rarest form of anomalous systemic arterial supply to lung [2,3]. It can be of two types: isolated systemic arterial supply to normal lung (ISSNL) and systemic arterial supply associated with normal pulmonary artery (dual supply) [4]. \nDuring normal lung development, the early lung bud is perfused by a vascular plexus from the dorsal aorta which regresses with the development of the main pulmonary artery. Systemic supply to normal lung occurs due to failure of regression of the primitive aortic branches to the developing lung bud [5]. The basal segments of the lower lobes are commonly affected with a slightly higher incidence noted in the left lower lobe. The systemic supply usually arises from the thoracic aorta but can arise from the suprarenal abdominal aorta or the coeliac axis and in rare instances, from the left subclavian or internal mammary artery [6]. The venous drainage is usually through the inferior pulmonary vein into the left atrium.\nTransmission of the systemic pressure to the low-pressure pulmonary vasculature results in a focal pulmonary hypertension which in severe cases can develop into high-output cardiac failure. The most common presenting symptom is hemoptysis. Other manifestations include exertional dyspnea, congestive heart failure due to left heart overload.\nChest radiographs may show ill-defined opacity corresponding to the anomalous artery. CT angiography can demonstrate the origin and course of aberrant artery with the advantage of multiplanar and 3-D reconstructions. CT helps in excluding other causes of systemic arterialization of lung like bronchopulmonary sequestration and other pulmonary vascular anomalies like congenital pulmonary venolobar syndrome. Intralobar sequestration appears as an area of consolidation or rarely as a cystic lesion with systemic arterial supply and normal pulmonary venous drainage but without any visible communication with tracheobronchial tree. Conventional angiography has been superseded by CT angiography but remains an important problem-solving tool and plays a vital role in the endovascular management of these patients. Treatment options include surgery (lobectomy and segmentectomy), when aberrant systemic artery is the only supply, and occlusion of the aberrant vessel by surgical ligation or endovascular treatment (embolization) when the involved segment has dual blood supply [7].\nTeaching point\nAnomalous arterial supply to lung is an important differential diagnosis to consider in imaging of haemoptysis and should actively searched for in cases where no attributable causes are identified on first look.\nWritten informed consent for publication has been obtained.",
    "differential_diagnosis": "Systemic, arterialization, of, lung, without, sequestration, Intralobar, pulmonary, sequestration, Pulmonary, AV, malformation",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-11//17506_1_1.jpg?itok=pMyp3wM_",
            "caption": "Chest radiograph showing prominent vessels in the right lower zone"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-11//17506_2_1.jpg?itok=6Wu9LsUz",
            "caption": "Axial contrast enhanced CT showing abnormally dilated vessels in the right lower lobe"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-11//17506_3_1.jpg?itok=HJ0UkQB_",
            "caption": "Axial contrast enhanced CT showing the vessels originating from the descending thoracic aorta"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-11//17506_4_1.jpg?itok=A9xCpBNi",
            "caption": "Axial lung window shows no evidence of sequestration"
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-11//17506_5_1.jpg?itok=rUzxJtP-",
            "caption": "Contrast enhanced CT axial MIP"
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-11//17506_6_1.jpg?itok=lDlHLFDY",
            "caption": "Coronal MIP reformat showing the course of the anomalous vessel from the aort"
          }
        ]
      },
      {
        "number": "Figure 7",
        "subfigures": [
          {
            "number": "Figure 7",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-11//17506_7_1.jpg?itok=h0-wPSxT",
            "caption": "Selective angiography of the abnormal branch of aorta shows distal aneurysmal dilatation of the artery. No evidence of early venous drainage"
          }
        ]
      },
      {
        "number": "Figure 8",
        "subfigures": [
          {
            "number": "Figure 8",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-11//17506_8_1.jpg?itok=1szq_sIB",
            "caption": "Obliteration of the anomalous artery achieved through coil embolization (white arrow) distally and Amplatzer vascular plug (red arrow) in the proximal segment"
          }
        ]
      },
      {
        "number": "Figure 9",
        "subfigures": [
          {
            "number": "Figure 9",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_video/2021-11/9.PNG?itok=UPVM2vVS",
            "caption": "Axial lung window"
          }
        ]
      },
      {
        "number": "Figure 10",
        "subfigures": [
          {
            "number": "Figure 10",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_video/2021-11/10.PNG?itok=QoiGMoaK",
            "caption": "Axial contrast enhanced CT"
          }
        ]
      },
      {
        "number": "Figure 11",
        "subfigures": [
          {
            "number": "Figure 11",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_video/2021-11/11_1.PNG?itok=ZstrKcwt",
            "caption": "Selective angiogram"
          }
        ]
      },
      {
        "number": "Figure 12",
        "subfigures": [
          {
            "number": "Figure 12",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_video/2021-11/12.PNG?itok=ne79q20X",
            "caption": "Post-embolization"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Arteries / Aorta",
      "Pulmonary vessels",
      "Vascular"
    ],
    "imaging_technique": [
      "Catheter arteriography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/17506",
    "time": "04.11.2021"
  },
  "17507": {
    "case_id": 17507,
    "title": "Tracheobronchopathia osteochondroplastica: radiological-endoscopic correlation",
    "section": "Chest imaging",
    "age": "68",
    "gender": "male",
    "diagnosis": "Tracheobronchopathia osteochondroplastica",
    "history": "A 68-year-old man referred to the pulmonology consultation due to progressive worsening dyspnoea and persistent dry cough, with normal pulmonary function tests. He reported no other symptoms and physical examination was unremarkable.",
    "image_finding": "Computed tomography showed thickened tracheal cartilage with multiple nodules projecting into the airway lumen, some calcified, sparing the posterior membrane. \nBronchoscopy showed nodular excrescences protruding throw-out the entire extent of the anterolateral tracheal wall, without involvement of the posterior membranous wall, also affecting the proximal main bronchi, with intact mucosa.",
    "discussion": "Tracheobronchopathia osteochondroplastica is an uncommon idiopathic disorder affecting the tracheobronchial tree characterized by abnormal chondrification and ossification of cartilages [1,2].\nIt usually affects patients between the fourth and seventh decades of life, without gender preference [2,3].\nAlthough roughly 400 cases have been published [2,4], it is probably more frequent as reported, as it can be asymptomatic of present with non-specific symptoms like chronic cough, dyspnoea, haemoptysis, wheezing and recurrent pulmonary infections [1,3,5,6].\nThe location of the lesions and degree of airway obstruction determine the results of the pulmonary test, ranging from a normal spirometry in mild cases to an obstructive pattern in patients with extensive disease [2].\nDiagnosis is frequently incidental by computed tomography showing irregularly thickened tracheal wall, with anterolateral submucosal nodules, with or without calcification, that protrude to the tracheal lumen. It usually affects the lower third of the trachea, although it can extend anywhere from the larynx to the main bronchi, where cartilaginous rings are still present [1,2,4]. The membranous posterior wall is always spared, allowing distinction from other diseases as amyloidosis that tends to affect the airway concentrically [4,5]. In relapsing polychondritis (RP), another differential diagnosis, the posterior trachea wall is also spared, however, the presence of focal coarse calcification and ossification and absence of other involved systems, as in the case we present, favours tracheobronchopathia osteochondroplastica over relapsing polychondritis [4,6].\nBronchoscopy is considered the gold standard for diagnosis and allows better evaluation of disease extent. Multiple whitish and hard nodules measuring 1 to 10 mm are seen protruding into the airway lumen, sparing the posterior tracheal wall [1,2,5].\nThe need for histopathology is controversial, as direct visualization of the nodules is usually sufficient for diagnosis [1,2].\nIn symptomatic cases, management includes a combination of antitussives, inhaled bronchodilators, steroids, antibiotics or clearance therapies. The progression of the disease is benign with long-term stability, but a minority of patients can present with important airway obstruction requiring more invasive bronchoscopic or surgical interventions [1,2,3].\nTake-home message\nCT provides a non-invasive examination of the trachea wall, lumen and surrounding tissues, providing an adequate evaluation of diffuse tracheal diseases. \nAlthough bronchoscopy is the gold standard for the diagnosis of tracheobronchopathia osteochondroplastica and evaluation of disease extent, CT showing irregular, nodular thickening of the anterolateral tracheal wall, with frequent calcification, is highly suggestive and if often the first clue to the diagnosis.\nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Tracheobronchopathia, osteochondroplastica, Relapsing, polychondritis, Tracheobronchial, amyloidosis, Sarcoidosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-11//17507_1_1.jpg?itok=U4tk6aYi",
            "caption": "Axial CT reconstruction in mediastinal window showing irregular thickening of the anterolateral tracheal wall with multiple nodules, sparing the posterior membrane"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-11//17507_2_1.png?itok=Lg1ySqEZ",
            "caption": "Axial CT reconstruction in bone window showing irregular thickening of the anterolateral tracheal wall with calcified nodules, sparing the posterior membrane"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-11//17507_3_1.png?itok=kqESTxGx",
            "caption": "Coronal CT reconstruction in mediastinal windows showing the cranio-caudal extent of the irregular narrowing of the tracheal lumen"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-11//17507_4_1.jpg?itok=bSKpo-Mm",
            "caption": "Bronchoscopy image illustrating the mildly narrowed tracheal lumen with multiple irregular submucosal protruding lesions, sparing the posterior wall"
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-11//17507_5_1.png?itok=pcxOSRM3",
            "caption": "Bronchoscopy images showing the right (a) and left (b) main bronchi lumen with some submucosal nodular lesions, not depicted in CT"
          },
          {
            "number": "Figure 5b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-11//17507_5_2.png?itok=K8Sg-9CX",
            "caption": "Bronchoscopy images showing the right (a) and left (b) main bronchi lumen with some submucosal nodular lesions, not depicted in CT"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Respiratory system",
      "Thorax"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/17507",
    "time": "04.11.2021"
  },
  "17535": {
    "case_id": 17535,
    "title": "Lung pseudosequestration: Anomalous systemic arterial supply to normal right lower lobe",
    "section": "Chest imaging",
    "age": "47",
    "gender": "female",
    "diagnosis": "Anomalous systemic arterial supply to normal right lower lobe with normal pulmonary artery",
    "history": "A 47-year-old female patient presented with bronchospasm for the last 14 days as chief complaint. Previous medical history was otherwise irrelevant. As part of her medical work up, a chest CT was requested and upon findings a thoracoabdominal CT angiography (CTA) was ordered.",
    "image_finding": "Chest CT displayed no signs of bronchopulmonary disorders but showed an abnormal vascular structure coursing through the basal segments of the right lower lobe along with regional subtle ground-glass opacities. This finding had an apparent infradiaphragmatic origin (Fig. 1). No other structural alteration of the lung parenchyma or tracheobronchial tree was found. A thoracoabdominal CTA confirmed the previous finding and revealed its origin in the coeliac trunk (Fig. 2,3). An anomalous systemic arterial supply to the normal right lower lobe (with normal pulmonary artery; dual supply) was diagnosed. \nA multidisciplinary team meeting was adjourned to discuss possible treatments. While no consensus was reached regarding the optimal treatment alternative, the patient opted for strict clinical follow up. The patient's chief complaint faded days after the initial CT scan. A year has passed since the diagnosis was made, and the patient still remains asymptomatic.",
    "discussion": "Anomalous systemic arterial supply to the lung with normal tracheobronchial development is a rare condition. Sade et al introduced the concept of a \u201csequestration spectrum\u201d to classify a wide range of bronchovascular anomalies. Clemens and Warner also presented a similar spectrum notion term \u201cpulmonary malinosculation\u201d [1,2]. Since the bronchopulmonary tree and the lung parenchyma are normal, the term pseudosequestration has been proposed. As seen in the present case, this combination is the rarest, as it most commonly affects the left lower lung and the aberrant artery emerges from the lower thoracic aorta. On the contrary, when the right lower lung is affected, the anomalous artery often arises from the coeliac trunk or abdominal aorta [1-3]. There are two subtypes: isolated systemic arterial supply to normal lung and systemic arterial supply associated with normal pulmonary artery (dual supply). The origin of this condition is believed to be an abnormal embryogenesis due to a lack of regression of the primitive aortic branches to the developing lung bud [4].\nTraditionally, the anomalous systemic artery accesses the lung through the pulmonary hilum or the pulmonary ligament. Additionally, ground-glass opacities or some lung volume loss can be observed [5]. It has been stated that ground-glass opacities can be caused by intra-alveolar haemorrhage [6]. \nMost adult patients who suffer from lung pseudosequestration are asymptomatic and the main form of presentation is an incidental finding in imaging studies. Symptoms include cough, hemoptysis, dyspnea, or congestive cardiac failure due to left-sided volume overload secondary to left-to-left shunt later in life [1-7]. In the pediatric population, a typical exhibiting symptom is a cardiac murmur [8].\nCT and CTA are non-invasive techniques used for a definitive diagnosis. Multidetector CT can demonstrate the origin, the course of the aberrant artery, and the architecture of the bronchopulmonary tree including the lung configuration. Multiplanar reformation and 3D volumetric imaging play an important role in pretreatment planning. Plain radiography and MRI play a secondary role in reaching the definitive diagnosis. An effort should be made to correctly individualize and name the bronchovascular components of these anomalies and their interrelationship rather than encasing the findings under a proper medical label. Conventional angiography still remains a vital tool in endovascular management. Treatment strategies include lobectomy or segmentectomy, with ligation or anastomosis of the abnormal systemic artery, or endovascular embolization if there is a dual arterial supply to the lung [1-8].",
    "differential_diagnosis": "Anomalous, systemic, arterial, supply, to, normal, right, lower, lobe, with, normal, pulmonary, artery, Lung, sequestration, Partial, anomalous, pulmonary, venous, return, Scimitar, syndrome",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-12//17535_1_1.jpg?itok=_yOfqMKy",
            "caption": "Chest CT reveals a vascular structure coursing the posterior segment of the right lower lobe (arrow), associated with subtle ground glass opacities (arrowhead). It accesses the lung through the pulmonary ligament"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-12//17535_2_1.jpg?itok=qGDVIQJg",
            "caption": "Maximum intensity projection shows previous finding to be an artery originating below the diaphragm (arrow)"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-12//17535_3_1.jpg?itok=PHTvplUI",
            "caption": "Volume\u2011rendered\u2011image depicts anomalous systemic artery originating from the coeliac trunk, coursing cephalad to the posterior segment of the right lower lobe (arrow). It is worth noting that the descending interlobar artery is visible thus confirming double arterial supply to the lung (arrowhead)"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax",
      "Vascular"
    ],
    "imaging_technique": [
      "CT-Angiography"
    ],
    "link": "https://www.eurorad.org/case/17535",
    "time": "01.12.2021"
  },
  "17537": {
    "case_id": 17537,
    "title": "-cigarette or vaping product use associated lung injury (EVALI) in the immediate post-operative peri",
    "section": "Chest imaging",
    "age": "31",
    "gender": "male",
    "diagnosis": "E-cigarette or vaping product use associated lung injury (EVALI)",
    "history": "A 31-year-old male underwent epigastric hernia repair under general anaesthesia without intra-operative complications. Minutes after extubation acute symptoms of dyspnoea, haemoptysis and thoracic discomfort developed with hypoxia (80% SpO2) and hypoxemia (64 mmHg pO2). Apart from regular use of e-cigarettes, the patient had been healthy before surgery. Pre-operative thoracic computed tomography (CT) scan was normal.",
    "image_finding": "Pre-operative thoracic CT scan with intravenous contrast with axial reconstructions in lung window demonstrated no alveolar pathology. (Fig. 1)\nFrontal supine thoracic x-ray in the recovery room showed symmetrical diffuse hazy alveolar opacities, most apparent in the dependent lung regions. (Fig. 2)\nShortly after the x-ray, a thoracic CT scan with intravenous contrast was performed. No lung embolism was seen. Axial reconstructions in lung window showed symmetrical diffuse centrilobular ground-glass attenuation most apparent in the upper pulmonary lobes and posterior in the lower pulmonary lobes. The ground glass opacities were suggestive for diffuse alveolar damage/haemorrhage considering the haemoptysis and acute onset. (Fig. 3)\nFollow-up thoracic CT scan without intravenous contrast was performed two days later. Axial reconstructions in lung window showed important volume and density decrease of the ground glass opacities in all pulmonary lobes. (Fig. 4)",
    "discussion": "Background \nE-cigarette or vaping product use associated lung injury (EVALI) or vaping associated pulmonary injury (VAPI) are terms combining lung injury associated within 90 days after the last incidence of vaping or smoking tobacco or cannabis, without alternative diagnosis. [1] Pathophysiology is still unknown, but an association with alveolar tetrahydrocannabinol (THC), nicotine and vitamin E acetate has been found. [1-4] The majority of affected people were younger than 35 years of age. [5]\nClinical Perspective \nPatients usually present with (sub)acute pneumonia-like symptoms like dyspnoea, tachypnoea, tachycardia, cough, chest pain, fever and sometimes haemoptysis. Gastrointestinal symptoms are often associated but are less prominent. Patients commonly progress to respiratory distress and sometimes death. [1]\nBlood analysis, lung biopsy and bronchoalveolar lavage might be helpful ruling out other infectious, inflammatory or neoplastic pathology. Infectious pneumonia must always be ruled out. [1]\nImaging is useful in evaluating the extent of the lung injury, ruling out other more frequent pathology and in follow-up of disease evolution. [1, 6, 7]\nImaging Perspective \nThoracic x-ray is the first imaging step that shows diffuse bilateral hazy alveolar opacities or consolidations. In case of respiratory distress, thoracic high resolution computed tomography (HRCT) or lung embolism protocol in patients with risk factors are advised. [1, 6]\nEVALI is a spectrum of lung injury like acute eosinophilic pneumonia, diffuse alveolar damage/haemorrhage, hypersensitivity pneumonitis, lipoid pneumonia and organizing pneumonia. [8, 9]\nDiffuse bilateral ground-glass opacities and/or consolidations are the common main CT findings, sometimes with basilar dominance or subpleural sparing. [1, 6]\nOutcome \nAlmost all patients require hospital admission for supportive care. Most patients need oxygen supplementation and some need mechanical ventilation in severe cases of respiratory distress. [1]\nEmpiric antibiotic therapy is given to cover for (sur)infection. [1]\nSystemic glucocorticoid therapy can be used in patients deteriorating under antibiotics and oxygen supplementation. [1]\nThe patient can be discharged from the hospital one to two days after resolution of symptoms, diminishing oxygen demand and decreasing imaging abnormalities. Short term clinical and radiological follow-up is advised until complete resolution. Cessation of smoking and vaping is critical to prevent relapse. [6, 7]\nTake-Home Message / Teaching Points\nThorough anamnesis revealing (e-)cigarette use is the only way to make the right diagnosis. Consider EVALI in a history of smoking or vaping, diffuse bilateral alveolar opacities and no other alternative diagnosis in a patient with respiratory distress. Imaging is especially useful in ruling out other pathology, evaluating the extent of lung injury and follow-up.\nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "E-cigarette, or, vaping, product, use, associated, lung, injury, (EVALI), Bacterial, or, viral, pneumonia, Lung, embolism, Vasculitis, Granulomatous, disease, Medication-induced, lung, injury, Acute, respiratory, distress, syndrome, (ARDS)",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_video/2021-12/Figure%201.PNG?itok=cva_ft02",
            "caption": "Normal pre-operative thoracic CT scan with intravenous contrast with axial reconstructions in lung window"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-12//17537_2_1.jpg?itok=Ha7oSuGF",
            "caption": "Frontal supine thoracic x-ray: symmetrical diffuse hazy alveolar opacities most apparent in the dependent lung regions"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_video/2021-12/Figure%203.PNG?itok=DyvlD2m8",
            "caption": "Thoracic CT scan with intravenous contrast in axial lung window: symmetrical diffuse centrilobular ground glass attenuation most apparent in the upper lobes and posterior in the lower pulmonary lobes"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_video/2021-12/Figure%204.PNG?itok=M6_Nhgzd",
            "caption": "Follow-up thoracic CT scan without intravenous contrast with axial reconstructions in lung window two days later: important volume and density decrease of the ground glass opacities in all pulmonary lobes"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Respiratory system",
      "Thorax"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/17537",
    "time": "01.12.2021"
  },
  "17550": {
    "case_id": 17550,
    "title": "The floating aorta or CT angiogram sign",
    "section": "Chest imaging",
    "age": "56",
    "gender": "male",
    "diagnosis": "Non-Hodgkin lymphoma",
    "history": "A 56-year-old man presented with severe chest pain in the emergency room and elevated D- dimmer levels. A CT pulmonary angiogram (CTPA) was requested in order to rule out pulmonary embolism.",
    "image_finding": "CTPA showed a posterior mediastinal soft-tissue attenuating mass arising posterior to the aorta and displacing it anteriorly. The mass was expanding bilaterally reaching the parietal pleura of both lungs and its maximum dimensions on axial plane was 67x 68 mm. Despite the fact that the mass was encasing aorta and its branches, posterior intercostal arteries were patent with no sign of occlusion. There was also a thickening of the diaphragmatic pleura and dilatation of the bronchial arteries (Figure 1-2). \nThe CT of the pelvis that followed showed a similar mass measuring 10 x 93 x 10 mm (Transverse x Anteroposterior x Craniocaudal respectively). This mass caused obstruction of the left ureter, leading to its dilation (Figure 3). \nBiopsy results of this tissue showed that it was a Diffuse large B cells lymphoma (non-Hodgkin lymphoma) stage IV according to the Cotswolds-modified Ann Arbor classification.",
    "discussion": "Aortic displacement from the vertebral column, known as floating aorta or CT angiogram sign, has been described as a CT sign of retroperitoneal masses [1]. The paraspinal mass may elevate the aorta and inferior vena cava off the spine without causing stenosis or invasion, a sign that is characteristic of lymphoma [2]. The normal abdominal aorta maintains a close relationship to the vertebral column. Any retroperitoneal mass arising posterior to the aorta can slide between the aorta and the vertebral column and displace the aorta anteriorly, and hence the term floating aorta or CT angiogram sign. The distance between the vertebral column and the aorta should not be more than 10 mm in men and 7.3 mm in women. [3]\nLymphoma, mediastinal cysts, and neurogenic neoplasms are the most common primary middle and posterior mediastinal tumours. Lymphoma may involve the anterior, middle and posterior mediastinum, as lymphadenopathy or as a discrete mass. [4] More specifically, non- Hodgkin lymphoma (NHL) frequently manifests in extranodal structures in the chest, often in the form of secondary involvement but occasionally as primary disease too. Radiologists should have a high degree of suspicion in patients at risk such as in immune-compromised patients with autoimmune diseases, a history of stem cell or solid organ transplant or with particular imaging appearances including the floating aorta or CT angiogram sign, the vertebral wraparound sign, non-resolving lung consolidation, an infiltrative soft-tissue mass, and lesions demonstrating vascular encasement without invasion. [5]\nSpinal involvement in lymphoma may also appear as a wrapping paraspinal soft-tissue mass associated with extensive involvement of a vertebral body but with relatively sparing of the bony trabecula and cortex that could account for the absence of vertebral compression fractures and height loss, despite extensive bone marrow involvement.[2] This appearance has been termed the wraparound sign and is thought to represent extensive marrow disease infiltrating through the vertebral cortex into the paraspinal tissues with relatively little involvement of the structural bone.[6] It is a specific feature that allows the radiologist to make a relatively confident diagnosis of lymphoma. [6] \nCONCLUSION\nSome tumours grow and extend into spaces between pre-existing structures and surround vessels without compressing their lumina. Lymphomas, lymphangiomas and ganglioneuromas are examples of such tumours. The floating aorta or CT angiogram sign and the wraparound sign should raise our suspicion for such neoplasms, especially for NHL.",
    "differential_diagnosis": "Non-Hodgkin, lymphoma, Mediastinal, fibrosis, Pleural, mestastases, Mesothelioma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-12//17550_1_2.jpg?itok=SepDEUMQ",
            "caption": "CT angiography of the pulmonary arteries in an axial plane reveals a soft tissue mass enveloping the descending aorta. The posterior intercostal arteries are seen to originate from the aorta and follow their course without invasion or displacement"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-12//17550_2_2.jpg?itok=l-1oMfpU",
            "caption": "Maximum Intensity Projection (MIP)reconstruction in the sagittal plane shows the soft tissue mass encasing the descending aorta and displacing the vessel to a more ventral position"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2021-12//17550_3_2.jpg?itok=xevJyETf",
            "caption": "CT of the pelvis in the portal phase reveals a thickening of the fundus of the urinary bladder caused by an exophytic soft tissue mass. The seminal vesicles cannot be discriminated"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lymph nodes"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/17550",
    "time": "04.01.2022"
  },
  "17553": {
    "case_id": 17553,
    "title": "A rare cause of hemoptysis: unilateral right pulmonary artery agenesis with collateral circulation.",
    "section": "Chest imaging",
    "age": "32",
    "gender": "male",
    "diagnosis": "Unilateral right pulmonary artery agenesis",
    "history": "A 32-year-old man came to the emergency department with mild hemoptysis (<100mL/day) of 10 days duration, with no respiratory symptoms or fever. He was an active smoker (10 cigarettes a day). He did not have any pre-existing respiratory disease.",
    "image_finding": "Chest X-ray showed a remarkable volume reduction of the right lung with consecutive mediastinal shift to the right side and absent right hilar shadow. \nCT scan with contrast media was performed to evaluate the anatomy of the mediastinum and lungs. CT images revealed the absence of the right pulmonary artery, volume loss of right lung and ipsilateral mediastinal shift.\u00a0 Arterial supply of the right lung was produced by numerous systemic collateral arteries were identified dependent on hypertrophic bronchial arteries, originated in descending aorta,\u00a0 with orthotopic and ectopic origin, that run through the right mediastinum and hilum. The pleuro-pulmonary interface shows multiple wedge-shaped pleural abnormalities due to transpleural branches, which run through the costal pleura and fissures, extended into thin intrapulmonary septa. Ground-glass opacity in apical segment of right superior pulmonary lobe was identified, compatible with pulmonar haemorrhage, which\u00a0was believed to be caused by rupture of some dilatated transpleural vessels. No other abnormalities were found in the CT scan.",
    "discussion": "Unilateral absence of the pulmonary artery (IUAPA) is the congenital absence of the left or right pulmonary artery.\u00a0 Absence of the pulmonary artery is a result of misdevelopment of the proximal portions of sixth arch of embryonal circulation. In 60% it is associated with congenital heart disease, that we must look for:\u00a0 tetralogy of Fallot, coarctation of the aorta, subvalvular aortic stenosis, transposition of the great arteries and Scimitar syndrome. In the present case, no congenital heart disease was found. Adult patients with IUAPA can be asymptomatic (30%). The clinical presentation can be dyspnea, chest pain, pleural effusion and recurrent bronchopneumonias [1] due to hypoperfusion and V-Q mismatch. Hemoptysis is caused by rupture of dilatated collateral vessels.\u00a0\nIn chest X-ray we will find a volume reduction of one hemithorax with ipsilateral mediastinal and tracheal shift, ipsilateral hemidiaphragm elevation, absent hilar shadow, a reticular pattern in the hemithorax affected due to collateral circulation and contralateral lung hyperinflation with prominent pulmonary artery.\u00a0 In CT scan we will see the absence of pulmonary artery (more common right side), dilatated bronchial arteries and transpleural branches. [2] It also can show bronchiectasis secondary to recurrent bronchopneumonias. [3] Pulmonary hypertension is the most important factor of the prognosis. \nDifferential diagnosis of unilateral volume reduction in chest X-Ray includes Swyer-James Syndrome that, unlike UAP, manifests as\u00a0unilateral hemithorax lucency, as a result of postinfectious\u00a0obliterative bronchiolitis, with decreased vasculature. Also, we have to think of congenital abnormalities of the pulmonary artery (unilateral hypoplasia or aplasia) and volume loss due to chronic pneumonia or previous surgery. \nThe treatment depends upon the clinical presentation and the presence of pulmonary hypertension. Surgical modalities available to patients with hemoptysis or recurrent infections include pneumonectomy, embolization and closure of selected collateral arteries [4]. In our patient hemoptysis was self-limited, and no specific treatment was needed.",
    "differential_diagnosis": "Unilateral, right, pulmonary, artery, agenesis, Swyer-James, syndrome, Right, pulmonary, hypoplasia, Previous, lung, surgery",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-01//17553_1_1.jpg?itok=Z36Vx9BY",
            "caption": "PA (a) and lateral (b) chest X ray shows volume loss of right lung, mediastinal ipsilateral shift and absent hilar shadow. Also in the affected lung we see a reticular pattern caused by the collateral branches of intercostal and bronchial arteries"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-01//17553_1_2.jpg?itok=Kizh0HV2",
            "caption": "PA (a) and lateral (b) chest X ray shows volume loss of right lung, mediastinal ipsilateral shift and absent hilar shadow. Also in the affected lung we see a reticular pattern caused by the collateral branches of intercostal and bronchial arteries"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-01//17553_2_1.jpg?itok=deOkRRc1",
            "caption": "Axial contrast-enhanced CT image demonstrates the absence of right pulmonar artery"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-01//17553_3_1.jpg?itok=7GctzFuf",
            "caption": "Sagittal CT scan image obtained with a lung window shows a ground-glass opacity in right upper lung due to hemorrhage (blue arrow). It also reveals multiple linear opacities perpendicular to the pleural surface that correspond to transpleural systemic vessels (yellow rectangle)"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-01//17553_4_1.jpg?itok=5WjLVkMF",
            "caption": "Axial (4a) and coronal (4b) contrast-enhanced CT images demonstrate abnormal dilatated bronchial arteries (>2 mm in diameter) originated from descendent aorta, with a tortuose course. (purple arrow)"
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-01//17553_4_2.jpg?itok=UDwWMUf4",
            "caption": "Axial (4a) and coronal (4b) contrast-enhanced CT images demonstrate abnormal dilatated bronchial arteries (>2 mm in diameter) originated from descendent aorta, with a tortuose course. (purple arrow)"
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-01//17553_5_1.jpg?itok=Wnz2HICp",
            "caption": "CT scan with contrast media, MIP axial (5a) and sagittal (5b) reconstruction, where dilatated bronchial arteries (arrow) and transpleural vessels (arrowhead) can be seen better"
          },
          {
            "number": "Figure 5b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-01//17553_5_2.jpg?itok=ttoqkDmU",
            "caption": "CT scan with contrast media, MIP axial (5a) and sagittal (5b) reconstruction, where dilatated bronchial arteries (arrow) and transpleural vessels (arrowhead) can be seen better"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Cardiovascular system",
      "Thorax"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/17553",
    "time": "05.01.2022"
  },
  "17566": {
    "case_id": 17566,
    "title": "Pulmonary sclerosing pneumocytom",
    "section": "Chest imaging",
    "age": "22",
    "gender": "female",
    "diagnosis": "Pulmonary sclerosing pneumocytoma",
    "history": "A 22-year-old lady presented to the emergency department with a one-week history of productive cough with green-yellow sputum, on a background of coryzal symptoms. She reported associated chest pain and shortness of breath which had settled before presentation. The only abnormal blood result was a C-reactive protein of 27.",
    "image_finding": "A chest radiograph (Figure 1) was performed which demonstrated a 3.3cm opacity in the left mid zone adjacent to the left hilum. The report was alerted and urgent CT scan of the chest was advised in the first instance.\nFigures 2 and 3:\u00a0 CT of the Thorax and Abdomen with Contrast which demonstrates a well-defined rounded lesion measuring approximately 30 x 22 mm in the left upper lobe anterior to the left upper lobe bronchus, with amorphous calcification demonstrated in the lower aspect of the lesion. Carcinoid tumour was suggested as the initial primary diagnosis. \nFigure 4: A PET-CT which demonstrates an avid left upper lobe lung mass. Differentials including malignancy or carcinoid as these can be FDG avid, particularly if poorly differentiated.",
    "discussion": "Background\nA solitary pulmonary lesion is one which is a well-defined, rounded lesion that is surrounded by lung parenchyma and/or visceral pleura, does not touch the hilum or mediastinum, and is not associated with adenopathy atelectasis or pleural effusion[1]. If the lesion is less than 3cm it is called a nodule, and if it is greater than 3cm it is labelled as a mass; the latter of which has an increased malignant potential.\nClinical perspective\nThere are various radiological features which have been described to help differentiate between benign and malignant lesions on imaging. Below is a table which broadly demonstrates this (Table 1):\nTable 1: Benign and malignant radiological features of pulmonary nodules [2]\n\nDifferentials for a solitary pulmonary lesion can be categorized into different groups of differentials, namely neoplastic, inflammatory, congenital and miscellaneous. There are also some mimics worth considering including nipple shadow, cutaneous lesion and rib fracture/bone lesion.\nSclerosing pneumocytoma is an example of a benign, rare neoplasm of the lung. It typically presents in people aged 30-50 years of age, and there is a recognized female predilection [3]. Most people who present with it are asymptomatic or present with non-specific pulmonary symptoms. \nHistologically, the tissue is typically composed of solid, papillary, sclerotic or hemangiomatous components [4] as was demonstrated in the case described above which was confirmed via a biopsy.\nManagement is typically surgical excision which is curative in nature. This patient chose the surgical route of lobar pneumonectomy.\nLearning points\n\nSclerosing pneumocytoma is an example of a rare, benign pulmonary neoplasm which typically presents as an incidental finding and is often unrelated to clinical presentation.\nDifferent radiological characteristics can help to risk stratify solitary pulmonary nodules including size, growth rate, margins, type of calcification, presence of fat, cavitating, attenuation, enhancement and distribution.\n\nHistological assessment of tissue specimens is required for definitive diagnosis of sclerosing pneumocytoma and management is typically curative surgical excision.",
    "differential_diagnosis": "Pulmonary, sclerosing, pneumocytoma, Pulmonary, Hamartoma, Carcinoid, tumour",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-01//17566_1_1.jpg?itok=yi-bbmIZ",
            "caption": "Chest X-Ray with an opacity"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-01//17566_2_1.jpg?itok=tiUaa_ZP",
            "caption": "Lung window with a rounded well defined soft tissue"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-01//17566_3_1.jpg?itok=8pkXVN-d",
            "caption": "Mediastinal window"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-01//17566_4_1.jpg?itok=v6NIjoUN",
            "caption": "PET-CT showing lung mass in the left upper lobe"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Respiratory system"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT",
      "PET-CT"
    ],
    "link": "https://www.eurorad.org/case/17566",
    "time": "10.01.2022"
  },
  "17576": {
    "case_id": 17576,
    "title": "Post-traumatic diaphragmatic rupture with splenic injury",
    "section": "Chest imaging",
    "age": "25",
    "gender": "male",
    "diagnosis": "Post-traumatic left diaphragmatic rupture with intrathoracic herniation of stomach and splenic injury",
    "history": "A 25-years-old male presented to the emergency department with a recent road traffic accident. He had a few lacerations over his chest and complained of chest pain. There was no history of hemoptysis. He had no previous surgery.",
    "image_finding": "An anteroposterior radiograph of the chest revealed mild left hemothorax with fractures in the left lower ribs. The left diaphragm was elevated with an irregular contour. A colonic loop was visualized in the left lower zone. An intercostal drainage tube was inserted. Computed tomography (CT) of the chest with contrast was performed. \nThe scout image confirmed the findings seen on the chest radiograph earlier. A large defect was seen in the left hemidiaphragm with herniation of spleen, pancreatic tail, mesentery, fat, left transverse colon, and splenic flexure into the left hemithorax. The stomach was collapsed, intra-abdominal, and displaced medially. Bilateral hemopneumothorax (left more than right) was present with an underlying collapse of the lower lobes. Spleen showed extensive ill-defined hypodense non-enhancing areas (up to 4.7 cm in size), involving more than 50% of splenic parenchyma. Focal areas of contrast blush on arterial phase were seen in the upper pole of spleen- suggestive of devascularization with active arterial bleed (AAST Grade IV injury). There was a subcapsular hematoma along the posterior aspect of the spleen measuring ~ 6mm in thickness. Few bilateral lower rib fractures were present. Laparotomy was performed for the repair of the diaphragmatic rupture.",
    "discussion": "Intrathoracic injuries are common in blunt trauma. Left-sided diaphragmatic injury is two to three times more common than right-sided injury.[1] A chest radiograph is a common initial investigation performed in the setting of trauma. The signs on a radiograph may be subtle and easily missed. The loss of normal diaphragmatic contour may be due to pulmonary contusion or hemothorax. The presence of intrathoracic bowel gas shadows and the tip of the nasogastric tube in the chest may be diagnostic. The role of ultrasound has been described by a few studies. [2] The absence of diaphragmatic movements on one side or the use of M-mode can help predict injury. It is also useful in predicting solid organ injury. Computed tomography is the next step for a better assessment of abdominal injuries. There are many direct and indirect signs of diaphragmatic rupture. A focal constriction at the site of diaphragmatic rupture constitutes the \u2018collar sign\u2019. The direct contact between the herniated organ and the posterior chest wall, without any intervening lung, represents the \u2018dependent viscera sign. [3] Intrathoracic herniation, the collar, and depen\u00addent viscera signs are more commonly seen in blunt injury, whereas con\u00adtiguous injury on either side of the diaphragm occurs more often in penetrating trauma.\nThe differential diagnoses include- congenital hernia, eventration, and diaphragmatic fenestration. The most common type of congenital diaphragmatic hernia seen is the Bochdalek hernia, which occurs in the posterolateral portion. This has an embryological basis, as the pleuroperitoneal membrane fuse at that site. [3] In case of eventration, there may be thinning of the diaphragm, however, there is no defect. The use of CT allows thin reconstructions and coronal reformats to overcome the partial volume effects. [4] Case reports have highlighted the \u2018delayed\u2019 presentation of post-traumatic diaphragmatic rupture. The repair for any type of diaphragmatic rupture is either through an open laparotomy or thoracotomy or through laparoscopy or thoracoscopy. [5]",
    "differential_diagnosis": "Post-traumatic, left, diaphragmatic, rupture, with, intrathoracic, herniation, of, stomach, and, splenic, injury, Congenital, diaphragmatic, hernia, Diaphragmatic, eventration",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-01//17576_1_1.jpg?itok=F1ndPsbM",
            "caption": "Supine chest radiograph shows left mild hemothorax with an intercostal drainage tube in situ. The left diaphragmatic outline is not visualized. There are fractures in the left 10th and 11th ribs."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-01//17576_2_1.jpg?itok=_2qKvC6z",
            "caption": "A CT scout image showing the same findings. Few loops of the colon are seen in the left lower chest"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-01//17576_3_1.jpg?itok=AFRQ_enA",
            "caption": "Coronal multiplanar reconstructed CT image in the arterial phase showing a large defect in the left hemidiaphragm with herniation of spleen (white arrow), pancreatic tail, mesentery, fat, left transverse colon, and splenic flexure (white arrow) into the left hemithorax"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-01//17576_4_1.png?itok=tyGRR5PV",
            "caption": "Axial CT image in the arterial phase shows the \u2018dependent viscera sign\u2019, with the spleen contacting the left posterior chest wall. Extensive areas of devascularization are seen within the spleen. Focal arterial blush (white arrow) signifies active arterial bleeding"
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-01//17576_5_1.jpg?itok=N6l3Hogf",
            "caption": "Axial CT image in the bone window shows a fracture (white arrow) in the posterolateral aspect of the left 10th rib"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax",
      "Trauma"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/17576",
    "time": "10.01.2022"
  },
  "17598": {
    "case_id": 17598,
    "title": "Pinch-Off Syndrome",
    "section": "Chest imaging",
    "age": "19",
    "gender": "male",
    "diagnosis": "Pinch-Off Syndrome",
    "history": "A 19-year-old male patient diagnosed with chronic granulomatous disease (CGD) when he was eight and complicated by chronic cavitary pulmonary aspergillosis in the last year had a port-a-cath inserted into his right subclavian vein. After thirteen months, resistance in aspiration and instillation was noticed during a routine heparin flushing.",
    "image_finding": "Chest X-ray performed a few hours after port-a-cath insertion (figure 1) shows an apparently well-positioned catheter inserted into the right subclavian vein with its tip in the superior vena cava. There is however mild angulation of the catheter as it passes through the right clavicle and the first rib. \nAn X-ray performed two months after (figure 2) shows worsening of this angulation. This represents the classical pinch-off sign. Port-a-cath was properly functioning at the time and it was decided not to remove it. \nThirteen months post-implantation after noticing catheter dysfunction, fluoroscopy images (figure 3) show catheter fragmentation and migration of the distal fragment into the right inferior lobar artery. The patient was asymptomatic.\nFluoroscopy images (figure 4) show a femoral vein catheter reaching the right inferior lobar artery (a), snare insertion (b), and removal of the port-a-cath fragment (c). There were no complications associated with the procedure.",
    "discussion": "CGD is a primary immunodeficiency caused by a genetic defect resulting in the inability of phagocytes to destroy catalase-positive microorganisms such as Aspergillus, which increases the risk of chronic infection as seen in this case [1]\nPort-a-cath, a long-term totally implantable venous access device, was used to administrate medication for thirteen months. It allows minimization of discomfort associated with repeated venous puncture and reduction of peripheric venous damage associated with drug toxicity. [2] Although generally safe, it can be rarely associated with immediate and long-term complications, which vary between 3,1 and 33,9%. [3] Chest X-ray is ideal to evaluate post-implantation complications. [4]\nPort-a-cath insertion into the subclavian vein in a medial position near the sternum may cause catheter compression by the clavicle and the first rib. The impossibility of blood aspiration and detection of resistance in instillation should raise the possibility of catheter compression. Chest X-ray confirms the diagnosis by revealing a pathognomonic catheter indentation beneath the clavicle named pinch-off sign. [4]\nHinke et al develop a classification of this sign. Grade 1 represents a deviation of the catheter course, grade 2 deviation and lumen narrowing, and grade 3 catheter fragmentation. [4]\nCompression of the catheter may result in occlusion, tear, fragmentation, or embolization. This last complication is known as Pinch-Off Syndrome (POS) and its incidence varies between 0,06 and 0,2%. It can be asymptomatic or present with edema, pain, and paresthesia [3]. The catheter may embolize to the superior vena cava, jugular vein, heart, or pulmonary arteries. [5]\nDetection of embolization should prompt urgent catheter removal to prevent fatal consequences, such as arrhythmias and septic and thromboembolic complications. [6]\nCurrently, fragment removal by percutaneous intervention is the gold standard. It is a minimally invasive and safe procedure with a low rate of complications. The embolized catheter can be retrieved by introducing a snare via femoral vein catheterization after local anaesthesia. In selected cases, open surgery or no treatment may be considered. [7]\nPOS can be prevented by a more lateral puncturing approach of the subclavian vein or by using the internal jugular or cephalic vein as an alternative central venous access [3].\nTo sum up, port-a-cath implantation is a very safe procedure, allowing long-term venous access with acceptable patient comfort. POS is an extremely rare complication. However, it is important not only to be familiarized with this condition but also with the possibility of treatment by Intervention Radiology.",
    "differential_diagnosis": "Pinch-Off, Syndrome, Catheter, occlusion, Catheter, fragmentation, Catheter, embolization, /, Pinch-Off, Syndrome",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-01//17598_1_1.png?itok=yLPjJD_q",
            "caption": "Postero-anterior (PA) Chest X-ray a few hours after port-a-cath insertion shows the catheter inserted into the right subclavian vein with its tip in the superior vena cava. There is mild angulation of the catheter as it passes through the right clavicle and the first rib (Grade 1 Pinch-Off Sign)"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-01//17598_2_1.png?itok=U_RGjCJy",
            "caption": "PA Chest X-ray two months post-implantation shows a Grade 2 Pinch-Off Sign"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-03/figure3.png?itok=JoQjsSaW",
            "caption": "Fluoroscopy images thirteen months post-implantation show catheter fragmentation (*) and migration of the distal fragment (\u2192) into the right inferior lobar artery"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-03/figure4.png?itok=QVvtIfCf",
            "caption": "Fluoroscopy images show a catheter inserted via femoral vein into the right inferior lobar artery (a), followed by snare introduction (b) and grabbing and removal of the port-a-cath fragment (c)"
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-03/figure5.png?itok=nWxG5mEF",
            "caption": "Photo of the port-a-cath fragment (white) and snare (blue)"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Interventional vascular",
      "Pulmonary vessels"
    ],
    "imaging_technique": [
      "Digital radiography",
      "Fluoroscopy"
    ],
    "link": "https://www.eurorad.org/case/17598",
    "time": "25.01.2022"
  },
  "17613": {
    "case_id": 17613,
    "title": "Mediastinal spindle cell sarcoma presenting as paraneoplastic pemphigus: Very rare case report",
    "section": "Chest imaging",
    "age": "55",
    "gender": "female",
    "diagnosis": "Mediastinal spindle cell sarcoma of uncertain differentiation causing paraneoplastic pemphigus",
    "history": "A 55-year-old woman presented with two months of bullous skin lesions, oral ulcers and conjunctivitis. She gave no history of prior medications or medical disease. Family history was unremarkable. Systemic examination and laboratory investigations were within normal limits. She was advised of Contrast-enhanced computed tomography (CECT) of chest and abdomen for ruling out underlying neoplasia.",
    "image_finding": "CECT chest and abdomen revealed a smooth well defined markedly enhancing mass with few non-enhancing necrotic/cystic areas, measuring 4\u00d73.5\u00d73 cm in the left paratracheal area of the visceral compartment (ITMIG classification), without calcification or fatty attenuation. The lesion was noted to lie between aortic arch and pulmonary artery bifurcation and was indenting over lower trachea and left main bronchus. Marginal fat planes were maintained without evidence of invasion (Figure 1,2). No other enlarged lymph nodes or lung parenchymal lesion was noted. \nShe underwent Endoscopic guided fine needle aspiration which revealed tissue fragments of bland spindle cells in the background of spindle cells, lymphoid cells and squamoid cells raising possibility of spindle cell thymoma. \nThe mass was subsequently excised by video-assisted thoracic surgery and final histopathological diagnosis of Low-grade spindle cell sarcoma of uncertain differentiation was made, based on Immunohistochemistry (IHC) staining (Positive for Vimentin & CD-56 and negative for Synaptophysin, SMA, S-100, SOX-10, TLE- 1, PAX-8).",
    "discussion": "Paraneoplastic pemphigus (PNP), also called as paraneoplastic autoimmune multiorgan syndrome (PAMS) is a rare and often fatal autoimmune blistering disease accompanied by both benign and malignant neoplasms.\u00a0The most frequently reported associated malignancies are lymphomatoid and hematologic, namely B-cell lymphoma (39%), chronic lymphocytic leukaemia (18%) and Castleman\u2019s disease (18%). A minor fraction is also associated with non-hematologic neoplasms, including thymoma (6%), sarcoma (6%), malignant melanoma (<1%), and various epithelial-origin carcinomas [1,2].\nPrimary mediastinal sarcomas are rare tumours, accounting for 2-6% of mediastinal masses [3,4]. The sarcomas can be classified histopathologically as pleomorphic, biphasic and monophasic spindle cell tumours. Undifferentiated high-grade pleomorphic sarcoma (2013 WHO classification), previously categorized as malignant fibrous histiocytoma (MFH), are usually found in extremities and retroperitoneum. The prognosis of this sarcoma is generally poor, because surgical resection is often incomplete and chemotherapy and/or radiotherapy often yield only temporary improvement [5].\nThere are limited case reports and series for mediastinal sarcoma [6-9]. Patnaik et al [6] and Aggarwal et al [7] studied biological diversity of mediastinal lesions and found sarcomas in minority of cases, of which spindle cell sarcoma of undifferentiated origin as only isolated cases.\nCECT of the neck, chest, abdomen, and pelvis should be the first-line imaging test for patients with PAMS without a known malignancy. The ideal Computed Tomographic (CT) protocol should be multiphasic including arterial and venous phases, specifically, vascular invasion of residual/recurrent sarcomas needs to be assessed during arterial phase for the lesions in the visceral compartment of the mediastinum. \n18F-FDG PET/CT has an added value in staging, grading and evaluating response to therapy in sarcomas, thus improving patient management [10]. PET/CT may additionally detect lymphomatous involvement missed by CT in normal-sized lymph nodes or normal-appearing spleen and can detect bone marrow involvement [1].\nThe different histologic types of sarcomas are frequently indistinguishable at radiologic and PET/CT analysis. The undifferentiated sarcomas tend to be large and typically have heterogeneous attenuation at CT and heterogeneous signal intensity on T1- and T2-weighted MR images [10]. IHC and molecular/genetic techniques play a pivotal role in supplementing histology for clinching the diagnosis [9]. \nAlthough few cases of paraneoplastic pemphigus are noted with mediastinal follicular dendritic cell sarcoma [11], only one case of spindle cell sarcoma is found in the literature [12].\nThe pemphigus improved after surgical resection of the mediastinal tumour, systemic chemotherapy, and low-dose oral glucocorticoids.\nTeaching points:\n\nThe possibility of occult malignant tumour should always be taken into consideration as a possible etiological factor for pemphigus skin lesion.\nMediastinal sarcoma, though rare, may be encountered in clinical practice and can be a potentially treatable cause of paraneoplastic pemphigus.\nThe imaging features of rare mediastinal masses have to be kept in mind for appropriate evaluation.\nIHC plays a pivotal role in supplementing histology for clinching the diagnosis.\n\nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Mediastinal, spindle, cell, sarcoma, of, uncertain, differentiation, causing, paraneoplastic, pemphigus, Castleman\u2019s, disease, Lymphoma, Mesenchymal, tumour",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-01//17613_1_1.jpg?itok=zNi5oh1R",
            "caption": "A well-defined markedly enhancing mass with few non-enhancing necrotic/cystic areas is noted in the left paratracheal area, lying between aortic arch and pulmonary artery bifurcation with preserved marginal fat planes"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-01//17613_1_2.jpg?itok=jKT_tKVs",
            "caption": "A well-defined markedly enhancing mass with few non-enhancing necrotic/cystic areas is noted in the left paratracheal area, lying between aortic arch and pulmonary artery bifurcation with preserved marginal fat planes"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-01//17613_2_1.jpg?itok=zDZUF-VG",
            "caption": "The mass is lying between aortic arch and pulmonary artery bifurcation, and causing indentation over lower trachea and left main bronchus"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-01//17613_2_2.jpg?itok=y5cwgpP8",
            "caption": "The mass is lying between aortic arch and pulmonary artery bifurcation, and causing indentation over lower trachea and left main bronchus"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/17613",
    "time": "27.01.2022"
  },
  "17614": {
    "case_id": 17614,
    "title": "Swyer-James-MacLeod Syndrome",
    "section": "Chest imaging",
    "age": "14",
    "gender": "male",
    "diagnosis": "Swyer-James-MacLoad syndrome",
    "history": "A 14-year-old girl presented with a three-day history of fever and cough with sputum. At age of two, she had been hospitalized due to severe pulmonary infection. Her medical history has been uneventful since then.",
    "image_finding": "Chest radiograph showed reduced right lung volume and rightward mediastinal shift. Subsequent CT scan depicted right hyperlucent lung with diminished vascularity. The calibre of the right pulmonary artery was slightly smaller than the left one.\nThere were also a few scattered subsegmental areas of increased parenchymal lucency with patchy distribution in the normal-sized left lung.\nNo bronchiectasis or atelectasis were present.",
    "discussion": "Swyer-James-MacLeod syndrome (SJMS) is a rare pulmonary entity characterized by unilateral hyperlucent lung. This acquired condition occurs due to vascular and parenchymal development impairment in an area affected by bronchiolitis obliterans in childhood, resulting in hypoplastic vascular regions and hyperlucent pulmonary areas [1].\nThe usual presentation involves recurrent chest infections and, typically, this disorder is diagnosed during childhood. However, some patients have fewer symptoms and, in such cases, the diagnosis can be missed until adolescence or adulthood [2].\nSJMS diagnosis is based on characteristic imaging findings. The radiographic hallmarks of this syndrome are unilateral lung or lobar hyperlucency with reduced lung volume. The diagnosis is supported by the demonstration of expiratory air trapping [3].\nOn computed tomography (CT) there is low attenuation of lung tissue and decreased vascular markings in the affected regions. The entire lung can be affected, but there can also be lobar, segmental or subsegmental involvement in a patchy distribution. Islands of low-attenuated parenchyma can be seen between areas of spared parenchyma in both lungs [4]. Bronchiectasis, minor subpleural parenchymal scarring, atelectasis and pulmonary artery hypoplasia on the affected side can be observed [1]. \nSJMS must be differentiated mainly from an endobronchial lesion incompletely obstructing the lumen of a lobar or main bronchus, such as a foreign body in children or a bronchial tumour in adults. Other differentials include pulmonary bullae and pulmonary artery agenesis [3]. CT plays an important role in the differential diagnosis, as it may demonstrate the patency of the bronchial tree and better characterize the pulmonary parenchyma and vessels. CT is superior in showing the extent and distribution of the disease and can better delineate accompanying conditions such as bronchiectasis [4].\nA conservative symptomatic approach is the mainstay of treatment, managing current and preventing future pulmonary infections. Long-term complications in adulthood include pulmonary hypertension, but the real morbidity and mortality associated with this syndrome is not well established [1, 2]. \nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Endobronchial, obstruction, with, air, trapping, Unilateral, bullae/asymmetric, pulmonary, emphysema, Congenital, lobar, overinflation, Swyer-James-MacLoad, syndrome, Pulmonary, artery, agenesis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-02/Figure%201_small_0.jpg?itok=chhCVKIC",
            "caption": "Chest radiograph shows reduced right lung volume and rightward mediastinal shift. There is relative hyperlucency of the right hemithorax"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-01//17614_2_1.jpg?itok=RXBm5r9w",
            "caption": "Axial CT image shows right hyperlucent lung with diminished vascularity"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-01//17614_3_1.jpg?itok=rjjCFMHG",
            "caption": "Coronal CT image with maximum intensity projection (MIP) shows right hyperlucent lung with diminished vascularity"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Paediatric"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/17614",
    "time": "02.02.2022"
  },
  "17621": {
    "case_id": 17621,
    "title": "A rare cause of multiple cavitating pulmonary nodules: Pyoderma gangrenosum",
    "section": "Chest imaging",
    "age": "67",
    "gender": "female",
    "diagnosis": "Pyoderma gangrenosum with pulmonary involvement preceding onset of skin lesions",
    "history": "A 67-year-old female presented with a non-productive cough for 3-weeks. Blood investigations showed high Erythocyte Sedimentation Rates and was otherwise normal (including testing for AntiNeutrophilic Cytoplasmic Antibody). Chest X-ray and Computed Tomography (CT) scan were taken for further evaluation. Histopathological testing for tuberculosis and malignancy turned negative. Ulcerative skin lesions appeared 3 months later with persisting cough.",
    "image_finding": "Initial chest X-ray showed a non-homogenous opacity with central lucency and thick walls in right middle zone(Fig.1 arrow), with nodular shadows in the apices and left lower zone. Contrast-enhanced CT thorax showed multiple well-defined nodular lesions in both lung fields, with some of the lesions showing cavitation (Fig. 2 A,B). CT-guided aspiration cytology was non-diagnostic with only neutrophilic infiltrates. At this point, the patient was unwilling to undergo further investigations and was started empirically on Anti-tuberculous therapy. She presented to the dermatology department with ulcerative skin lesions 3-months later (Fig.3). X-ray showed an increasing size of nodular lesions, with a few new lesions as well. Repeat CT confirmed the above findings(Fig.4,5). Increasing cavitation was also noted in some of the lesions. Biopsy was taken from the skin lesion, which showed ulcerated epidermis and multiple microabscesses (Fig.6).",
    "discussion": "Pyoderma gangrenosum (PG) is a rare ulcerative neutrophilic dermatosis, often associated with underlying chronic inflammatory conditions like inflammatory bowel disease, rheumatoid arthritis, connective tissue disorders, haematological malignancies, etc [1]. Annual worldwide incidence is estimated to be around 3-10 cases per million, with peak occurrence between 20-50 years of age affecting males and females equally[2][3]. The pathophysiology is not well understood. Current studies have implied that genetic predisposition, contributed by clonal T expansion, neutrophil dysfunction, and increased inflammatory mediators (interleukin 17,23) play a role[2].\nThe skin lesions initially present as papules, vesicles or pustules, that rapidly progress into painful, irregular ulcers with a violaceous border and undermined margin[2][5]. Visceral involvement is rare, with the lung being the most common extra-cutaneous site, yet only about 40 cases have been reported in the literature[4]. Patients usually present with cough, fever, dyspnoea, or chest pain [1]. The pulmonary manifestations may occur before, during, or after the onset of skin lesions, making diagnosis difficult, especially when the onset of pulmonary lesions occurs before the skin manifestation [5]. Imaging shows nodular infiltrates often with cavitation. The nodular infiltrates tend to be bilateral, with no zonal predominance[4]. Interstitial infiltrates, consolidation, mediastinal lymphadenopathy are other commonly seen lung manifestations [5]. Other system involvements of PG are ocular (scleritis, ulcerative keratitis, ulcerative lesions of eyelids), renal involvement (proteinuria, leukocyturia), splenic sterile abscesses, bone involvement (osteomyelitis, osteitis, osteolysis), pituitary granulomas, myositis, fasciitis, aortitis, etc.[5]. Cytology from the lung lesions shows chronic granulomatous inflammation, with no signs of vasculitis[4]. Biopsies of skin lesions show neutrophilic abscesses with necrotic debris[1]. \nTreatment is with immune modulator agents (prednisolone used in combination with azathioprine, cyclosporine, or dapsone). Rapid response to steroid therapy indirectly supports the diagnosis of PG[2][4]. One of the main imaging differentials is Wegener\u2019s granulomatosis (Granulomatosis with polyangiitis), which is distinguished by its more common pulmonary involvement and c-ANCA positivity[4]. Other differentials like malignancy and lung abscesses can be excluded by histology. The final diagnosis is made by a combination of clinical presentation with ulcerative skin lesions, sterile neutrophilic abscesses on histopathology, and rapid clinical response of lesions to steroids. Currently, the patient is under follow-up with a notable reduction of the skin lesions and pulmonary infiltrates on chest X-ray(Fig.7).\nThis case stresses on the importance of keeping in mind the rarer possibilities, having interdepartmental discussions (dermatology, pulmonology, and radiology in our case), and follow-up.",
    "differential_diagnosis": "Pyoderma, gangrenosum, with, pulmonary, involvement, preceding, onset, of, skin, lesions, Wegener\u2019s, granulomatosis, Tuberculosis, Pyoderma, gangrenosum",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-02//17621_1_1.JPG?itok=rmY9MpEV",
            "caption": "Chest X-ray PA view showing right middle zone non- homogenous opacity (arrow mark) with central lucency and thick walls, suggesting a cavitating lesion. Shadows also seen at bilateral upper zone."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-02//17621_2_1.JPG?itok=sKh9CSDq",
            "caption": "Lung window axial image of Contrast enhanced CT Thorax shows a central cavitating nodule in the apicoposterior segment of left upper lobe(A) and another nodule in the antero-medial segment of left lower lobe(B), with a tiny central air focus, suggesting early cavitation. A smaller nodule is noted in the lower part of right middle lobe"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-02//17621_2_2.JPG?itok=va42N3qG",
            "caption": "Lung window axial image of Contrast enhanced CT Thorax shows a central cavitating nodule in the apicoposterior segment of left upper lobe(A) and another nodule in the antero-medial segment of left lower lobe(B), with a tiny central air focus, suggesting early cavitation. A smaller nodule is noted in the lower part of right middle lobe"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-02//17621_3_1.JPG?itok=PWAAbLtz",
            "caption": "Multiple discrete and coalesced well defined shallow ulcers in the right leg with hypopigmented margins, sloping edges, necrotic slough in the floor and surrounding erythema"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-02//17621_4_1.JPG?itok=yCx95pYA",
            "caption": "Lung window sagittal images of Contrast enhanced CT Thorax shows multiple cavitating and non-cavitating nodules in both lung fields [right lung(A) and left lung(B)]"
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-02//17621_4_2.JPG?itok=yY9-mmb6",
            "caption": "Lung window sagittal images of Contrast enhanced CT Thorax shows multiple cavitating and non-cavitating nodules in both lung fields [right lung(A) and left lung(B)]"
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-02//17621_5_1.JPG?itok=_NxGI6BR",
            "caption": "Lung window axial image of Contrast enhanced CT Thorax shows a cavitating nodule in the apicoposterior segment of left upper lobe. In comparison with the CT scan taken 3 months before (Fig.2A), the nodule shows increasing cavitation and increase in size. A smaller early nodular density and focal infiltrate noted in the apical segment of right upper lobe"
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-02//17621_6_1.JPG?itok=JgxgjtvE",
            "caption": "Histopathology of Skin biopsy specimen shows: 6A) Ulcerated epidermis extending into the deeper dermis with micro abscess and cell debris. 6B) The periphery shows fibrinoid necrosis of small to medium sized vessels and foci of leucocytoclasis. Occasional giant cells seen (arrow in 6B)"
          },
          {
            "number": "Figure 6b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-02//17621_6_2.JPG?itok=Rud3Ya45",
            "caption": "Histopathology of Skin biopsy specimen shows: 6A) Ulcerated epidermis extending into the deeper dermis with micro abscess and cell debris. 6B) The periphery shows fibrinoid necrosis of small to medium sized vessels and foci of leucocytoclasis. Occasional giant cells seen (arrow in 6B)"
          }
        ]
      },
      {
        "number": "Figure 7",
        "subfigures": [
          {
            "number": "Figure 7a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-02//17621_7_1.JPG?itok=JmKFMLcZ",
            "caption": "On follow up after steroid therapy:  7A) The patient\u2019s skin lesions have significantly improved. 7B) The Chest X-ray also shows reduction in the size of nodules and infiltrates"
          },
          {
            "number": "Figure 7b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-02//17621_7_2.JPG?itok=7JnioB5D",
            "caption": "On follow up after steroid therapy:  7A) The patient\u2019s skin lesions have significantly improved. 7B) The Chest X-ray also shows reduction in the size of nodules and infiltrates"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/17621",
    "time": "14.02.2022"
  },
  "17623": {
    "case_id": 17623,
    "title": "Coccidioidomycosis",
    "section": "Chest imaging",
    "age": "58",
    "gender": "female",
    "diagnosis": "Coccidioidomycosis",
    "history": "A 58-year-old female with no past medical history presented with a 1-month history of a productive cough, breathlessness, lethargy, arthralgia and a rash on both of her legs. On examination, there were right basal crackles and erythema nodosum on both legs. Routine blood tests were normal. Blood and Tuberculosis cultures were negative.",
    "image_finding": "A chest radiograph was performed which showed a small cavitating lesion in the left upper lobe (Fig.1). Consequently, a CT thorax was performed with contrast which showed a 1.3 cm cavitating nodule in the left upper lobe suspicious for malignancy although, infective/inflammatory aetiology remained a possibility at this stage (Fig.2). As a result, a fluorodeoxyglucose PET CT scan was executed which depicted the cavitating lesion with low-grade up-take and no further pathological uptake throughout the body (Fig.3). It was therefore concluded that the lesion was more likely to be infective rather than a malignancy.\u00a0 The patient was a frequent traveller and often visited Arizona for camping trips. A sample was sent for culture and serology for a possible fungal infection however these came back negative. It was decided that we would watch, wait and treat with antibiotics. Two months later, another CT thorax was performed which showed no improvement of the lesion (Fig.4).",
    "discussion": "Coccidioides is a dimorphic fungus which\u00a0denotes\u00a0that it can exist in two morphologies\u00a0depending on its environment. In the external environment, it exists as mycelia and in vivo, it converts to spherules. There are two species\u00a0C.immitis\u00a0and\u00a0C.posadasii.\u00a0The former is found predominantly within California\u00a0and Arizona. The\u00a0latter\u00a0is\u00a0more widespread\u00a0around the world.\u00a0[1,7,8]\u00a0\nOnce\u00a0inhaled\u00a0in sufficient amounts, it can lead to an infection known as Coccidioidomycosis. Anthroconidia\u00a0are the infectious\u00a0spores that congregate in the alveoli before\u00a0they metamorphose into spherules.\u00a0Spherules subsequently rupture to enhance the infection. Pulmonary Coccidioidomycosis\u00a0constitutes 95% of\u00a0cases. It is mostly self-limiting and resolves in 6 weeks. A minority suffer with\u00a0a\u00a0disseminated or chronic form of the disease.\u00a0\u00a0[2,3,7,8]\nIncubation period is 7-21 days and can clinically present with a cough (possible haemoptysis), fever, malaise, chest pain, night sweats and fatigue. A disseminated infection may present with cutaneous lesions such as erythema nodosum, miliary pulmonary nodules, extra-thoracic lymphadenopathy and involve the bones, joints and central nervous system.\u00a0 This is as a result of haematogenous spread. [3,7]\u00a0\nHigh-risk\u00a0individuals\u00a0are those who are\u00a0immunocompromised or exposed to\u00a0aerosolization of soil.\u00a0These include military\u00a0personnel,\u00a0archaeologists, solar-farm workers, construction workers\u00a0and\u00a0populations who inhabit areas susceptible to natural disasters such as earthquakes.\u00a0[3] Most commonly encountered by adults over 40 years. [4]\nThe most frequent radiological finding is consolidation which can be solitary, multifocal, lobar or segmental. Coccidioides distribution is commonly unilateral with perihilar dominance. Parenchymal changes can range from a ground glass opacification to a dense homogenous consolidation which can mimic a bacterial pneumonia. Other findings include nodules, interlobular-septal thickening, granulomatous lesions, lymphadenopathy and pleural effusions. CT imaging is preferable due to its higher sensitivity and specificity [3,7]\u00a0\nCoccidioidomycosis can be diagnosed in a multitude of techniques:\n\nSpecial stains - methenamine silver\nSerology - Enzyme immunoassay and complement fixation to detect IgM and IgG. The former being highly sensitive and the latter highly specific. \nBronchoscopy\nCT-guided biopsy\nSurgical biopsy [3,7]\n\nAs malignancy remained a possibility, the patient opted to have surgery. She underwent a video-assisted thoracoscopic surgery (VATS). Biopsies retrieved confirmed lung tissue with florid necrotising inflammation, peripheral palisading of histiocytes and well-formed granulomas. No evidence of malignancy. Samples sent for staining and serology were positive for C.immitis.\u00a0 \nTreatment:\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 \n\nAsymptomatic/mild \u2013 no medication, close monitoring.\nModerate to severe symptoms \u2013 Fluconazole or Itraconazole\n\nIf symptoms and lesions are persistent despite medication, surgical intervention is advised. [8]",
    "differential_diagnosis": "Coccidioidomycosis, Malignancy, Tuberculosis, Bacterial, pneumonia, Lung, abscess",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-02//17623_1_1.jpeg?itok=B_Nv0XmN",
            "caption": "CXR demonstrating the cavitating lesion in the left upper zone"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-02//17623_2_1.jpeg?itok=V8YWn-Sm",
            "caption": "Axial CT thorax post contrast image demonstrating a small cavitating lesion in the left upper lobe. No further lesions. No lymphadenopathy"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-02//17623_3_1.jpeg?itok=7j3F5kQ7",
            "caption": "FDG PET CT image of the left upper lobe lesion demonstrated low grade uptake (SUV max 3.6) and no further pathological uptake elsewhere"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-02//17623_4_1.jpeg?itok=ZbNvZxut",
            "caption": "Follow up axial CT thorax demonstrates no appreciable change in the cavitating lesion \u2013 referred for surgery"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT",
      "PET-CT"
    ],
    "link": "https://www.eurorad.org/case/17623",
    "time": "14.02.2022"
  },
  "17647": {
    "case_id": 17647,
    "title": "Diffuse Idiopathic Pulmonary Neuroendocrine Cell Hyperplasia (DIPNECH) with multifocal carcinoid tumours",
    "section": "Chest imaging",
    "age": "69",
    "gender": "female",
    "diagnosis": "Diffuse Idiopathic Pulmonary Neuroendocrine Cell Hyperplasia (DIPNECH) with carcinoid tumours",
    "history": "A 69-year-old female non-smoker presented with a 6-month history of progressive breathlessness. She had no relevant past medical history or drug history. Spirometry showed FEV1 32% predicted and a flow-volume loop suggesting severe small airway disease. Transthoracic echocardiogram was normal.",
    "image_finding": "High Resolution Computed Tomography (HRCT): There is widespread mosaicism with geographic air-trapping, exacerbated in expiration (figure 1).\u00a0 There are multiple peribronchovascular and endobronchial smoothly lobulated solid nodules and masses throughout both mid and lower zones, the largest in the anterior segment of the right upper lobe measures 33mm with a density of 32 Hounsfield Units (HU) (figures 2 & 3). The mass described is airway-centric, with thickening of the proximal airway (figure 3) and plugging of the distal airway (figure 4). \u00a0Multiple other airways are also distally plugged. \nPost-contrast CT thorax/abdomen/pelvis: The right upper lobe pulmonary mass demonstrates heterogeneous enhancement (68 HU) with some patchy areas of less marked enhancement anteriorly (figure 5). Nodules in the middle lobe, left upper and lower lobes also enhance, some avidly. No extra-thoracic primary tumour identified. No lymphadenopathy or metastases below the diaphragm.\n18-gauge CT-guided coaxial biopsy of the largest mass yielded carcinoid tumour.",
    "discussion": "Background\nDiffuse Idiopathic Pulmonary Neuroendocrine Cell Hyperplasia (DIPNECH) is a rare pulmonary condition first described in 1992 since confined to case reports and small case series[1,2]. The World Health Organisation defines DIPNECH as a preinvasive condition on a spectrum of neuroendocrine cells proliferation and a precursor to carcinoid tumour[3]. Neuroendocrine cells confined to airway mucosa proliferate into aggregates that may extend through the basement membrane to cause constrictive bronchiolitis[2,4]. Neuroendocrine aggregates are defined by size; <5mm (tumourlets) and >5mm (carcinoid)[3,4].\u00a0 \nClinical perspective\nMiddle-aged females with a history of chronic cough or asthma[2,4,5]. \u00a0There is no relationship with smoking. Pulmonary function tests demonstrate an obstructive or mixed obstructive/restrictive\u00a0pattern, although can be normal[2,4,5]. Imaging plays an important role due to non-specific clinical features, although often cases are initially misdiagnosed[4]. When present, pulmonary carcinoid tumours are divided by location into central or peripheral; the former more symptomatic due to the sequelae of airway obstruction[6,7]. Carcinoid syndrome is uncommon (<5%)[6,7].\nImaging perspective\nHRCT findings include mosaic attenuation due to constrictive bronchiolitis causing air-trapping and small (<5mm) random pulmonary nodules (absence of nodularity does not exclude DIPNECH)[4]. Bronchial wall thickening, mucus plugging/impaction and bronchiectasis are also reported. When present, pulmonary carcinoid tumours are usually central and may be multiple[6,7]. Carcinoid tumours are smoothly defined, rounded/lobulated, <5cm and homogenously enhance due to increased vascularity [4,6,7]. If present, calcification is coarse and eccentric. Fluorodeoxyglucose-positron emission tomography\u00a0(FDG-PET) is of limited utility (low-moderate uptake, ~25% false-negative rate)[6,7]. Somatostatin receptor-PET demonstrates higher sensitivity and specificity; Gallium-68 DOTATATE Octreotide-PET/CT being the evolving modality that out-performs traditional Octreotide scintigraphy, although is limited by centre availability[7,8].\nOutcome\nNo consensus treatment or follow-up protocols exist due to rarity. Somatostatin analogues and inhaled corticosteroids have been used with varying success to treat small airways disease[2,4]. CT follow up is generally accepted given risk of developing carcinoid tumours[4]. When carcinoid is present, surgical resection is the treatment of choice for localised disease[6].\nTake-home messages\nAlthough rare, DIPNECH is being increasingly described with typical clinical and radiological findings, especially when mosaicism and either random nodules or endobronchial tumours are present. The radiologist may be first to suggest the diagnosis. Ultimately histological sampling of larger nodules/tumours is required to confirm carcinoid. Giving intravenous contrast is a simple step to differentiate carcinoid on background DIPNECH from bronchoceles on background small airways disease/asthma or allergic bronchopulmonary aspergillosis.\nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Diffuse, Idiopathic, Pulmonary, Neuroendocrine, Cell, Hyperplasia, (DIPNECH), with, carcinoid, tumours, Pulmonary, metastases, on, background, small, airways, disease, Small, airway, disease, with, multiple, nodules, (e.g.,, follicular, bronchiolitis;, graft-versus-host, disease, following, bone, marrow, transplantation), Chronic, pulmonary, hypertension",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-02//17647_1_1.png?itok=53TG0-5G",
            "caption": "Axial unenhanced high resolution CT slices through the thorax (lung windows) in inspiration (A) and expiration (B). Mosaicism exacerbated in expiration suggests air-trapping (arrow).  Vessel calibre within the hypoattenuated regions is reduced (arrow head)"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-02//17647_2_1.png?itok=2NOAOQ2K",
            "caption": "Unenhanced axial slices through the thorax on mediastinal windows demonstrating bilateral homogenous solid soft-tissue nodules and masses (arrows)"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-02//17647_3_1.png?itok=E4NkngUC",
            "caption": "33mm smoothly lobulated airway-centric solid mass in the right upper lobe (arrow). The proximal traversing airway is thick-walled"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-02//17647_4_1.png?itok=VbtJ-ZO5",
            "caption": "Sagittal HRCT shows finger-like plugging of the airway (arrow head) immediately beyond the mass (asterisk) with intermittent patency of the distal airway (arrow)"
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-02//17647_5_1.png?itok=0QsbLAqd",
            "caption": "Axial post-contrast CT thorax demonstrates heterogeneous enhancement of the right upper lobe mass (arrow), 32 HU non-contrast, 68 HU post contrast"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "CT",
      "CT-High Resolution"
    ],
    "link": "https://www.eurorad.org/case/17647",
    "time": "23.02.2022"
  },
  "17685": {
    "case_id": 17685,
    "title": "A rare case of silicosis with splenic calcifications",
    "section": "Chest imaging",
    "age": "44",
    "gender": "male",
    "diagnosis": "Silicosis with splenic involvement",
    "history": "A 44-year-old male patient presented with complaints of breathlessness and cough with expectoration for the past 6 months. He had a history of working in a silica plant manufacturing company for the past 20 years. There was no history of fever, hemoptysis, chest pain, joint pain, skin rash, or wheeze.",
    "image_finding": "High-resolution CT images of the above-mentioned patient studied on the same date showed multiple hyperdense sub-centimetric randomly arranged pulmonary nodules(Figure 1a & 1b) and conglomerate calcific nodules in bilateral upper lobes predominantly in perilymphatic location(Figure 2a & 2b). Multifocal patchy areas of ground-glass opacities were noted in the bilateral lung parenchyma(Figure 4).\nFibrosis with collapse consolidatory changes, traction bronchiectasis, and architectural distortion were noted in bilateral upper lobes(Figure 3). Multiple enlarged lymph nodes with eggshell calcifications were noted in prevascular, right upper paratracheal, and bilateral lower paratracheal, subcarinal, paraaortic, and subaortic regions, largest measuring ~1.4x1.0 cm in the paraaortic region(Figure 5). There was no evidence of pleural effusion/pericardial effusion. The Chest wall including the ribs and soft tissue were normal. Multiple sub centimetric micronodular calcifications were noted diffusely involving the splenic parenchyma with relative subcapsular sparing with few adjacent calcified peripancreatic nodes(Figure 6a & 6b).",
    "discussion": "Silicosis is caused by the inhalation of fine particles of crystalline silicon dioxide (silica)[1]. Quartz is the most common form of crystalline silica but is less fibrogenic than tridymite or cristobalite. Occupations such as mining, quarrying, and tunnelling are associated with silicosis [2]. The disease occurs in two clinical forms: acute silicosis, which manifests as alveolar silicoproteinosis; and classic silicosis, which manifests as chronic interstitial reticulonodular disease. Cases of classic silicosis may be classified as either simple or complicated, according to the radiographic findings [1]. Simple silicosis is defined by a radiographic pattern of small and round or irregular opacities, whereas complicated silicosis, or progressive massive fibrosis, is characterized by large conglomerate opacities[1].\nCarcinoma and tuberculosis are potentially serious complications of silicosis[3]. The development of carcinoma or tuberculosis is a strong independent predictor of mortality in patients with silicosis[4] Pulmonary symptoms such as dyspnoea become increasingly severe as the radiologic abnormalities worsen with carcinoma or tuberculosis[5]\nAt CT, the most characteristic feature of simple silicosis is the presence of multiple small nodules 2\u20135 mm in diameter [3] accompanied by calcifications[7]. Subpleural nodules have a rounded or triangular configuration, and if they are confluent, they may resemble pleural plaques[7]\nComplicated silicosis, also known as progressive massive fibrosis, develops through the expansion and confluence of individual silicotic nodules. On chest radiographs, complicated silicosis usually is indicated by large symmetric bilateral opacities with a diameter of more than 1 cm and with an irregular margin[5,6] The large opacities result from nodule coalescence and are observed commonly in the middle lung zone or peripheral one-third of the lung on axial chest images and the upper lung zone on longitudinal images. The large opacities gradually migrate toward the hilum, leaving emphysematous lung tissue between the fibrotic tissue and the pleural surface [1]. The CT features of progressive massive fibrosis are focal soft-tissue masses, often with irregular or ill-defined margins and calcifications, surrounded by areas of emphysematous change [7,8] \nSplenic involvement of silicosis is rarely seen, and patients generally do not experience spleen-related symptoms. Radiologically, numerous well-circumscribed micronodular calcifications are seen in the splenic parenchyma, usually with subcapsular sparing. Although the mechanism of splenic involvement of silicosis is not fully understood, it is thought to occur with the hematogenous or lymphatic spread of silica (or both). Splenic involvement of silicosis may be accompanied by abdominal lymph nodes with eggshell calcification. Silicosis does not have a specific treatment, but removing the source of exposure is important to prevent the disease from worsening [9]\nTake home message: In silicosis, even if the imaging findings are specific for lungs, radiologists should look beyond lungs to identify other organ involvement.\nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Silicosis, with, splenic, involvement, Coal, workers, pneumoconiosis, Asbestosis, Berylliosis, Hard, metal, pneumoconiosis, Talcosis, Siderosis, Splenic, calcifications",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-04//17685_1_1.jpg?itok=eBP1OKTw",
            "caption": "Axial High-resolution CT of thorax, mediastinal window showing multiple hyperdense sub-centimetric randomly arranged pulmonary nodules with features of complicated silicosis depicted in other sections of the lung"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-04//17685_1_2.JPG?itok=wyEpv_Mx",
            "caption": "Axial High-resolution CT of thorax, lung window showing multiple hyperdense sub-centimetric randomly arranged pulmonary nodules with features of complicated silicosis depicted in other sections of the lung"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-04//17685_2_1.jpg?itok=jAvgoRAu",
            "caption": "Axial High-resolution CT of thorax, mediastinal window showing conglomerate calcific nodules in bilateral upper lobes predominantly in perilymphatic location suggestive of complicated silicosis"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-04//17685_2_2.JPG?itok=0C_rc-0V",
            "caption": "(Complicated) - Axial High-resolution CT of thorax, lung window showing conglomerate calcific nodules in bilateral upper lobes predominantly in perilymphatic location suggestive of complicated silicosis"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-04//17685_3_1.jpg?itok=O_tV6Xq7",
            "caption": "Axial High-resolution CT of thorax, lung window showing fibrosis with collapse consolidatory changes, traction bronchiectasis, and architectural distortion are noted in bilateral upper lobes suggestive of complicated silicosis"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-04//17685_4_1.jpg?itok=GYdPVGr3",
            "caption": "Axial High-resolution CT of thorax, lung window showing multifocal patchy areas of ground glass opacities are noted in the bilateral lung parenchyma with features of complicated silicosis depicted in other sections of the lung"
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-04//17685_5_1.jpg?itok=s0RaXL4B",
            "caption": "Axial High-resolution CT of thorax, mediastinal window showing multiple enlarged mediastinal lymph nodes with egg shell calcifications with features of complicated silicosis depicted in other sections of the lung"
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-04//17685_6_1.jpg?itok=E083bUng",
            "caption": "(Extrapulmonary) \u2013 Axial CT images showing multiple sub centimetric micronodular calcifications noted diffusely involving the splenic parenchyma with relative subcapsular sparing"
          },
          {
            "number": "Figure 6b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-04//17685_6_2.JPG?itok=hwwPkpqr",
            "caption": "(Extrapulmonary) \u2013 Coronal CT images showing multiple sub centimetric micronodular calcifications noted diffusely involving the splenic parenchyma with relative subcapsular sparing"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "CT-High Resolution"
    ],
    "link": "https://www.eurorad.org/case/17685",
    "time": "07.04.2022"
  },
  "17712": {
    "case_id": 17712,
    "title": "Inflammatory Myofibroblastic Tumor: A rare cause of solitary pulmonary nodule (SPN)",
    "section": "Chest imaging",
    "age": "22",
    "gender": "female",
    "diagnosis": "Inflammatory Myofibroblastic tumor of lung",
    "history": "A 22-year-old female presented with cough for 1 week with 3 episodes of self-limited hemoptysis. No history of fever, weight loss, dyspnea.",
    "image_finding": "Chest radiograph revealed a well-defined rounded opacity in left lower zone (Fig.1). Subsequently, the patient underwent a contrast-enhanced CT of chest, which revealed a mildly enhancing, well-circumscribed solid nodule of size 2 X 1.5 cm with smooth margins in posterior-basal segment of left lower lobe (Figs. 2 and 3). There was no fat density/calcification/cavitation within the nodule. No associated lymphadenopathy/surrounding ground-glass opacity was seen. Subsequently, PET-CT was performed, which demonstrated increase FDG activity in the nodule. (Figs 4 and 5).",
    "discussion": "Solitary pulmonary nodule (SPN) is defined as a lung nodule which is a rounded or irregular opacity, which may be well or poorly defined, measuring \u2a7d3 cm in diameter, surrounded by normal lung on radiological imaging [1]. CT has a better efficiency in detection of SPN than radiographs and also provides better evaluation opportunity. [2] Radiologically, SPN is of two types: solid and subsolid. Subsolid nodules may have purely ground-glass attenuation, be partly solid, or have mixed solid and ground-glass attenuation. [3] The differentials for solid and subsolid SPNs include benign as well as malignant causes. [3] The differentials for subsolid SPNs includes infection, inflammation, haemorrhage, and malignancy, specifically lung adenocarcinoma. [3] The evaluation of SPNs is vital because they may be an early manifestation of lung malignancy. [3] Inflammatory Myofibroblastic tumours (IMTs) are a rare group of neoplasms composed of a mixture of spindle-shaped myofibroblasts or fibroblasts with a variable number of inflammatory cells. [4] IMT can occur in almost any organ, however, lungs and orbits are most frequently affected. [4] Different aetiologies have been proposed for IMT, including chronic infections, autoimmune diseases and trauma; however, scarce information is available about the natural history. Rarely an aggressive behaviour with metastases is seen.[4] IMT represents 0.7% of all lung tumours in general population. Common complaints includes non-specific respiratory symptoms, like cough, chest pain, haemoptysis and non-specific inflammatory symptoms such as fever, malaise and weight loss. On imaging, it appears as a well-circumscribed solitary peripheral lung mass, with predominance for the lower lobes. Calcification is not very common (about 15 %). On CECT, it presents as a soft tissue mass with variable degree of enhancement. [4] Because of their similar radiological appearance to malignant lung masses, biopsy is necessary to confirm the diagnosis. The treatment of choice is surgery and it usually achieves cure. [4] \u00a0We performed CT guided biopsy for the histopathological confirmation which revealed, neoplastic spindle cells intricately admixed with inflammatory cells without atypia.(Fig.6) Surgical resection was performed afterwards to achieve the cure.\nSPN is a common finding of routine radiology practice, and when encountered, should be carefully evaluated considering possibilities of both malignant and benign causes, including IMT.\n\u00a0\nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Inflammatory, Myofibroblastic, tumor, of, lung, Hamartoma, Granuloma, Rheumatoid, nodule, AVM, Metastasis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-04//17712_1_1.jpg?itok=WKMwScNH",
            "caption": "Frontal chest radiograph shows a nodular opacity in left lower zone (arrow)"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-04//17712_2_1.jpg?itok=ZO_SPiyw",
            "caption": "Axial CT (lung window) shows a well circumscribed solid solitary parenchymal nodule (SPN) (arrow) with normal surrounding lung"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-04//17712_3_1.jpg?itok=6Si2JJuN",
            "caption": "Similar finding on mediastinal window of CT image in axial plane"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-04//17712_4_1.jpg?itok=ESdJofys",
            "caption": "Axial and sagittal fusion images of PET-CT show increased FDG activity in the nodule (arrow)"
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-04//17712_5_1.jpg?itok=soytfsLC",
            "caption": "Axial and sagittal fusion images of PET-CT show increased FDG activity in the nodule (arrow)"
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-04//17712_6_1.JPG?itok=JIekR8PE",
            "caption": "Neoplastic spindle cells are intricately admixed with inflammatory cells (arrow). No evidence of significant atypia or mitosis"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/17712",
    "time": "13.05.2022"
  },
  "17741": {
    "case_id": 17741,
    "title": "A rare case of persistent left superior vena cav",
    "section": "Chest imaging",
    "age": "44",
    "gender": "female",
    "diagnosis": "Persistent left superior vena cava",
    "history": "A 44-year-old female patient with pain and redness of both eyes and mild frontal headache presented with eye Outpatient department. Ophthalmoscopic examination revealed a salmon patch in the left eye. Secondary lymphoma of both eyes was clinically suspected. A routine blood picture showed microcytic normochromic anaemia.",
    "image_finding": "Contrast-Enhanced Computed Tomography (CECT) of chest showed an accessory contrast-filled vessel in the left visceral mediastinum extending from the thoracic inlet to the right atrium. It originates from the confluence of the left subclavian vein laterally and the left internal jugular vein superomedial, separate from the left common carotid artery and left subclavian artery (figure 1a). Figures 1b and 1c show a vessel running in the left prevascular space anterolateral to the arch of the aorta and draining into coronary sinus. Right-sided superior vena cava appears smaller. In addition,coronary sinus appears mildly dilated, commonly a sign of persistent left superior vena cava. Figure 2a shows vessel running laterally to the arch of the aorta and left main pulmonary artery. Figure 2b shows vessel joining the coronary sinus, terminating in right atrium. Figure 3 shows the arch of the aorta, causing mild posterior indentation of the vessel.",
    "discussion": "Superior vena cava (SVC) duplication is most common form of a left-sided SVC, where\u00a0standard right-sided SVC remains. Therefore, When variable course of catheter or wire is noted in left prevascular /visceral mediastinum in chest X-ray, persistence of left SVC should be suspected. This variant occurs in 0.3% to 0.5% of general population and up to 4.5% of patients with other associated cardiac anomalies [1,2]. Lin et al. [3] demonstrated that SVC is often irregular in shape on cross-sectional images. They have suggested a normal range for the major axis (1.5\u20132.8 cm) and minor axis (1\u20132.4 cm).\nThree paired cardinal veins drain the embryo's body at 5th week, cephalic portion is drained by paired anterior cardinal vein, and\u00a0 caudal part is drained by paired posterior cardinal vein. Usually positioned right-sided SVC is formed by proximal right anterior cardinal vein, right common cardinal vein and right horn of sinus venosus. Posterior cardinal vein forms part of azygos vein.\nPart of left anterior cardinal vein forms left superior intercostal vein and adjacent left brachiocephalic vein[1].\nRaghib syndrome/unroofed coronary sinus is when persistent left SVC opens into left atrium with absent coronary sinus, creating a right-to-left shunt. In symptomatic patients with stroke, brain abscess and systemic embolisation ligation of left SVC can be performed with an adequately sized bridging vein. In addition, persistent left SVC may generate difficulty placement of pacemakers, implantable cardioverter-defibrillator leads, and Swan-Ganz catheters[4,5].\nPersistent left SVC is a relative contraindication to performance of retrograde cardioplegia during coronary artery bypass grafting [6].\nContrast-enhanced Computed Tomography is the investigation of choice that detects vessel's origin, course and drainage. Dedicated contrast-enhanced CT protocols include a 60\u201375 seconds delay after injection. Furthermore, during CT angiography, window level,100 HU; window width,600-700 HU, and diluted contrast material can minimise streak artefacts. In addition, to detect an SVC thrombus and to minimise mixing artefacts, additional delayed acquisition at 60 seconds is often valuable [7].\nMagnetic Resonance Imaging (MRI) can be reserved as a problem-solving modality.\nTeaching point\nAppropriate knowledge of appearance of SVC variants and their drainage before any central vascular intervention or catheterisation can minimise significant vascular complications or bleeding risks.\nWritten informed consent for publication has been obtained.",
    "differential_diagnosis": "Persistent, left, superior, vena, cava, Left, internal, mammary, vein, Left, superior, intercostal, vein, Left, pericardiophrenic, vein",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-05//17741_1_1.jpeg?itok=sJ71Y7qJ",
            "caption": "Axial contrast CT at thoracic inlet shows a contrast filled accessory vessel (red arrow) at the left visceral mediastinum separate from the left common carotid (black arrow) and left subclavian artery"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-05//17741_1_2.jpeg?itok=NE-b2Q4W",
            "caption": "Axial CECT at mid thorax level shows two contrast filled vessels seen on both sides of the visceral mediastinum. Left-sided vessels appear larger"
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-05//17741_1_3.jpeg?itok=5oRlvx3-",
            "caption": "Axial CECT of lower thorax shows mildly dilated coronary sinus"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-05//17741_2_1.jpeg?itok=sbdkkbAJ",
            "caption": "Coronal contrast-enhanced CT show two clear, visceral mediastinal veins. Mild indentation of a left visceral mediastinal vein is seen by an arch of the aorta"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-05//17741_2_2.jpeg?itok=GszATop0",
            "caption": "Coronal Contrast-enhanced CT of thorax show mildly dilated coronary sinus"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-05//17741_3_1.jpeg?itok=eMw1F2ND",
            "caption": "Sagittal sections at the left side of the midline show the arch of the aorta causing posterior indentation over the left visceral mediastinal vessel"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Cardiac",
      "Vascular"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/17741",
    "time": "10.06.2022"
  },
  "17745": {
    "case_id": 17745,
    "title": "Pulmonary nodules in Tularaemi",
    "section": "Chest imaging",
    "age": "65",
    "gender": "male",
    "diagnosis": "Pulmonary tularaemia",
    "history": "A 65-year-old male with a history of hypertension and prostate carcinoma in remission was referred to the emergency department. He presented with the following symptoms: high fever (up to 39.0oC), generalised weakness, joint pain and headache. His medications included the antihypertensive agent Perindopril Erbumine 4mg daily.",
    "image_finding": "X-Ray imaging revealed three lesions: 6 mm nodular thickening in the left lower lung field and two similar lesions in the right middle and lower lung fields. Pleural effusion was absent. The contrast-enhanced CT demonstrated numerous irregular nodular consolidations, predominantly located peripherally and inferiorly. Some lesions exhibited signs of central necrosis or cavitation. Lesion margins were blurred due to ground-glass opacities disseminated over the parenchyma. \nA follow-up CT scan was performed six days later due to the patient's ambiguous clinical presentation, resembling septic emboli usually found in infective endocarditis (IE). The extent of the previously described thickenings was similar, individual thickenings were discretely regressing, no newly formed lesions were seen. Two consolidations (superior segment of the right lower lobe) obtained newly formed cavitations. \nDue to clinical suspicion and the increasing incidence of tularaemia in the region, serology tests for Francisella Tularensis were performed to confirm the diagnosis.",
    "discussion": "Tularaemia is a rare zoonotic infection, caused by Francisella tularensis, a gram-negative aerobic coccobacillus. The disease is often referred to as Rabbit fever, with rodents and lagomorphs (hares and rabbits) being the most common animal reservoir [1]. \u00a0It is usually transmitted via skin contact with infected animals, tick bites or more uncommonly - via inhalation or consumption of contaminated food or water [1,2] . \nThere are six described clinical manifestations of tularaemia. The most prevalent is ulceroglandular tularaemia, which accounts for 75-85% of all cases. It presents itself as fever, ulcerative lesions and regional lymphadenopathy. Other manifestations include glandular, oculoglandular, oropharyngeal, typhoid and pulmonary tularaemia. The latter is the most severe form of the disease, with a mortality rate approaching 60% if untreated [3].\nThe disease usually starts out with flu-like symptoms such as fever, fatigue, arthralgias, myalgias, headache, and gastrointestinal issues. Due to pulmonary involvement, cough, dyspnoea and chest pain can be present as well. The presentation (both radiological and clinical) is quite alterable, making the diagnosis difficult. Serological tests are the simplest and most reliable diagnostic tool available, potentially eliminating the need for PET\u2013CT (Positron Emission Tomography) imaging or CT-guided lung biopsies, thus minimising the risk of complications and patient distress. [4]. \n\u00a0\nPulmonary lesions are generally primarily assessed for their malignancy potential and further action is taken according to the prediction models and current guidelines. The decision-making parameters include: nodule size, risk of malignancy, patient preferences and overall health status. The management options comprise of: (1) no further action, (2) CT interval monitoring (applied in this case), (3) a PET-CT scan, (4) CT-guided transthoracic biopsy, (5) surgical excision with histological diagnosis, or (6) radiation therapy. [5].\nIn radiological imaging, the predominant manifestation of tularaemia is enlarged hilar and/or mediastinal nodes. Suppuration of the nodes can also occur [6]. Occasionally, newly formed incoherent multifocal pulmonary nodules or consolidations can be mistaken for lung cancer or, as in this case, septic emboli. The regression of the nodules is gradual, lasting approximately three months. [7]. \nEstablished treatment is IV antibiotic therapy with streptomycin, gentamycin or fluoroquinolones, in duration for 10-21 days [2]. In our case, gentamycin 360mg IV, once daily for 10 days was chosen and the patient fully recovered.\nTeaching points\n\nIt is important to correctly diagnose the infection in the early stages due to the high mortality rate of the Illness. \nPulmonary lesions visible on the CT-scan are nonspecific and resemble septic emboli, thus obscuring the underlying cause.\nClinicians ought to be aware of the typical and atypical presentations of the disease, raising clinical suspicion, especially during the summer months.\n\nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Pulmonary, tularaemia, Hantavirus, haemorrhagic, fever, with, renal, syndrome, Infective, endocarditis, -, Septic, emboli, Pneumonia, Metastasis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-06//17745_1_1.jpg?itok=lYG3p5ET",
            "caption": "Chest X-Ray in the posterior \u2013 anterior projection, marking three radio-opaque nodular lesions in the right middle lung field, right lower lung field and left lower lung field (arrows)"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-06//17745_2_1.png?itok=k3KfB7J2",
            "caption": "Representative cross-sectional CT scan of the lungs, showing multiple nodular lesions (arrows) in both lower pulmonary lobes. Also present are ground - glass opacities (arrowheads)"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-06//17745_3_1.jpg?itok=iHpTj6f5",
            "caption": "Longitudinal CT scan of the posterior segments of the lungs, showing numerous lesions, mainly in the posterior -inferior lung lobules"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-06//17745_4_1.jpg?itok=969jFHyc",
            "caption": "Primary CT imaging \u2013 anterior lung portion, presenting with the lowest cumulative number of lesions"
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-06//17745_4_2.jpg?itok=4xQfrw50",
            "caption": "Primary CT imaging \u2013 middle lung portion"
          },
          {
            "number": "Figure 4c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-06//17745_4_3.jpg?itok=PoFVsVsX",
            "caption": "Primary CT imaging \u2013 posterior lung portion, presenting the highest prevalence of lesions"
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-06//17745_5_1.jpg?itok=q6nGhSDK",
            "caption": "A Follow-up CT-scan (6 days later) \u2013 anterior lung portion"
          },
          {
            "number": "Figure 5b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-06//17745_5_2.jpg?itok=UwWAbEYJ",
            "caption": "A Follow-up CT-scan (6 days later) \u2013 middle lung portion"
          },
          {
            "number": "Figure 5c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-06//17745_5_3.jpg?itok=MQzVtiYR",
            "caption": "A Follow-up CT-scan (6 days later) \u2013 posterior lung portion, discrete regression of the nodules and some newly formed intranodular cavitation are seen"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Thorax"
    ],
    "imaging_technique": [
      "CT-High Resolution"
    ],
    "link": "https://www.eurorad.org/case/17745",
    "time": "02.06.2022"
  },
  "17767": {
    "case_id": 17767,
    "title": "A rare cause of exertional dyspnoea in SLE \u2013 Shrinking lung syndrome",
    "section": "Chest imaging",
    "age": "48",
    "gender": "female",
    "diagnosis": "Shrinking lung syndrome",
    "history": "A 48-year-old female, on irregular follow-up for systemic lupus erythematosus (SLE), came to the pulmonary medicine outpatient department with a 2-year history of easy fatiguability and exertional dyspnea progressing to current dyspnea at rest. She had no history of orthopnea or paroxysmal nocturnal dyspnea.",
    "image_finding": "Chest X-Ray (CXR) in posteroanterior view revealed an elevated right hemidiaphragm with reduced lung volume on the right. No obvious lung parenchymal, cardiac, and mediastinal abnormalities were noted.\nOn further evaluation with high-resolution computed tomography (HRCT) of the chest, conclusive evidence of an elevated right hemidiaphragm and significant volume loss in the right middle and lower lobes with subsegmental atelectasis were seen. No features of parenchymal/pleural/vascular disease were noted.\u00a0 \nAdditionally, an M mode ultrasound of the chest was performed, demonstrating a paradoxical movement of the right hemidiaphragm on inspiration.",
    "discussion": "Shrinking Lung Syndrome (SLS) is a rare diagnosis of exclusion, usually occurring in female patients, after a mean duration of 4-6.5 years from the diagnosis of SLE.[1,2] It was first described by Hoffman and Beck in 1965 and is characterized by unexplained dyspnea and a decrease in lung volume, with or without a hemidiaphragm elevation, in the absence of implicit alveolar or interstitial disease. [3] Currently, a combination of pathophysiological mechanisms including pleural inflammation and chronic hypoventilation due to SLE-associated neuro-myopathy have been attributed to SLS. [4\u20136] \nAs with our case, SLS often presents as exertional dyspnea progressing over months (98.87%) [2,7] and pleuritic chest pain (76%).[2] It may also rarely present as fever (19%) or dry cough (8%).[2] \u00a0Features of SLS occur independently of the course, severity, and biomarkers of SLE and are non-collateral with features of other major organ involvement.[8] Examination usually reveals tachypnea with the use of accessory respiratory muscles and bilateral shrinking of lung borders without characteristic auscultatory findings apart from rare basal crepitations.[9] Sequential pulmonary function testing shows gradually decreasing lung volumes in a restrictive pattern.[2]\nThe moderately slow progression of SLS not only increases its morbidity but also contributes to a delay in diagnosis, (11 +/- 20 months) leading to possible drastic complications including respiratory arrest.[2,10] Findings of an elevated hemidiaphragm on Chest X-ray and/or CT findings of diaphragmatic elevation, pleuritis +/- basal laminar atelectasis without features of interstitial pneumonitis in a female patient with chronic SLE, should prompt a radiologist to report a possible diagnosis of SLS.[4,7,11,12] Additional evidence of paradoxical diaphragmatic movement can also be confirmed on M-mode ultrasonography.[13]\nIn our case report, a middle-aged female patient, presented with gradual onset, progressive dyspnea for the past 2 years, 8 years after a diagnosis of SLE. Her pulmonary function tests showed a restrictive pattern. CXR revealed an elevated right hemidiaphragm with reduced lung volume on the right when compared to a previous CXR performed 2 years before her presentation. The finding was further confirmed on CT, along with establishing evidence of significant volume loss in the right middle and lower lobes with subsegmental atelectasis without features suggestive of pulmonary/pleural/vascular disease. M mode ultrasound also demonstrated paradoxical movement, clinching the diagnosis of shrinking lung syndrome.\nFortunately, despite the scarcity of clinical trials, available literature on isolated cases shows a near-complete resolution of clinical and pulmonary function test results with moderate to high-dose corticosteroids in the range of 0.5-1.0mg/kg/day.[9] The addition of immunosuppressants such as Methotrexate, Rituximab, and Colchicine not only improves imaging parameters but also prevents the recurrence of SLS features while tapering corticosteroids. [9,14\u201316]\nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Shrinking, lung, syndrome, Phrenic, nerve, palsy, Diaphragmatic, eventration, Pulmonary, hypoplasia, Subpulmonic, effusion, Neuromuscular, disorders, involving, the, chest, wall",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-06//17767_1_1.jpg?itok=Ml2H2Vm5",
            "caption": "Chest x-ray PA view done 2 years before the presentation \u2013 Unremarkable cardia and lungs. The diaphragm is normal in position"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-06//17767_1_2.jpg?itok=GfpgB8mX",
            "caption": "Chest x-ray performed at the time of presentation \u2013 shows elevated right hemidiaphragm and reduced lung volume on the right. No obvious lung parenchymal abnormality was noted"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-06//17767_2_1.jpg?itok=jb5IqupP",
            "caption": "High resolution computed tomography of the chest \u2013 Lung window. The study shows elevated right hemidiaphragm with volume loss of right middle and lower lobes. No features of pleural/interstitial abnormalities."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-06//17767_3_1.jpg?itok=KoybFTdE",
            "caption": "High resolution computed tomography of the chest \u2013 Lung window. The study reveals a normally positioned left hemidiaphragm and unremarkable left-sided lung fields"
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-06//17767_3_2.jpg?itok=ojrpDGAG",
            "caption": "High resolution computed tomography of the chest \u2013 Lung window. The study reveals elevated right hemidiaphragm with volume loss of right middle and lower lobes with subsegmental atelectasis. No features of pleural/interstitial abnormalities"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "CT",
      "CT-High Resolution",
      "Ultrasound",
      "Ultrasound-Colour Doppler"
    ],
    "link": "https://www.eurorad.org/case/17767",
    "time": "13.06.2022"
  },
  "17769": {
    "case_id": 17769,
    "title": "Multiple pulmonary nodules with halo sign: A case of primary pulmonary sarcom",
    "section": "Chest imaging",
    "age": "69",
    "gender": "female",
    "diagnosis": "Primary pulmonary angiosarcoma",
    "history": "A 69-year-old transsexual woman presented with a 1-month history of cough, dyspnoea and haemoptysis. She had medical history of arterial hypertension, HIV controlled with antiretroviral treatment and hepatitis B virus. She carried breast prosthesis and had history of multiple subcutaneous silicone injections.",
    "image_finding": "A first contrast-enhanced thoracic CT showed multiple and bilateral randomly distributed lung nodules with halo sign (Figure 1).\u00a0 \nAfter biopsy of a lingula nodule, a chest radiograph was performed, showing multiple bilateral nodular opacities and post-surgical alterations in left hemithorax (Figura 2a y 2b).\nAfter two months, a significant worsening was observed, with increase in the size and number of lung nodules, all of them with halo sign. A new pleural effusion was also visualised (Figure 3). \nA third contrast-enhanced chest CT performed 20 days after the second one, due to clinical worsening of the patient, showed a rapid increase in the number and size of the lung nodules (Figure 4).",
    "discussion": "Pulmonary angiosarcoma is a neoplasm of the vascular endothelium [1,2,3]. It is an infrequent tumour, mostly secondary to an extrapulmonary primary angiosarcoma, being the primary pulmonary angiosarcoma a very rare entity [3,4,5].\nIts clinical course is aggressive, with symptoms due to tumour erosion of blood vessels with haemoptysis, anaemia and coagulation disorders with increase of the D-dimer [3]. Other usual symptoms are cough, dyspnoea, chest pain and loss of weight [1,3,6]. \nThe aetiology is unknown, although risk factors, such as exposition to vinyl chloride, have been described [1,7]. \nImaging findings are variable and include lung nodules, which in more than 70% of the cases are multiples and bilateral; ground glass lung opacities, lung nodules with halo sign and infiltration of adjacent tissues [2,6,7]. \u00a0\nIn the pulmonary angiosarcoma, the ground glass halo is due to haemorrhage secondary to the rupture of fragile abnormal vessel of the tumoural nodules, whereas, the central solid zone corresponds to the tumoural lesion itself [8].\nThe bronchoscopy is a nonspecific test because there are more frequent entities which show vessels proliferation like pulmonary arteriovenous malformations. Furthermore, in many cases not enough tissue is obtained for the histopathology analysis [4,9].\nDefinitive histopathology diagnosis is usually achieved after a surgical biopsy, as it was in our case. Histopathologically, pulmonary angiosarcomas are characterised by a proliferation of vascular channels covered by polygonal and ovoid neoplastic cells with atypical and irregular nucleus. Usually there are adjacent haemorrhagic foci [4,6]. \nImmunochemistry techniques show the endothelial origin of the tumour, with CD-31, CD-34 and factor VIII-related antigen positivity [1,2,3].\u00a0\u00a0\u00a0 \nWhen tumours are localised, these are treated by surgery and radiotherapy. However, due to the nonspecific respiratory symptoms and the rarity of this disease, a late diagnose is the rule. This, associated with the aggressive behaviour of the tumour, leads to the ominous prognosis of this entity [1,2,5].",
    "differential_diagnosis": "Primary, pulmonary, angiosarcoma, Pulmonary, angiosarcoma, Kaposi, sarcoma, Haemorrhagic, hypervascular, metastases, Lymphoma, Angioinvasive, fungal, infections, (aspergillosis,, mucormycosis), Mycobacterial, infections, Granulomatosis, with, polyangiitis, Organising, pneumonia, Lung, infarcts, Silico",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-06//17769_1_1.jpg?itok=ei9-1z9R",
            "caption": "Axial post-contrast CT thorax in lung parenchymal window: multiple and bilateral lung nodules with halo sign"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-06//17769_2_1.jpg?itok=pRMPID4o",
            "caption": "Chest radiograph postero-anterior and lateral view shows multiple nodular opacities in both lungs. Post-surgical alterations in left hemithorax"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-06//17769_2_2.jpg?itok=3SN1y6W1",
            "caption": "Chest radiograph postero-anterior and lateral view shows multiple nodular opacities in both lungs. Post-surgical alterations in left hemithorax"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-06//17769_3_1.jpg?itok=8k9Plxmz",
            "caption": "Axial contrast-enhanced chest TC, lung window: increase in the size and number of lung nodules, all of them with halo sign, and new pleural effusion in right major fissure"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-06//17769_4_1.jpg?itok=1hzESoo5",
            "caption": "Axial contrast-enhanced chest TC: rapid increase in the number and size of the lung nodules"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Pulmonary vessels",
      "Thorax"
    ],
    "imaging_technique": [
      "CT",
      "CT-Angiography"
    ],
    "link": "https://www.eurorad.org/case/17769",
    "time": "13.06.2022"
  },
  "17789": {
    "case_id": 17789,
    "title": "A rare case of extensive low-flow vascular venous malformation.",
    "section": "Chest imaging",
    "age": "54",
    "gender": "male",
    "diagnosis": "Extensive low-flow vascular venous malformation.",
    "history": "A 54-year-old male was referred to general surgery in view of a new-onset change in bowel habit. He denied weight loss or rectal bleeding and had no past medical history of note. Clinical examination was unremarkable. Initial investigations included routine bloods, which revealed raised inflammatory markers, and an elective Computed Tomography (CT) Virtual Colonography.",
    "image_finding": "A CT Virtual Colonography was performed which did not show evidence of colonic malignancy. CT however revealed an incidental finding of an extensive serpiginous soft tissue nodularity with multiple calcific foci, in the lower mediastinum, surrounding the distal oesophagus and distal thoracic aorta, with extension to the left infra-diaphragmatic region. These soft tissue changes were also noted in the middle mediastinum anterior to the heart.\u00a0\nAn elective magnetic resonance imaging (MRI) of the upper abdomen was performed to further characterise the CT findings. Pre-contrast fat-suppressed T1 and T2, in and out-of-phase T1, diffusion-weighted (b=800) and post-contrast arterial, portovenous and delayed venous phases were acquired.\u00a0\nThe soft tissue nodularity seen on CT demonstrated serpiginous T2 hyperintensity with slow venous phase enhancement. Scattered T1 and T2 hypointense foci were seen throughout the lesion, which correspond to the calcific foci seen on CT, consistent with phleboliths. No large feeding artery was identified, and the solid abdominal organs were all normal.",
    "discussion": "Background\nAmong\u00a0vascular malformations, venous malformations are the most common (50%), followed by arterial and arterio-venous\u00a0malformations (35%), lymphatic malformations (10%), and mixed combined malformations (5%). A subset of venous malformations are low-flow venous malformations, most found in the head and neck (40%), extremities (40%), trunk (20%) and very rarely in the mediastinum [2].\nVascular malformations, formerly referred to as haemangiomas, are congenital structural lesions resulting from errors of vascular morphogenesis. They never regress spontaneously but will continue to grow gradually throughout life.\u00a0They are often diffuse and infiltrative and involve multiple tissue planes and compartments, however, may be focal or multifocal.\nLymphatic malformations consist of chyle filled cysts lined with endothelium rather than blood as in venous malformations. Most lymphatic malformations present in early childhood, with 65% present at birth and 90% seen by the age of two. \n\u00a0\nClinical Perspective\nClinical presentation depends on the extent and anatomical location of the lesion. Although, low-flow venous malformations are present at birth, they do not usually present clinically until late childhood or early adulthood [3].\nSuperficially, venous malformations present as a non-pulsatile compressible mass, associated with a bluish tint to the skin which becomes darker with age [4]. They may demonstrate a dramatic enlargement when in a dependent position or during Valsava manoeuvre [2]. Other presentations include severe pain from intralesional bleeding, thrombosis, or compressive neuropathy. In the setting of a complex clinical presentation, multi-modality imaging, especially MRI, is crucial for image-based diagnosis and patient management.\u00a0\n\u00a0\nImaging Perspective\nUltrasound and MRI are the primary imaging modalities for the investigation and diagnosis of vascular malformations.\u00a0\nVascular malformations on ultrasound are demonstrated as compressible heterogenous, predominantly hypoechoic lesions. The presence of a phlebolith is a hallmark sign, especially in paediatric cases, where the presence of phleboliths in soft tissue masses is rare. Low-flow venous malformations reveal low-velocity with a non-modulated spectrum on Doppler interrogation, whilst high-flow malformations show arterial waveforms or arteriovenous shunting [7].\u00a0\nIn cases of extensive and deep lesions, contrast-enhanced MRI is preferred due to its ability to delineate the extent of non-superficial malformations and for characterisation of flow dynamics.\u00a0\nVenous malformations are seen as septated lesions with intermediate to decreased signal intensity on T1-weighted images and hyperintensity on T2-weighted and STIR sequences. The extent of the venous malformation is best seen on fat-suppressed T2-weighted and STIR images [8].\u00a0\u00a0\nPhleboliths are seen as small low-signal-intensity foci in all sequences.\u00a0 Venous malformations are also characterized by lack of arterial and early venous enhancement and absence of flow voids, enlarged feeding vessels or arteriovenous shunting [8].\u00a0\n\u00a0\nOutcome\n\u00a0\nTreatment of vascular malformations should be limited to patients with complications or functional impairment.\u00a0 Treatment options include conservative management, with compression and antiplatelet therapy, surgical or radiological intervention with sclerotherapy or embolisation [6].\u00a0\n\u00a0\nTake-Home Message\nAccurate diagnosis and proper classification of vascular malformations is essential as they often require aggressive treatment. Multi-modality imaging, especially contrast-enhanced MRI, plays an important role in establishing a long-term management plan.",
    "differential_diagnosis": "Extensive, low-flow, vascular, venous, malformation., Lymphatic, malformation, Epithelioid, haemangioma, Portosystemic, collateral, pathways",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-07//17789_1_1.png?itok=qvpHkHDC",
            "caption": "54 year-old-male presented with an incidental finding on CT Virtual Colonography of an extensive serpiginous soft tissue nodularity with multiple calcific foci (A), in the lower mediastinum surrounding the distal oesophagus and distal thoracic aorta (B), with extension to the left infra-diaphragmatic region (C, D). These soft tissue changes were also noted in the middle mediastinum anterior to the heart (A)."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-07//17789_1_2.png?itok=GYcUad6s",
            "caption": "54 year-old-male presented with an incidental finding on CT Virtual Colonography of an extensive serpiginous soft tissue nodularity with multiple calcific foci (A), in the lower mediastinum surrounding the distal oesophagus and distal thoracic aorta (B), with extension to the left infra-diaphragmatic region (C, D). These soft tissue changes were also noted in the middle mediastinum anterior to the heart (A)."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-07//17789_1_3.png?itok=S0iAorxb",
            "caption": "54 year-old-male presented with an incidental finding on CT Virtual Colonography of an extensive serpiginous soft tissue nodularity with multiple calcific foci (A), in the lower mediastinum surrounding the distal oesophagus and distal thoracic aorta (B), with extension to the left infra-diaphragmatic region (C, D). These soft tissue changes were also noted in the middle mediastinum anterior to the heart (A)."
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-07//17789_1_4.png?itok=diIGDbgt",
            "caption": "54 year-old-male presented with an incidental finding on CT Virtual Colonography of an extensive serpiginous soft tissue nodularity with multiple calcific foci (A), in the lower mediastinum surrounding the distal oesophagus and distal thoracic aorta (B), with extension to the left infra-diaphragmatic region (C, D). These soft tissue changes were also noted in the middle mediastinum anterior to the heart (A)."
          },
          {
            "number": "Figure 1e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-07//17789_1_5.png?itok=kwhlsewY",
            "caption": "54 year-old-male presented with an incidental finding on CT Virtual Colonography of an extensive serpiginous soft tissue nodularity with multiple calcific foci (A), in the lower mediastinum surrounding the distal oesophagus and distal thoracic aorta (B), with extension to the left infra-diaphragmatic region (C, D). These soft tissue changes were also noted in the middle mediastinum anterior to the heart (A)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-07//17789_2_1.png?itok=HpJJ_fn8",
            "caption": "Axial fat-suppressed T2 images demonstrate serpiginous hyperintense foci in the middle mediastinum, anterior to the heart (A), in the inferior mediastinum surrounding the oesophagus and distal thoracic aorta (B), and extending inferiorly to the left upper abdomen posterior to the left kidney (C). Scattered hypointense foci (blue arrow) are seen in the described lesion, consistent with phleboliths."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-07//17789_2_2.png?itok=1BNZd8bf",
            "caption": "Axial fat-suppressed T2 images demonstrate serpiginous hyperintense foci in the middle mediastinum, anterior to the heart (A), in the inferior mediastinum surrounding the oesophagus and distal thoracic aorta (B), and extending inferiorly to the left upper abdomen posterior to the left kidney (C). Scattered hypointense foci (blue arrow) are seen in the described lesion, consistent with phleboliths."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-07//17789_2_3.png?itok=mz2P0xWv",
            "caption": "Axial fat-suppressed T2 images demonstrate serpiginous hyperintense foci in the middle mediastinum, anterior to the heart (A), in the inferior mediastinum surrounding the oesophagus and distal thoracic aorta (B), and extending inferiorly to the left upper abdomen posterior to the left kidney (C). Scattered hypointense foci (blue arrow) are seen in the described lesion, consistent with phleboliths."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-07//17789_2_4.png?itok=EATwL-oY",
            "caption": "Axial fat-suppressed T2 images demonstrate serpiginous hyperintense foci in the middle mediastinum, anterior to the heart (A), in the inferior mediastinum surrounding the oesophagus and distal thoracic aorta (B), and extending inferiorly to the left upper abdomen posterior to the left kidney (C). Scattered hypointense foci (blue arrow) are seen in the described lesion, consistent with phleboliths."
          },
          {
            "number": "Figure 2e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-07//17789_2_5.png?itok=KicmxpQv",
            "caption": "Axial fat-suppressed T2 images demonstrate serpiginous hyperintense foci in the middle mediastinum, anterior to the heart (A), in the inferior mediastinum surrounding the oesophagus and distal thoracic aorta (B), and extending inferiorly to the left upper abdomen posterior to the left kidney (C). Scattered hypointense foci (blue arrow) are seen in the described lesion, consistent with phleboliths."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-07//17789_3_1.png?itok=Wb6CCv-K",
            "caption": "Axial dynamic contrast fat-suppressed T1 pre-contrast (A1, B1), arterial (A2, B2) and delayed venous (A3,B3) phases were obtained. The soft tissue nodularity is hypointense on T1-weighted sequences and demonstrates delayed venous enhancement (blue arrows). Scattered hypointense foci are again seen throughout the lesion, consistent with phleboliths."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-07//17789_3_2.png?itok=Jr9M_FN4",
            "caption": "Axial dynamic contrast fat-suppressed T1 pre-contrast (A1, B1), arterial (A2, B2) and delayed venous (A3,B3) phases were obtained. The soft tissue nodularity is hypointense on T1-weighted sequences and demonstrates delayed venous enhancement (blue arrows). Scattered hypointense foci are again seen throughout the lesion, consistent with phleboliths."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-07//17789_3_3.png?itok=yrZHaZ4u",
            "caption": "Axial dynamic contrast fat-suppressed T1 pre-contrast (A1, B1), arterial (A2, B2) and delayed venous (A3,B3) phases were obtained. The soft tissue nodularity is hypointense on T1-weighted sequences and demonstrates delayed venous enhancement (blue arrows). Scattered hypointense foci are again seen throughout the lesion, consistent with phleboliths."
          },
          {
            "number": "Figure 3d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-07//17789_3_4.png?itok=FKbhw6GB",
            "caption": "Axial dynamic contrast fat-suppressed T1 pre-contrast (A1, B1), arterial (A2, B2) and delayed venous (A3,B3) phases were obtained. The soft tissue nodularity is hypointense on T1-weighted sequences and demonstrates delayed venous enhancement (blue arrows). Scattered hypointense foci are again seen throughout the lesion, consistent with phleboliths."
          },
          {
            "number": "Figure 3e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-07//17789_3_5.png?itok=YlkV3Oag",
            "caption": "Axial dynamic contrast fat-suppressed T1 pre-contrast (A1, B1), arterial (A2, B2) and delayed venous (A3,B3) phases were obtained. The soft tissue nodularity is hypointense on T1-weighted sequences and demonstrates delayed venous enhancement (blue arrows). Scattered hypointense foci are again seen throughout the lesion, consistent with phleboliths."
          },
          {
            "number": "Figure 3f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-07//17789_3_6.png?itok=Pt-_KxV3",
            "caption": "Axial dynamic contrast fat-suppressed T1 pre-contrast (A1, B1), arterial (A2, B2) and delayed venous (A3,B3) phases were obtained. The soft tissue nodularity is hypointense on T1-weighted sequences and demonstrates delayed venous enhancement (blue arrows). Scattered hypointense foci are again seen throughout the lesion, consistent with phleboliths."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Vascular"
    ],
    "imaging_technique": [
      "CT",
      "MR"
    ],
    "link": "https://www.eurorad.org/case/17789",
    "time": "19.07.2022"
  },
  "17822": {
    "case_id": 17822,
    "title": "Title. A pulmonary exacerbation.",
    "section": "Chest imaging",
    "age": "14",
    "gender": "female",
    "diagnosis": "Allergic broncho-pulmonary aspergillosis.",
    "history": "A fourteen-year-old female with cystic fibrosis was referred for a recent modification of symptoms. First-line antibiotic therapy was introduced. Three weeks later, the patient's condition was not relieved, and a CT scan was completed.",
    "image_finding": "Figures A and B correspond to coronal reformations of the chest computed tomography in mediastinal (A, B) and parenchymal (C, D) and reformations. On panels A and C, there is a collapse and consolidation of the entire right lung. On panel A, the airway tree within the lung collapse/consolidation is dilated and filled with material of higher attenuation than the adjacent lung parenchyma. Panels B and D were obtained after three months of oral corticosteroid treatment.",
    "discussion": "Background \nCystic fibrosis is one of the most common genetic mutation in Caucasians. The genetic disorder induce a lack of hydration and thickening of the airway secretions. The modified bronchial mucus is prone to favour various episodes of airway inflammation, most usually infectious inflammation but also allergic inflammation to non-bacterial pathogens such as Aspergillus fumigatus.\nClinical Perspective \nAllergic broncho-pulmonary aspergillosis (ABPA) is not rare in patients with cystic fibrosis and may affect up to 15% of these patients[1]. The disease is often difficult to establish since there is a wide overlap in respiratory symptoms and biological or immunological data with other infectious processes. However, ABPA is an allergic process that cannot improve by using antibiotics but require corticosteroid treatment at high doses, which are conversely not relevant in patients suffering from a bacterial infection.\nImaging Perspective \nABPA is obtained thanks to a combination of criteria, including imaging. Non-specific imaging criteria are central bronchiectasis, mucus plugs, and consolidation[2]. Lung \u201cinfiltrate\u201d is considered an imaging criterion of ABPA, however, its definition is unclear[3]. In our practice, we define \u201cinfiltrate\u201d as an area of consolidation within which the air bronchogram is not visible but replaced by mucus-filling of the airway tree. \nRecently, it has been highlighted that mucus plugs with high attenuation values (HAM) (from 70 to 150 Hounsfield Units) is a highly specific criterion of ABPA, if not pathognomonic, allowing the clinicians to confirm the disease[4, 5].\nOutcome.\nABPA requires a corticosteroid treatment. Panel C and D of the Figure demonstrate complete clearance of HAM under treatment, which is replaced by central airway bronchiectasis. The collapsed lung was treated and got back to a normally aerated lung.\nTake-Home Message / Teaching Points\nLung infiltrates with high attenuation mucus is a specific sign of allergic broncho-pulmonary aspergillosis.",
    "differential_diagnosis": "Allergic, broncho-pulmonary, aspergillosis., Bacterial, infection, Viral, infection, Fungal, infection",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-07//17822_1_1.png?itok=gEDGmPdA",
            "caption": "Chest CT in coronal reformation in mediastinal (panels A, B) and parenchymal (panels C, D) reformations, before (A, C) and after (B, D) three months of oral corticosteroid treatment"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/17822",
    "time": "25.07.2022"
  },
  "17823": {
    "case_id": 17823,
    "title": "Hypoplastic right upper lobe in an asymptomatic 28-year old female: a case report",
    "section": "Chest imaging",
    "age": "28",
    "gender": "female",
    "diagnosis": "Pulmonary hypoplasia, right upper lobe",
    "history": "A 28-year-old female presented at the outpatient department for an annual physical examination\u00a0as part of the yearly employment requirement. She was asymptomatic with no subjective complaints. Each year, she would present prior chest radiographs to rule out pulmonary tuberculosis. A physical evaluation was unremarkable, and laboratory examinations (i.e. sputum exam, spirometry, whole abdominal ultrasound, etc.) were normal.",
    "image_finding": "Chest radiograph (Fig. 1) showed mild volume loss of the right lung with a \u201ckinked,\u201d tubular structure seen in the right cardiophrenic region. Contrast-enhanced chest CT-scan showed only a middle lobe and a right lower lobe (Fig. 2A), with compensatory hype-aeration of both lobes. There was normal bifurcation of the right intermediate bronchus into the middle and lower lobe bronchi, and a single obliquely-oriented fissure (Fig. 2B) was visualized. The right upper lobe and its bronchus and the right superior pulmonary vein were not identified. The right inferior pulmonary vein (Fig. 3A) drained the entire right lung, with note of tortuous and dilated tributaries. The right pulmonary artery was small (Fig. 3B). The rest of the vasculature were unremarkable.",
    "discussion": "Lung development anomalies are usually encountered during the neonatal period and early childhood.[6][15] However, some of these may produce symptoms during late adolescence or even be discovered incidentally during adulthood. Tracheobronchial development normally occurs at about the 24-36 days of intrauterine life. By the 36th day, all segmental bronchi have been formed, and fusion of the lung bud plexus with the sixth branchial arches have occurred, giving rise to definite pulmonary arteries and establishing vascular supply.[1, 6, 7, 14]\nFraser, et al. [5] classified arrested lung development into three types: (1) agenesis, complete absence of one or both lungs; (2) aplasia, suppression of all lung parenchyma and pulmonary vasculature, but rudimentary bronchus that ends in a blind pouch remains; and, (3) hypoplasia, unremarkable gross lung morphology, but with decreased number or size of airways, vessels, and alveoli. These types represent the rare agenesis-hypoplasia complexes of lung developmental failure.[3]\nPulmonary hypoplasia is sometimes accompanied by other congenital anomalies, which may be important in the pathogenesis of the disease.[1, 11, 12] If only involving one lobe, there are usually accompanying anomalies of the ipsilateral pulmonary artery and anomalous pulmonary venous.[5][9][10] However, other pieces of literature [2, 3, 4] may overlap the definition of pulmonary hypoplasia with that of isolated lobar agenesis based on classification of Spencer. Collectively, the incidence for all pulmonary hypoplasia is 1: 12,000-15,000.[3][8][13] Isolated cases of unilobar pulmonary hypoplasia are uncommonly reported. Various mechanisms are implicated in the formation of the pathology, including decreased pulmonary perfusion, decreased fetal respiratory movement and decreased lung fluid.[8] Radiographic findings depend on the type and degree of the disease. Chest x-rays usually show reduced volume, elevation of the hemidiaphragm, ipsilateral shift of the mediastinum and compensatory hyperaeration of the contralateral lung. [5][8] When a chest x-ray is not diagnostic, the use of a chest CT-scan may be the most conclusive examination to diagnose congenital lung anomalies and associated vascular abnormalities. [3][10] In all five cases of arrested lung development studied by Mata, et al. [9] where one patient had aplasia while the other four had hypoplasia, CT scan showed shift in the mediastinal structures and herniation of the contralateral lung. Contrast-enhanced chest CT scan was helpful in delineating the abnormalities of the bronchi and associated arterial and venous structures, showing decreased calibre of the affected bronchi and involved vessels. Treatment modalities would depend on the type of lung abnormality present, and usually,\u00a0no intervention is needed for asymptomatic cases.",
    "differential_diagnosis": "Pulmonary, hypoplasia,, right, upper, lobe, Swyer-James, syndrome, Mild, lung, atelectasis, Scimitar, syndrome, Poland, syndrome",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-07//17823_1_1.jpg?itok=dBUQe3Wn",
            "caption": "Chest radiograph showing right lung volume loss evidenced by slight shifting of the mediastinal structure to the right. Note the \u201ckinked\u201d vessel in the right cardiophrenic region"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-07//17823_2_1.jpg?itok=Yx3t2H9b",
            "caption": "Contrast-enhanced chest CT-Scan (axial view) at the normal bifurcation of the intermediate bronchus into the lower and middle lobe bronchi"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-07//17823_2_2.jpg?itok=cSmjf8TN",
            "caption": "Sagittal view showing a single obliquely oriented fissure on the right lung"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-07//17823_3_1.jpg?itok=3Wmq29L2",
            "caption": "Contrast enhanced CT-Scan (coronal view) showing a single right pulmonary vein (inferior) draining the right lung and enters into the left atrium. The right superior pulmonary vein is not visualized"
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-07//17823_3_2.jpg?itok=_R1nEczw",
            "caption": "Contrast-enhanced chest CT-Scan (axial view) at the level of the pulmonary artery bifurcation showing the small right pulmonary artery as compared to the normal sized left pulmonary artery"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/17823",
    "time": "25.07.2022"
  },
  "17830": {
    "case_id": 17830,
    "title": "Widened mediastinum in chest x-ray: Think about anatomic variants; azygous continuation of inferior vena cava.",
    "section": "Chest imaging",
    "age": "45",
    "gender": "female",
    "diagnosis": "Azygous continuation of inferior vena cava syndrome",
    "history": "A 45-years old woman presented to the radiological laboratory for routine examination in the context of pre-insurance control. Her personal medical history was unremarkable.",
    "image_finding": "The chest x-ray showed widened mid-mediastinum at the level of the aortic arch, without any other pathologic findings from the pulmonary parenchyma. To find the cause of the mediastinal enlargement, a chest/abdomen CT scan was performed, which showed a dilatated azygous vein. There was absence of any mass or any mediastinal lymph node enlargement. Intra-abdominally, there was aplasia of the intrahepatic part of the inferior vena cava, with continuation of the latter to the azygous and hepatic vein flow straight into the right atrium. This is a rare case that concerns anatomical variants of the inferior vena cava.",
    "discussion": "Background: The inferior vena cava and its branches develop between the 6th and the 8th week of pregnancy [1]. At this period, three pairs of venous stems develop, reverse and anastomose: posterior major, sub-major and epi-major veins [3].\n\u00a0Classification of anatomical variants of the inferior vena cava: \n\u0391. Anatomical variants of venous outflow. \n1. Outflow to the left atrium. 2. Outflow of the pulmonary veins to the inferior vena cava a) completely abnormal communication of the pulmonary veins b) partially abnormal communication of the pulmonary veins 3. Congenital extrahepatic portosystemic shunt-CEPS or Abernethy anomaly\n\u00a0B. Development problems 1. Interruption of the inferior vena cava (it continues as azygous vein) 2. Absence of the subrenal part of the inferior vena cava. \nC. Persistence of embryonic venous stems: 1. Duplication of the inferior vena cava 2. Periaortic left renal vein. \nD. Combination of causes: 1. Left inferior vena cava 2. Posterior atrial ureter 3. Posterior aortic left renal vein 4. Pre-aortic convergence of the iliac veins or marsupial inferior vena cava. \nAzygous continuation of inferior vena cava syndrome\nThis congenital problem, which is related to the current case, is caused by non-development of part of the inferior vena cava or by the lack of union between the hepatic and the pre- renal part of the inferior vena cava [8]. The upper extension of the right sub-major vein anastomoses with the common hepatic vein that is the caudal part of the hepatocardiac vein- the latter in turn develops from the right umbilical-mesenteric or vitelline vein [4]. When this anastomosis is not created, the hepatic veins and the right sub-major vein do not unite. The latter reverses [8]. Consequently, the hepatic veins do not outflow to the inferior vena cava, but directly to the right atrium [7]. Finally, the sub-renal part of the inferior vena cava can continue as azygous and outflow to the right upper vena cava or as hemi-azygous to the left upper vena cava-if the latter exists.\nClinical perspective\nThe incidence of this anomaly is 0.3% in the healthy population [4] and 0.6-2% in patients with cardiovascular anomalies [5,6]. It is usually asymptomatic and a random finding during imaging tests. In some cases, heterotaxia, polysplenia, deficits of the interatrial and interventricular septum, abnormal communication of the pulmonary veins and pulmonary atresia coexist [5,6]. The clinical value of the timely ascertainment of this anatomical variant is great prior to interventions such as the catheterization of the right heart, the promotion of a venous catheter or temporary pacemaker from the femoral vein, and the placement of an inferior vena cava filter and prior to heart surgery. Specifically, its ligation via abdominal and thoraco-abdominal surgery can prove fatal because the azygous vein is the only route of venous drainage under the diaphragm [8].\n\u00a0Imaging perspective\nAlthough chest x-ray is usually the initial method to recognize the existence of this anatomic variant incidentally, chest CT scan is the appropriate diagnostic modality. Imaging features of azygous continuation of inferior vena cava in chest x-ray, imitate other pathological situations as adenopathy, malignancy or aortic pathology.\nOutcome\nMost individuals are asymptomatic, and there is no clinical impact of this anatomic variant. \nTake-home message\nWidened mediastinum can be related to \u201cnormal\u201d situations such as vascular anatomic variants. Radiologists should be familiar with azygous continuation of inferior vena cava, recommending a chest Computed Tomography scan to diagnose the situation.\nPatient written informed consent for publication has been obtained.",
    "differential_diagnosis": "Azygous, continuation, of, inferior, vena, cava, syndrome, Right, paratracheal, mass., Dissociating, thoracic, aortic, aneurysm., Adenopathy.",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-07//17830_1_1.jpg?itok=tAwPAXZh",
            "caption": "The initial chest x-ray. Right-sided widened mediastinum"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-07//17830_2_1.jpg?itok=tN2LpBzL",
            "caption": "CT scan cross section at the level of aortic arch shows dilatation of azygous vein"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-07//17830_3_1.jpg?itok=HQqm8cIg",
            "caption": "CT scan cross section at the level of hepatic veins, shows absence of the intrahepatic part of inferior vena cava"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-07//17830_4_1.jpg?itok=xtIiXmqb",
            "caption": "Coronal anasynthesis of the chest CT scan  (mediastinal window) shows the right- widened mediastinum at the level of aortic arch (blue arrow)"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Abdomen",
      "Breast",
      "Head and neck"
    ],
    "imaging_technique": [
      "CAD",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/17830",
    "time": "26.07.2022"
  },
  "17847": {
    "case_id": 17847,
    "title": "Kartagener Syndrome",
    "section": "Chest imaging",
    "age": "25",
    "gender": "female",
    "diagnosis": "Kartagener Syndrome",
    "history": "The patient presented with complains of chronic cough with mucoid expectorations since 10 years. Patient has recurrent episodes of rhinitis since childhood. Patient is married and unable to concieve for more than 1 year.",
    "image_finding": "Bronchiectatic changes in form of cystic and varicoid bronchiectasis with bronchial wall thickening are noted in left middle lobe and right lower lobe with internal air-fluid level in few of them. Multiple centrilobular nodules in tree in bud pattern of distribution with surrounding ground glass opacity are noted involving bilateral lower lobes. Dextrocardia, a left-sided liver, right-sided stomach and spleen, and the left lung having three lobes as identified by a left-sided horizontal fissure.",
    "discussion": "Sinusitis, situs inversus, and bronchiectasis make up the characteristic trio of Kartagener's syndrome, an extremely rare hereditary condition. [1]. This syndrome is a subset of primary ciliary dyskinesia, an autosomal recessive disorder with defective ciliary structure or function that impairs mucociliary clearanceRecurrent bronchitis, pneumonia, and sinusitis are the three most typical clinical symptoms. Infertility in men and decreased fertility in women may accompany it. Recurrent infections and airway inflammation are the main causes of bronchiectasis. The primary method used to illustrate and evaluate the severity of bronchiectasis is often an HRCT of the lung\u00a0[2]. Bronchiectasis are classified into three morphologic types depending on the severity of bronchial dilatation (cylindrical, varicose and cystic) and wall abnormalities [2]. A mucosal biopsy is used to confirm the diagnosis and check for ciliary activity. Screening tests include the saccharin test and the measurement of nasal and exhaled nitric oxide [3]. Treatment of this rare congenital disorder includes antibiotics, intravenous or oral, intermittent or continuous, and are used to treat upper and lower airway infections. Bronchiectasis should be treated with inhaled bronchodilators, mucolytics, and chest physiotherapy. Influenza and pneumococcal vaccination should be encouraged to prevent complications [1].",
    "differential_diagnosis": "Kartagener, Syndrome, Primary, ciliary, dyskinesia, Young, syndrome, Cystic, fibrosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-08//17847_1_1.jpg?itok=PgipOKQK",
            "caption": "On HRCT thorax Axial section, bronchiectatic changes in form of  cystic and varicoid bronchiectasis with bronchial wall thickening are noted"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-08//17847_2_1.jpg?itok=JbcGSasT",
            "caption": "On HRCT thorax Axial section, multiple centrilobular nodules in tree in bud pattern of distribution with surrounding ground glass opacity are noted involving bilateral lower lobes"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-08//17847_3_1.jpg?itok=w3qKIdFy",
            "caption": "On HRCT thorax Coronal section, dextrocardia, a left-sided liver, right sided stomach and spleen"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-08//17847_4_1.jpg?itok=4y0fjl0Z",
            "caption": "On HRCT thorax Coronal section, left lung having 3 lobes"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Cardiac",
      "Lung"
    ],
    "imaging_technique": [
      "CT-High Resolution"
    ],
    "link": "https://www.eurorad.org/case/17847",
    "time": "17.08.2022"
  },
  "17862": {
    "case_id": 17862,
    "title": "Lymphocytic interstitial pneumoni",
    "section": "Chest imaging",
    "age": "35",
    "gender": "female",
    "diagnosis": "Lymphocytic interstitial pneumonia",
    "history": "A 35-year-old woman accessed our Emergency-Department complaining of a two-week history of oedema, associated with pain and muscular weakness in both arms.",
    "image_finding": "A non-contrast high-resolution chest CT study demonstrated multiple thin-walled cysts diffusely involving both lungs. Cysts were mostly distributed peripherally with lower lobe predominance; the largest one reached a diameter of 23 mm (Fig. 1). Besides, interstitial reticular thickening, patchy ground glass opacities and minimum bilateral pleural effusion were found (Fig. 2). \n\u00a0\nMultiple lymphadenopathies were identified at mediastinum, armpits, supraclavicular and infraclavicular levels. Although none of them was notable size-wise (the biggest one had 14 mm diameter on the shorter axis), the number of lymphadenopathies was remarkable.\n\u00a0\nAfter clinical exams, the patient was diagnosed of systemic lupus erythematosus (SLE) and provided with corticosteroid treatment. Two months later, another non-contrast thoracic CT was performed with resolution of the lymphadenopathies, the interstitium thickening and the pleural effusion. The cystic component remained stable (Fig. 3 and Fig. 4).",
    "discussion": "Background\nBronchus-associated lymphoid tissue (BALT) is a lymphoid component of bronchus walls. BALT develops in childhood to finally involute and disappear in adulthood. This tissue may reappear because of antigenic stimulation caused by infection, chronic inflammation, etc. Lymphocytic interstitial pneumonia (LIP) is a polyclonal lymphoproliferative disorder related to the reappearance of BALT [1, 2]. Swigris et al have postulated that most of LIP cases are associated with autoimmune diseases such as Sj\u00f6gren syndrome and SLE, among others [1].\nClinical perspective\nLIP arises most commonly in women between the fourth and seventh decades. Some of the symptoms are cough, dyspnea, weight loss and night sweats. Pulmonary function studies usually show restrictive ventilatory defect with a decreased carbon monoxide diffusing capacity and hypoxemia [1, 2, 3] .\nImaging perspective\nImaging findings are nonspecific, usually predominant in the lower lobes [2, 3]. CT shows ground-glass opacities, centrilobular nodules, pulmonary cysts and bronchovascular and peribronchovascular bundle thickening. Pulmonary cysts are typically found in the depth of lung parenchyma with perivascular or peripheral location and variable size (1 - 30 mm) [4, 5, 6]. Pleural effusion, growing nodules, large nodules and airspace consolidation are uncommon and its presence suggests an underlying malignant process [5]. Final diagnosis is histological: infiltration of lymphocytes and plasma cells in the interstitium [1, 2].\nWhen lung cysts are the only abnormality, differentiation should be made with Pulmonary Langerhans cell histiocytosis (upper lobe predominance and sparing of the costofrenic recesses), Lymphangioleiomyomatosis (diffusely distributed in lung parenchyma) and pneumocystis pneumonia (randomly distributed, history of HIV usually associated) [6].\nOutcome\nThe most useful therapeutic options are corticosteroids and treatment of the underlying aetiology with different outcomes (at least one-third of the cases progress with fibrosis despite treatment) [3]. \nWhile approximately 5% of patients with LIP develop slow-growing mucosa-associated lymphoid tissue lymphoma (MALT). The risk is increased in patients with Sj\u00f6gren's syndrome. It is unclear whether LIP undergoes malignant transformation or whether the lymphoma develops as a comorbid process [2].\nClose monitoring is recommended with imaging (chest X-ray) and pulmonary function studies, although there is no evidence of the optimal interval and duration of follow-up [7].\nTake-Home Message / Teaching points\nLIP is included in the spectrum of cystic lung diseases. Key findings: association with autoimmune diseases (as in our case with SLE), thin-walled cysts with a lower lobe distribution, lymphadenopathies, interstitium thickening, ground-glass opacities, centrilobular nodules and clinical and radiological improvement with corticosteroid therapy.",
    "differential_diagnosis": "Lymphocytic, interstitial, pneumonia, Lymphangioleiomyomatosis, Birt-Hogg-Dub\u00e9, syndrome, Pneumocystis, pneumonia, Langerhans, cell, histiocytosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-08//17862_1_1.jpeg?itok=IUHjciVU",
            "caption": "Axial CT shows several cystic lung bilateral lesions. Associated tenuous ground glass opacities converging at lower segments of both lungs are also seen."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-08//17862_2_1.jpeg?itok=obMbuknj",
            "caption": "Coronal CT shows cystic lung lesions with a peripheral location at the bottom lobes, interstitium enlarge-ment and minimum bilateral pleural effusion."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-08//17862_3_1.jpeg?itok=Mh-roWq_",
            "caption": "Axial CT performed after corticosteroid treatment shows persistence of the cystic lesions and resolution of the opacities previously seen."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-08//17862_4_1.jpeg?itok=o7UK2V6F",
            "caption": "Coronal CT performed after corticosteroid treatment shows persistence of the cystic lesions and resolution of the interstitium enlargement and pleural effusion."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Respiratory system",
      "Thorax"
    ],
    "imaging_technique": [
      "CT-High Resolution"
    ],
    "link": "https://www.eurorad.org/case/17862",
    "time": "30.08.2022"
  },
  "17863": {
    "case_id": 17863,
    "title": "Pulmonary interstitial emphysema after lung transplantation: an early sign of chronic lung allograft rejection.",
    "section": "Chest imaging",
    "age": "25",
    "gender": "male",
    "diagnosis": "Pulmonary interstitial emphysema signifying chronic lung allograft rejection.",
    "history": "We present a case of a 25-year-old male who was hospitalized due to respiratory deterioration several years after bilateral lung transplantation. He had a history of neonatal bronchiolitis obliterans and recurrent infections, leading to severe bronchiectasis and organizing pneumonia, warranting lung transplantation.",
    "image_finding": "Computed tomography (CT) of the chest showed extensive multifocal linear and cystic air spaces distributed in the subpleural, perifissural, septal and peribronchovascular spaces, with ground glass attenuation of the background parenchyma (Fig. 1). These findings were markedly progressive compared to the CT scans performed two and three years prior (Fig. 2, 3). Consecutive CT performed three months after hospital admission showed the formation of large cysts/bullae in the subpleural and perifissural spaces along with extensive parenchymal destruction, volume loss and fibrosis (Fig. 4).",
    "discussion": "Pulmonary interstitial emphysema (PIE) is a rare condition defined by air dissecting within the interstitial tissues of the lung. This creates cystic air spaces histologically characterized by a surrounding inflammatory and fibrotic reaction [1]. \nThe Macklin effect describes air from these ruptured alveoli spreading along the bronchovascular bundles to the pulmonary hilum and subpleural space, causing pneumomediastinum and pneumothorax respectively [2\u20136].\u00a0 \nPIE is a well-known condition in the pre-term neonate, most often occurring in cases of surfactant deficiency and mechanical ventilation [7, 8]. In this discussion we focus on PIE in adults, often occurring as an acute sequela of barotrauma. It has also been documented in various interstitial lung diseases (ILD), severe asthma, drug inhalation, chronic graft-versus-host disease, and post-lung transplantation. The spectrum of associated ILDs is broad, ranging from idiopathic pulmonary fibrosis to hypersensitivity pneumonitis and connective tissue disease-associated ILDs [5, 6, 9\u201322].\u00a0 \nPIE seen in the first thirty days after lung transplantation is a sign of dehiscence of the bronchial anastomosis [23, 24]. Slowly progressive, refractory PIE reflects underlying structural parenchymal damage due to chronic rejection and remodeling of the transplanted lung, causing destruction of the secondary pulmonary lobule. PIE may be seen before the diagnosis of CLAD (chronic lung allograft dysfunction) can be made clinically, and before other radiological signs of BOS (bronchiolitis obliterans syndrome) and RAS (restrictive allograft syndrome) may be present [25, 26]. \nPIE can be seen on plain radiograph as linear or cystic radiolucencies converging towards the hilum. However, it is best characterized on CT, appearing as elongated pockets of air in the subpleural, septal and peribronchovascular spaces. PIE is accentuated on expiratory scans, due to the increased contrast to the adjacent parenchyma [27, 28]. PIE may appear as sharply and regularly delineated streaks, or as more irregular and branching emphysema in the pulmonary interstitium. PIE can mimic classic centrilobular and paraseptal emphysema; the distribution along the bronchovascular bundles can help differentiate these entities [6, 28]. \nPrognosis of PIE is variable, depending on etiology, comorbidities, and treatment [18]. Management is often centered around the causative pathology. In cases of barotrauma, supplemental oxygen can be administered to reduce hypoxia and increase the reabsorption rate of the air. Pneumomediastinum and pneumothorax may resolve without treatment, or require chest tube thoracostomy [29]. \nIn conclusion, the detection of slow onset, progressive and refractory PIE after lung transplantation is an important clue to the early diagnosis of CLAD.",
    "differential_diagnosis": "Pulmonary, interstitial, emphysema, signifying, chronic, lung, allograft, rejection., Pulmonary, interstitial, emphysema, in, thoracic, air, leak, syndrome., Cystic, lung, diseases, Centrilobular/paraseptal, emphysema",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-08//17863_1_1.jpg?itok=HnaAuQp2",
            "caption": "There is extensive pulmonary interstitial emphysema (PIE) in the perifissural and subpleural spaces (black arrows) and in the peribronchial and perivascular spaces (white arrows). There is ground glass attenuation of the background parenchyma due to mixed type CLAD."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-08//17863_2_1.jpg?itok=kuF3cBMj",
            "caption": "Findings are similar but less pronounced compared to figure 1. PIE can be clearly seen along the lung fissures (black arrows) and in the peribronchiolar and perivascular spaces (white arrows). The ground glass attenuation of the lung parenchyma is more subtle."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-08//17863_3_1.jpg?itok=11X-rUxZ",
            "caption": "Discrete PIE is seen along the lung fissures (black arrows), along the pulmonary vessels and interspersed throughout the normal parenchyma (white arrows). Windowing is slightly adjusted to enhance contrast and better depict the subtle findings."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-08//17863_4_1.jpg?itok=UnSljaRt",
            "caption": "There is progressive PIE with formation of extensive subpleural and perifissural cysts/bullae (black arrows). Furthermore, there is marked architectural destruction of lung parenchyma with volume loss and fibrosis (white arrows). There is ground glass attenuation of the background parenchyma due to mixed type CLAD."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Respiratory system",
      "Thorax"
    ],
    "imaging_technique": [
      "CT",
      "CT-High Resolution"
    ],
    "link": "https://www.eurorad.org/case/17863",
    "time": "30.08.2022"
  },
  "17889": {
    "case_id": 17889,
    "title": "Multiple cavitated pulmonary nodules",
    "section": "Chest imaging",
    "age": "48",
    "gender": "male",
    "diagnosis": "Granulomatosis with polyangiitis",
    "history": "48 years old male with hemoptysis and cavitated nodules in a chest x-ray. No other relevant medical history was provided.",
    "image_finding": "The chest x-ray image was reported as multiple bilateral nodules and masses in variable sizes, some of them cavitated and one of them with an apparent air-liquid level in the left paracardiac location [Fig. 1].\nA contrast-enhanced CT scan\u00a0of the thorax and mid-upper abdomen in the arterial phase at 35 seconds was performed. It showed masses and nodules in both lungs [Fig. 2 and 3], most of them cavitated, the biggest ones located in the right upper lobe (46 mm) and left lower lobe (55 mm) [Fig. 4 and 5]. Margins were thick and irregular with no air-liquid interface. Peribronchovascular distribution was more common but some had a subpleural distribution [Fig. 3 and 4]. Mediastinal lymphadenopathy was also present. No pleural effusion or other opacities were found.\nThe findings were consistent with granulomatosis with polyangiitis (GPA).",
    "discussion": "Granulomatosis with polyangiitis (GPA), previously known as Wegener granulomatosis, is a multisystem necrotizing non-caseating granulomatous c-ANCA positive vasculitis affecting small to medium-sized arteries, capillaries, and veins, with a predilection for the respiratory system and kidneys, and also with CNS, upper respiratory tract and orbital manifestations. \nThe damage is caused by an immune-mediated vascular injury which creates necrotizing granulomas with associated vasculitis. In about 90% of cases cANCA (PR3) is positive [1]. \nClinical presentation is varied and it depends on which organ systems are involved with lung manifestations being present in about 95% of cases. The variety of symptoms goes from cough and hemoptysis,\u00a0subacute to chronic history of nasal obstruction, rhinitis, and epistaxis to proteinuria and hematuria. Symptoms related to other organ systems are less frequent due to a corresponding infrequency of involvement (musculoskeletal symptoms, ocular symptoms, skin changes). Systemic symptoms such as anorexia, malaise and fever are also common. [2] \nThe main renal manifestation is reduced renal function, hematuria and proteinuria, but it is not shown on imaging. On the contrary, the CNS can present with small vessel vasculitis, hypertrophic pachymeningitis or intracranial haemorrhage; the orbital manifestation can range from diffuse inflammatory infiltrate in the orbital contour or proptosis, usually hypointense on T2-weighted MRI images. \nThe upper respiratory tract can be involved with many different conditions: sinusitis/mastoiditis/otitis, sclerosing osteitis of the nasal cavity, sinonasal mucosal ulcers, lacrimal gland involvement, nasal bone deformities or subglottic stenosis, to name a few. On non-contrast, CT will present as sinonasal thickening with or without air-fluid levels or soft tissue nodules, boy or cartilaginous erosions, etc., and on post-contrast CT as enhancing soft tissue nodules. On MRI T1 signal can vary from low to intermediate intensity nodules, T1 with gadolinium will enhance affected tissues, and T2 will show low signal nodules relative to edematous surrounding mucosa.\nThe presence of cavitated nodules in a plain thoracic film is always a challenging finding for a clinician as it presents him with a myriad of possible diagnoses. The characteristics of those nodules as well as other findings in a CT scan\u00a0provide valuable information which can guide further clinical and laboratory investigations. \nNodules or masses with variable size, cavitated, with irregular and thick margins and with a peribronchovascular or subpleural distribution are characteristic. The presence of ground glass opacities which suggest haemorrhages,\u00a0can also be the dominant CT presentation [3].\nUnfortunately, the radiographic appearances of GPA are widely variable, making a diagnosis by imaging alone often difficult. Four patterns are recognized, although the first two are the most common [4]: nodules with or without cavitation, pulmonary haemorrhage, reticulonodular pattern and peripheral wedge-like consolidation.\nThe final diagnosis is made based on the 1990 American College of Rheumatology criteria where two of the four listed are necessary to make the diagnosis: positive biopsy for\u00a0granulomatous vasculitis, urinary sediment with red blood cells, abnormal chest radiograph and oral or nasal inflammation [5].",
    "differential_diagnosis": "Granulomatosis, with, polyangiitis, Cavitating, malignancy, (squamous, cell, carcinoma,, metastases,...), Infection, (pulmonary, tuberculosis,, cavitating, pneumonia,, septic, pulmonary, emboli,...), Non-infective, granuloma, (granulomatosis, with, polyangiitis,, rheumatoid, nodules,...), Pulmonary, infarction",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-10//17889_1_1.PNG?itok=wn_4--8j",
            "caption": "Chest-XR. Multiple bilateral nodules and masses."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-10//17889_2_1.PNG?itok=swfE3kXw",
            "caption": "Axial Thoracic CT-Scan at the level of the carina. Cavitated nodules with thick walls."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-10//17889_3_1.PNG?itok=-ucwSPDr",
            "caption": "Axial Thoracic CT-Scan. Cavitated nodules with thick walls in a subpleural distribution in the RLL."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-10//17889_4_1.PNG?itok=gqbMBYj0",
            "caption": "Coronal Thoracic CT-Scan. Cavitated nodules with thick walls showing peribronchovascular distribution."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-10//17889_5_1.PNG?itok=6Z8yecCV",
            "caption": "Sagittal Thoracic CT-Scan. Cavitated nodules with thick walls showing peribronchovascular and subpleural distribution."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/17889",
    "time": "14.10.2022"
  },
  "17903": {
    "case_id": 17903,
    "title": "Bronchial carcinoid in a young woman",
    "section": "Chest imaging",
    "age": "29",
    "gender": "female",
    "diagnosis": "Typical bronchial carcinoid",
    "history": "A 29-year-old woman presented to the emergency department with fever, cough, hemoptysis, and dyspnea for 2 weeks. She denied chest pain or weight loss and had no history of smoking.\nOn examination, crackles and wheezes were appreciated at the left lung base during pulmonary auscultation.",
    "image_finding": "The patient underwent posteroanterior and lateral chest radiographs (Figs. 1a and Fig. 1b), which revealed a single round opacity with sharp margins projected to the left perihilar region. A left lower lobe consolidation with ill-defined margins was also noted. \nTo further characterize these findings, a contrast-enhanced multidetector computed tomography (MDCT) was performed (Figs. 2a, Fig. 2b, Fig. 2c, Fig. 2d). MDCT showed a single well-defined, rounded, 6x5x4 cm left perihilar mass with eccentric calcifications and homogeneous contrast enhancement. The coronal multiplanar reformatted CT image (Fig. 2c) demonstrated a small endobronchial component (\u201ciceberg\u201d lesion) and a dominant extraluminal component. At the basal segments of the left lower lobe, mucoid impaction and centrilobular micronodules were present (Fig. 2d). \nThe 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) (Fig. 3) showed a mass with increased activity.",
    "discussion": "The endobronchial biopsy revealed a typical carcinoid tumour.\nWell-differentiated lung neuroendocrine (bronchial carcinoid) tumours are an uncommon group of malignant pulmonary neoplasm, accounting for less than 2% of all lung cancers [1]. \nBased on histologic differentiation, the World Health Organization (WHO) classified bronchial carcinoid tumours into typical (<2 mitosis/2 mm2 and no necrosis) and atypical carcinoids (2-10 mitosis/2 mm2 or necrosis) that represent low-grade and intermediate-grade malignancies, respectively [2].\nOverall, patients with bronchial carcinoids are younger than those with common primary pulmonary neoplasms such as bronchogenic carcinoma [3]. The majority of carcinoid tumours are centrally located (being typical carcinoids more frequent than atypical carcinoids) and tend to manifest earlier with symptoms consistent with bronchial obstruction, such as cough, wheezing, and recurrent pneumonia or hemoptysis due to the vascular nature of the tumour. Patients with peripherally located carcinoids (almost always atypical carcinoids) can be asymptomatic and thus be found incidentally or in a later stage of the disease [4].\nThese tumours tend to be highly vascular and demonstrate high enhancement and, in approximately 30% of cases, eccentric calcifications are present [5].\nLung carcinoids produce lesser quantities of serotonin than midgut carcinoids, so carcinoid syndrome is not frequent (2-5% of cases), and when present is typically due to hepatic spread. Metastases to other organs occur in nearly 15% of bronchial carcinoids [3,6].\nApproximately, 80% of bronchial carcinoids were found to express somatostatin receptors. Both 68Ga- DOTATATE (somatostatin analog) and 18F-FDG are highly sensitive in detecting pulmonary carcinoids and reliable tools for identifying metastatic disease, particularly outside the lung \u00a0[7].\nRadical surgery is the only curative approach for these patients and can range from intraluminal resection by bronchoscopy to pneumonectomy, depending on the size and location. The outcome of typical carcinoid tumours, even with lymph node metastasis, is excellent with complete resection. Atypical carcinoids have a worse prognosis and a greater tendency to metastasize and recur following surgery [3].\nAlthough rare, a central tumour that causes narrowing or obstruction of a bronchus and exhibits eccentric calcifications should suggest the diagnosis of bronchial carcinoid.\nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Typical, bronchial, carcinoid, Bronchial, carcinoid, Adenoid, cystic, carcinoma, Mucoepidermoid, carcinoma, Metastases",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-10//17903_1_1.jpg?itok=OhTsRy56",
            "caption": "Posteroanterior chest radiograph shows a left perihilar, well-defined, rounded mass. At the left lower base there is an ill-defined opacity."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-10//17903_1_2.jpg?itok=LvmIL_Jb",
            "caption": "Lateral chest radiograph shows a peri-hilar rounded mass, with regular contours. There is an opacity distal to the lesion with a finger in glove morphology."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-10//17903_2_1.jpg?itok=NeNgP8lW",
            "caption": "Unenhanced axial CT image shows a left peri-hilar mass with eccentric calcifications."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-10//17903_2_2.jpg?itok=fsgMnH81",
            "caption": "Axial contrast-enhanced CT image shows a left peri-hilar mass with high enhancement."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-10//17903_2_3.jpg?itok=bfTksWqa",
            "caption": "Coronal contrast-enhanced CT image demonstrates a small endobronchial component (\u201ciceberg\u201d lesion) and a dominant extraluminal component."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-10//17903_2_4.jpg?itok=8yorwdLN",
            "caption": "Coronal CT image (lung window) evidencing mucoid impaction and centrilobular micronodules distal to the lesion."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-10//17903_3_1.jpg?itok=9zj43nSC",
            "caption": "Positron emission tomography with 18 FDG demonstrating a mass with high uptake (SUV max 12.0)."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT",
      "PET-CT"
    ],
    "link": "https://www.eurorad.org/case/17903",
    "time": "14.10.2022"
  },
  "17913": {
    "case_id": 17913,
    "title": "Pulmonary vein occlusion following ablation of atrial fibrillation: A rare but dangerous complication",
    "section": "Chest imaging",
    "age": "60",
    "gender": "male",
    "diagnosis": "Pulmonary vein occlusion following ablation of atrial fibrillation",
    "history": "A 60-year-old male presents to the emergency department with dyspnea, chest pain and hemoptysis lasting for 2 months.\nRelevant medical history included atrial fibrillation, for which he had been submitted to two ablation procedures, the most recent one around 6 months ago.\u00a0Physical examination and laboratory findings were unremarkable.",
    "image_finding": "A Chest CT Angiography (CTA) was performed and revealed normal opacification of the pulmonary arteries, with no signs of pulmonary embolism. However, there was evidence of occlusion of the left inferior pulmonary vein. The lung window images showed multiple peripheral consolidations in the left inferior lobe, some of them with wedge morphology, that were interpreted as pulmonary infarcts.\nA diagnosis of pulmonary vein occlusion with associated lung infarcts as a possible complication of ablation of atrial fibrillation was made.\nA follow-up Chest CTA was performed 9 months after the initial one, that demonstrated persistence of the pulmonary vein occlusion and appearance of new areas of pulmonary infarcts.\nThe patient was then referred to Cardiothoracic Surgery consultation and is now waiting for endovascular treatment with angioplasty of the occluded pulmonary vein.",
    "discussion": "Pulmonary vein stenosis or obstruction is a rare complication that can be difficult to manage, with a considerable mortality rate. In adults, the most common causes are radiofrequency ablation complications, neoplastic infiltration, and fibrosing mediastinitis. Other potential causes include surgical complications (for example, from heart surgery or lung transplantation) and extrinsic compression by a benign inflammatory process, such as tuberculosis. [1]\nClinical manifestations are usually progressive dyspnea and hemoptysis (commonly called \u201cpseudo\u2013mitral stenosis syndrome\u201d). After a long period of time, pulmonary vein stenosis can lead to pulmonary arterial hypertension and cor pulmonale. [1]\nThis complication can occur in up to 10% of patients who undergo radiofrequency ablation for atrial fibrillation, with severe stenosis occurring in less than 1.4% of the patients. It should always be suspected whenever a patient who has been submitted to these procedures develops respiratory symptoms (dyspnea or hemoptysis), either weeks or months after the procedure. [2]\nChest CTA is essential to the diagnosis and the choice of protocol will depend on the experience of each hospital center or institution. If there is enough experience with it, a choice of an electrocardiography gated cardiac CT protocol is recommended as it will provide higher-quality images for post-reconstruction techniques and better demonstrate the pulmonary vein ostia and the presence of pulmonary vein stenosis or occlusion. [1]\nTypically, the main findings will be an absence/abrupt cut-off or narrowing of a pulmonary vein. [3,4]\nAdditionally, these patients tend to develop lung oedema and infarction of the region drained by the occluded vein, as a result of venous hypertension. This will present on CTA as ground glass opacities, consolidations, and smooth interlobular septal thickening, usually confined to the lobe/region that is drained by the affected vein. [3,4] These indirect findings tend to wax and wane in serial evaluations due to transitory changes in venous pressure. [4]\nUntreated, eventually this venous hypertension can transmit retrogradely through the pulmonary capillaries and result in post-capillary pulmonary hypertension, for which right-heart catheterization can contribute to its detection (by showing mean pulmonary artery pressure (mPAP) \u226525\u2003mm\u2003Hg, pulmonary capillary wedge pressure (PCWP) \u226515\u2003mm Hg, and transpulmonic gradient (mPAP\u2212PCWP) <10\u2003mm\u2003Hg.) [5]\nTreatment of this acquired postprocedural stenosis is usually interventional, relying on catheter-related techniques, such as balloon angioplasty. [2]\nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Pulmonary, vein, occlusion, following, ablation, of, atrial, fibrillation, Pulmonary, vein, stenosis, due, to, several, causes, (like, fibrosing, mediastinitis, or, neoplasia), Septic, embolism",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-10//17913_1_1.png?itok=8tKn4cn5",
            "caption": "Axial Chest CTA, mediastinal window, at the level of the pulmonary arteries (a) showing normal opacification (blue star), without thromboembolism; at the level of the inferior pulmonary veins (images b and c), there is no opacification of the left inferior pulmonary vein (circle), findings consistent with occlusion."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-10//17913_1_2.png?itok=SUR8gVRb",
            "caption": "Axial Chest CTA, mediastinal window, at the level of the pulmonary arteries (a) showing normal opacification (blue star), without thromboembolism; at the level of the inferior pulmonary veins (images b and c), there is no opacification of the left inferior pulmonary vein (circle), findings consistent with occlusion."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-10//17913_1_3.png?itok=tHxny0k4",
            "caption": "Axial Chest CTA, mediastinal window, at the level of the pulmonary arteries (a) showing normal opacification (blue star), without thromboembolism; at the level of the inferior pulmonary veins (images b and c), there is no opacification of the left inferior pulmonary vein (circle), findings consistent with occlusion."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-10//17913_2_1.png?itok=Xi4-aTI8",
            "caption": "Axial Chest CTA, lung window, at the level of the posterior and lateral segments of the left lower lobe, showing multiple peripheral nodules/consolidations (arrows), some of them wedge-shaped and with the halo sign (ground glass density surrounding the nodule), findings that were suggestive of pulmonary infarction."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-10//17913_2_2.png?itok=N77SCLUz",
            "caption": "Axial Chest CTA, lung window, at the level of the posterior and lateral segments of the left lower lobe, showing multiple peripheral nodules/consolidations (arrows), some of them wedge-shaped and with the halo sign (ground glass density surrounding the nodule), findings that were suggestive of pulmonary infarction."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-10//17913_3_1.png?itok=AgCzZdrp",
            "caption": "Axial Chest CTA performed around 6 months - mediastinal window (a) showing persistence of the occlusion of the left inferior pulmonary vein (circle); lung window (b) showing new pulmonary infarction on the posterior segment of the left lower lobe (arrows)"
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-10//17913_3_2.png?itok=CMpy7acR",
            "caption": "Axial Chest CTA performed around 6 months - mediastinal window (a) showing persistence of the occlusion of the left inferior pulmonary vein (circle); lung window (b) showing new pulmonary infarction on the posterior segment of the left lower lobe (arrows)"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Cardiovascular system",
      "Thorax",
      "Veins / Vena cava"
    ],
    "imaging_technique": [
      "CT-Angiography"
    ],
    "link": "https://www.eurorad.org/case/17913",
    "time": "03.11.2022"
  },
  "17922": {
    "case_id": 17922,
    "title": "The unusual journey of a young man with pulmonary NUT Carcinom",
    "section": "Chest imaging",
    "age": "29",
    "gender": "male",
    "diagnosis": "Pulmonary NUT Carcinoma",
    "history": "29-year-old male, no significant past medical history, presented acutely with palpitations and shortness of breath on exertion. Over a few weeks experienced fevers, right sided chest pain with productive cough. Smokes 15 cigarettes a day and cannabis. Normal electrocardiogram, examination but C- Reactive Protein 56 and White Blood Cells 9.5.",
    "image_finding": "Initial chest x-ray demonstrated a bulky right hilum (Figure 1). CT showed 42mm right hilar mass with pretracheal, right paratracheal and anterior to the superior vena cava (SVC) lymphadenopathy (Figure 2). Small right pleural effusion. No abdominal pathology. Within 17 days the right hilar mass demonstrates progression and there is growth of the lymphadenopathy now causing increasing compression of the SVC (Figure 3). There are also new lymphangitic changes within the right upper and middle lobes. 12 days later the positron emission tomography imaging demonstrates the confluent right lung and hilar mass to be metabolically active ( Standard Uptake Value Max 8.6 ) (Figure 4) and no further metastatic disease\u00a0 11 days later CT Thorax shows a 6mm left upper lobe nodule (Figure 5). 1 month later CT Thorax, Abdomen and Pelvis shows widespread bony lytic lesions and on MRI Head/Spine there are skull base lesions and evidence of nerve root compression (Figure 6) but no parenchymal brain metastases.",
    "discussion": "Background\nPulmonary NUT carcinoma is rare and very aggressive squamous cell carcinoma defined by a rearrangement involving the NUTM1 (nuclear protein in testis, family member 1) gene on chromosome 15, typically affecting the head and neck and the mediastinum [1]. Diagnosis can be suspected on morphological appearances and confirmed by immunohistochemistry against NUT or detection of rearrangement of specific NUT variants [5]. \nClinical perspective\nTypically healthy younger adults, mean age 25 at presentation, with no particular smoking history [4]. Our patient had a clinical history consistent with infection, but the imaging findings were in keeping with aggressive malignancy. The patient was a smoker; this could have been a likely cause for shortness of breath.\u00a0 \nImaging perspective \nCharacteristic features include a large unilateral lung mass over 5cm with confluent hilar and mediastinal lymphadenopathy. The contralateral lung is usually clear. Bones were a common site for metastatic disease and a negative bone scan may not exclude metastases. Patients don\u2019t typically develop brain metastases although they have been reported. All sites of the tumour are fluorodeoxyglucose avid and occasionally demonstrated necrosis and central photopenia [1]. Imaging is important in order to assess the extent of disease, progression of disease, response to treatment, complications e.g SVC obstruction or nerve root compression and to guide biopsy. \nOutcome \nThe pathology is typically sent to a specialist centre for histological diagnosis which can delay results and the final prognosis for the patient. Unfortunately, the treatment is very limited as patients present with advanced disease and they are limited to chemotherapy and radiotherapy with a restricted role for surgery. Immunotherapy and new drugs are undergoing trials [2]. The prognosis is poor, presenting late in younger healthy adults with a median overall survival of 6.7 months and estimated 9% two-year progression-free survival [3]. \nTake-home message \nThis is a very rare and aggressive disease in younger adults who typically do not smoke. The patient needs to have prompt imaging and biopsy to help guide management and to help counsel the patient and their family. There is a pattern of imaging features, which although not specific, the differential of a pulmonary NUT carcinoma should be raised by the Radiologist early. If a biopsy is inconclusive for the suspected diagnosis then ensure a repeat biopsy is undertaken rapidly to facilitate a diagnosis for the patient; sadly, our patient died 84 days after the first biopsy.",
    "differential_diagnosis": "Pulmonary, NUT, Carcinoma, Lymphoma, Tuberculosis, Thymic, tumour, Metastases, of, a, testicular, cancer",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-11//17922_1_1.PNG?itok=7Nl9xjno",
            "caption": "Chest x-ray demonstrates bulky right hilum [thick arrow]. The lungs are clear"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-11//17922_2_1.PNG?itok=AqTJC081",
            "caption": "Axial post contrast CT Thorax imaging shows 42mm right hilar mass and extensive mediastinal lymphadenopathy [thick arrow]. Same day as initial chest x-ray"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-11//17922_3_1.PNG?itok=YhEGZ-pM",
            "caption": "Axial post contrast CT Thorax imaging shows lymphadenopathy causing compression of the superior vena cava [long arrow] with moderate right pleural effusion [short arrow]. 17 days post initial chest x-ray"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-11//17922_4_1.PNG?itok=od0GoWSc",
            "caption": "Avid uptake in the right hilar mass [thick arrow] on coronal FDG-PET imaging. 29 days after initial chest x-ray"
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-11//17922_5_1.png?itok=FJH3p0_M",
            "caption": "Axial post contrast CT Thorax imaging shows 6mm left upper lobe nodule [short arrow]. As already mentioned for the previous CT examination, there are lymphangitic changes of the right middle lobe as well [long arrow].  40 days after initial chest x-ray"
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-11//17922_6_1.PNG?itok=dtuJRs-w",
            "caption": "Left S1 nerve root compression by soft tissue [thick arrow] on axial MRI Spine T2 sequence. 70 days after initial chest x-ray"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Mediastinum",
      "Oncology"
    ],
    "imaging_technique": [
      "CT",
      "MR",
      "PET"
    ],
    "link": "https://www.eurorad.org/case/17922",
    "time": "28.11.2022"
  },
  "17925": {
    "case_id": 17925,
    "title": "Why a pneumomediastinum?",
    "section": "Chest imaging",
    "age": "18",
    "gender": "female",
    "diagnosis": "Traumatic left bronchial rupture",
    "history": "An 18-year-old female was admitted to our emergency department due to a car accident. The patient was referred to be hurled toward the car glass. The patient was transferred from the territory to our hospital after placing an endotracheal tube. All life parameters were good during the transport.",
    "image_finding": "The patient underwent whole-body contrast-enhanced computed tomography (CECT) to assess traumatic injuries. \nCECT showed diffuse and bilateral lung consolidations, partially with areas of ground-glass opacification, compatible with contusive lesions. Moreover, different thin-walled cystic spaces were found in the lung parenchyma, in line with pneumatoceles (Figure 1, 2 and 3). Finally, a large amount of air in the mediastinum was found, in particular in the anterior and posterior spaces, with the extension to cervical spaces and diaphragm\u2019s contours (Figure 2 and 3). The multiplanar reconstructions showed a lesion located at the origin of the bronchus for the left upper lobe (Figure 4). No rib fractures, pleural or pericardial effusion were found.",
    "discussion": "Bronchial rupture is a rare complication of blunt chest trauma. The diagnosis is typically delayed, sometimes because clinicians' attention is focused on more important life-threatening conditions [1]. \nDifferent pathological mechanisms have been purposed, including an explosive rupture [when the chest is crushed], the development of shearing forces at fixed points of the airways [during sudden deceleration], and chest compression along its anterior-posterior axis [2]. \nConsidering the location of the reported lesion and the trauma dynamics, it seems that the compression along the chest axis can be the most suitable for this patient. \nApproximately 75% of the injuries occur within 2\u00a0cm from the carina, and the right main bronchus is more commonly injured than the trachea or left main bronchus [3]. Reported findings in the literature, considering their rarity, are not in line with the presented case, with a lesion of the left bronchus. \nAs for all trauma patients, the first imaging technique is the chest radiograph, not executed in our patients due to the clinical conditions. \nOn the other hand, chest CT is the standard of reference imaging modality for the evaluation of tracheobronchial injuries. It can not only confirm the diagnosis but also add important information on the whole thorax. However, it has some limitations in detecting minor tears. The CT is a useful noninvasive technique for the evaluation of the tracheobronchial tree, especially in polytraumatic patients who typically undergo whole-body CECT for the detection of possible traumatic lesions. In this setting, the bronchoscopy is the best diagnostic tool for determining the location and extent of airway injuries [4-6], and should always be performed when the diagnosis is suspected. Our patient underwent bronchoscopy, confirming the abovementioned findings, and finally a surgically repair. \nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Traumatic, left, bronchial, rupture, Barotrauma, due, to, mechanical, ventilation, Esophageal, perforation, Asthma, Pulmonary, interstitial, emphysema",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-11//17925_1_1.jpeg?itok=dsgJ5x-2",
            "caption": "Axial CT image of the lungs, showing diffuse and bilateral consolidations, here more evident on the left side, associated with gas-filled cystic lesions (green arrows), referred to as pneumatocele. Moreover, it's possible to appreciate the pneumomediastinum in the anterior and posterior spaces (red arrows)"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-11//17925_2_1.jpeg?itok=2VqhNPd1",
            "caption": "Axial CT image of the lungs, showing diffuse and bilateral consolidations, here more evident on the left lower lobe, associated with some pneumatocele (green arrows). In this plane, the pneumomediastinum is more evident (red arrows)"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-11//17925_3_1.jpeg?itok=z7qXaZwr",
            "caption": "CT image reconstructed in the coronal plane of the lungs, the pneumatocele (green arrows), surrounded by the consolidation of lung parenchyma. It\u2019s possible to appreciate the pneumomediastinum extended in the cervical spaces (red arrows)"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-11//17925_4_1.jpeg?itok=dxjcsHZu",
            "caption": "Axial CT image of the lungs showing the traumatic left bronchial rupture, located at the origin of the main bronchus (red arrow). The green arrow clearly underlines the communication between the main bronchus and the extra-pleural spaces"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Mediastinum",
      "Trauma"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/17925",
    "time": "28.11.2022"
  },
  "17947": {
    "case_id": 17947,
    "title": "ndobronchial valve placement in patient with a broncho-pleuro-cutaneous fistul",
    "section": "Chest imaging",
    "age": "62",
    "gender": "female",
    "diagnosis": "Bronchopleural cutaneous fistula",
    "history": "A 62-year-old woman with non-small cell lung cancer in her right lung post-radiation and chemotherapy presented to the emergency department after a fall resulting in dyspnea. Imaging revealed subcutaneous emphysema likely secondary to a right-sided pneumothorax. A thoracostomy was performed, but her subcutaneous emphysema did not improve.",
    "image_finding": "CT chest with contrast 7 months prior to current presentation revealed a right-sided air cavity suspicious for a bronchopleural fistula with localized pleural thickening and rib deformities with some post-radiation changes (Figure 1).\nChest x-ray at current presentation revealed severe subcutaneous emphysema. There was no definitive pneumothorax (Figure 2).\nCT chest without contrast on day 11 of hospitalization. Right lateral chest tube is curled within the posterior aspect of the cavitary lesion (Figure 3).\nBronchoscopy of the right upper lobe on day 12 of hospitalization reveals bronchopleural fistula in which chest tube can be visualized (Figure 4).\nCT chest without contrast on day 13 of hospitalization. Endobronchial valve visualized in right upper lobe (Figure 5). Improving subcutaneous emphysema.\nChest x-ray on day 14 of hospitalization with chest tube clamped.\u00a0 Subcutaneous emphysema significantly improved since x-ray on presentation (Figure 6).",
    "discussion": "A bronchopleural fistula (BPF) is defined as a sinus tract between a mainstem, lobar, or segmental, bronchus and the pleural space [1]. A pleurocutaneous fistula is abnormal connection between the subcutaneous tissue and pleural space [2]. This can result in subcutaneous emphysema as seen in this patient.\u00a0 Most BPF\u2019s occur postoperatively with right-sided pneumonectomy or lobectomy being the most common risk factors [1]. Other causes include persistent spontaneous pneumothorax, mechanical ventilation, necrotizing pulmonary infection, malignancy, and acute respiratory distress syndrome among many others [3]. This connection between the pleural space and bronchus can lead to serious complications such as a pneumothorax or empyema [1]. Morbidity is estimated to be between 25% to 71% [4].\nBPF\u2019s can be classified into three categories: acute, subacute, and chronic. The most common acute BPF is a post-surgery tension pneumothorax [5]. Other manifestations of an acute fistula include expectoration of purulent sputum, subcutaneous emphysema, mediastinal and tracheal shifts [3]. Subacute and chronic BPF\u2019s are usually due to an infectious process and often have non-specific presentation with symptoms such as fever, cough, malaise, and pleural fibrosis [1].\nWhile a chest x-ray can be useful in diagnosing an underlying pneumothorax in a BPF, chest CT is a more valuable diagnostic tool [6]. CT can identify sinus tracts and can often be used to identify the underlying cause of the BPF. Three-dimensional reconstruction of CT images has proven to be a useful diagnostic tool as well.\nThe standard for BPF repair is video-assisted thoracoscopic surgery. However, this is an invasive procedure and is not optimal for certain patients [7]. The placement of endobronchial valves is a minimally invasive method used to treat BPF\u2019s in patients who are not strong surgical candidates such as in this case [7]. These valves are placed under bronchoscopy and provide a one-way flow of air out of the pleura [7]. Placement of these valves is not formally approved for BPF in the United States, but it has received the European Conformity certification and is approved for treatment of air-leak secondary to BPF [8]. Each case of BPF should be analyzed individually to determine if endobronchial valve placement is reasonable.\nThe placement of the endobronchial valves in the upper and lower bronchi of the right lung sealed the connection between the bronchi and pleura. The patient\u2019s subcutaneous emphysema gradually resolved most likely due to prevention of air leakage directly through the pleural puncture wound.\nAll patient data have been anonymised throughout the entire manuscript and related files.",
    "differential_diagnosis": "Bronchopleural, cutaneous, fistula, Abscess, secondary, to, infection, Cavitation, secondary, to, progression, of, non-small, cell, lung, cancer, Hemothorax",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-11/Figure%201.jpg?itok=dHIx-Jb5",
            "caption": "Enhanced axial CT image demonstrating a bronchopleural fistula"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-11/Figure%202.jpg?itok=fsS-1qwo",
            "caption": "Chest x-ray demonstrating severe subcutaneous emphysema"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-11/Figure%203.jpg?itok=Tebq-mqn",
            "caption": "Non-enhanced axial CT image showing the chest tube within the bronchopleural fistula"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-11//17947_4_1.jpg?itok=P1irnQ7z",
            "caption": "Chest tube can be visualized on bronchoscopy of right upper lobe"
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-11//17947_4_2.jpg?itok=f9L05oNn",
            "caption": "Endobronchial valve can be visualized in right upper lobe"
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-11//17947_5_1.png?itok=4fDl4Q-o",
            "caption": "Non-enhanced axial CT image demonstrating endobronchial valve in right upper lobe"
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-11/FIgure%206.jpg?itok=006RHsEM",
            "caption": "Chest x-ray with chest tube clamped exhibiting significantly improved subcutaneous emphysema compared to previous chest x-ray on admission"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/17947",
    "time": "29.11.2022"
  },
  "17948": {
    "case_id": 17948,
    "title": "Hypersensitivity pneumonitis",
    "section": "Chest imaging",
    "age": "55",
    "gender": "female",
    "diagnosis": "Non-fibrotic hypersensitivity pneumonitis",
    "history": "A 55-year-old female was referred to Pulmonology due to unexplained hypoxemia. The patient was an obese, hypertensive, ex-smoker who had progressive dyspnoea and dry cough for several months. She had a post-partum pulmonary embolism (PE) 20 years prior. ECG, echocardiogram, pulmonary function tests and Chest CTA (Computed Tomography angiography) were requested.",
    "image_finding": "The Chest CTA showed no signs of acute or chronic PE or indirect signs of pulmonary hypertension. However, it showed extensive bilateral ground glass opacities (GGO), interposed with well-defined areas of decreased lung attenuation and areas of normal lung, in keeping with the \u201cthree-density pattern\u201d. Additionally, bronchial wall thickening was present. No signs of fibrosis were noted (traction bronchiectasis, reticulation or honeycombing).",
    "discussion": "Background\nHypersensitivity pneumonitis (HP) is an inflammatory and/or fibrotic disease affecting the lung parenchyma and small airways, which results from an immune-mediated reaction provoked by an inhaled antigen in susceptible individuals. [1]\nNowadays, it is classified as fibrotic or non-fibrotic, because fibrosis is the primary determinant of prognosis. [2]\nClinical Perspective\nDyspnoea and cough are common. Constitutional symptoms, chest tightness, and wheezing are less frequent [3]. Onset may be acute or insidious.\nThe antigen and exposure are not identified in up to 60% of cases. [4]\nMost patients (80%\u201395%) with hypersensitivity pneumonitis are non-smokers. [1]\nPulmonary function tests characteristically demonstrate restriction, often with decreased diffusing capacity. Airflow obstruction may occur. [5]\nBAL (bronchoalveolar lavage) lymphocytosis is characteristically up to \u226530% in non/ex-smokers and \u226520% in smokers. [6] \nImaging Perspective\nThe typical HP pattern consists of diffusely distributed signs of lung infiltration (ground-glass opacity, mosaic attenuation) and at least one CT abnormality suggestive of small airway disease (small, ill-defined, centrilobular nodules and air trapping on expiratory images). [1]\nIn non-fibrotic HP, mosaic attenuation reflects coexistent lobules affected by pneumonitis (increased attenuation) interspersed with lobules of normal or slightly decreased attenuation (due to bronchiolar obstruction). These parenchymal patterns are usually diffuse, bilateral and symmetric. [1]\nCoexisting lung fibrosis and signs of bronchiolar obstruction are highly suggestive of fibrotic HP. \nThe \u201cthree-density pattern\u201d is highly specific for fibrotic HP and consists of lobules of decreased attenuation and vascularity, GGO and normal lung. [1]\nThe CT features that best differentiated HP from NSIP (Non-specific Interstitial pneumonia) and IPF (Idiopathic Pulmonary Fibrosis) are lobular areas with decreased attenuation, centrilobular nodules, and absence of lower zone predominance. [7]\nOutcome\nThe CT pattern was typical for hypersensitivity pneumonitis. \nThe timeframe where the symptoms were exacerbated coincided with her spending more time at home, where mould was abundantly present. \nBAL revealed 58% lymphocytosis. There were no other relevant laboratory findings.\nAccording to the recent guidelines [1], the diagnosis of HP was achieved with \u201cHigh Confidence\u201d and biopsy was not required.\nThe patient initiated 0,5mg/kg/day of prednisolone with a minor improvement in symptoms and pulmonary function tests, leading to a switch to mycophenolate mofetil. \nTake Home Message / Teaching Points\n\nHP is currently divided into fibrotic and non-fibrotic due to a better correlation with prognosis;\nThe typical HP pattern consists of diffusely distributed signs of lung infiltration and one abnormality suggestive of small airway disease.\nAccording to the new guidelines, to achieve a high or moderate confidence diagnosis of HP, biopsy is not mandatory.\n\nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Non-fibrotic, hypersensitivity, pneumonitis, NSIP, Respiratory, Bronchiolitis, \u2013, Interstitial, Lung, Disease, (RB-ILD), Obliterative, bronchiolitis/Asthma, Chronic, pulmonary, embolism, DIP, (Desquamative, Interstitial, Pneumonia), Atypical, infection",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-11//17948_1_1.jpg?itok=HKgyqaMb",
            "caption": "CT angiography shows no evidence of chronic or acute pulmonary embolism and the pulmonary artery trunk is within normal size limits"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-11//17948_1_2.jpg?itok=qwuL5uYW",
            "caption": "Chest CT showing diffuse ground glass opacities (yellow stars), bronchial wall thickening and the \u201cthree-density pattern\u201d (normal lung \u2013 red arrows), more evident in the left lower lobe (c-d), where one large (blue arrows) and a few smaller areas of reduced density are shown"
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-11//17948_1_3.jpg?itok=zdjDDsXW",
            "caption": "Chest CT showing diffuse ground glass opacities (yellow stars), bronchial wall thickening and the \u201cthree-density pattern\u201d (normal lung \u2013 red arrows), more evident in the left lower lobe (c-d), where one large (blue arrows) and a few smaller areas of reduced density are shown"
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-11//17948_1_4.jpg?itok=-qJd7bxx",
            "caption": "Chest CT showing diffuse ground glass opacities (yellow stars), bronchial wall thickening and the \u201cthree-density pattern\u201d (normal lung \u2013 red arrows), more evident in the left lower lobe (c-d), where one large (blue arrows) and a few smaller areas of reduced density are shown"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "CT",
      "CT-Angiography"
    ],
    "link": "https://www.eurorad.org/case/17948",
    "time": "29.11.2022"
  },
  "17951": {
    "case_id": 17951,
    "title": "Imaging findings of Amiodarone induced pulmonary and liver toxicity",
    "section": "Chest imaging",
    "age": "55",
    "gender": "male",
    "diagnosis": "Amiodarone toxicity",
    "history": "A 55-year-old male a known case of diabetes and hypertension, presented with progressive dyspnea, swelling of bilateral lower limbs and fever for the past week. ECG was suggestive of non-ST segment elevation myocardial infarction (NSTEMI). Blood investigations revealed elevated total counts. His blood culture was positive for Acinetobacter Baumenii. He had a prior history of ischaemic heart disease (IHD) for which he had undergone a coronary artery bypass graft (CABG) and was on long-term amiodarone therapy.",
    "image_finding": "Serial chest radiographs revealed inhomogeneous opacities in the right mid zone, bilateral basal zones, and left pleural effusion.\nHigh-Resolution Computed Tomography (HRCT) of the chest was performed on a 128-slice CT scanner, which demonstrated high attenuation dense consolidation involving the right upper lobe, superior and posterior segments of the right lower lobe, left apicoposterior segment and left lower lobe. There was also the presence of diffuse hyperattenuation of the liver with a mean HU (Hounsfield unit) of 93-95.\nThese findings were most consistent with Amiodarone toxicity.\nSubsegmental consolidation with surrounding ground glass opacities and septal thickening were also observed in bilateral lung fields. Multiple enlarged mediastinal lymph nodes and bilateral moderate pleural effusion were evidenced. \u00a0\nThese findings were consistent with infectious etiology. \nCardiomegaly with normal myocardial density was also noted.",
    "discussion": "Background \nAmiodarone lung is an interstitial lung disease that occurs in patients on amiodarone therapy. Amiodarone is an iodinated benzofuran derivative that is used to treat ventricular and supraventricular tachyarrhythmias. Pulmonary toxicity is one of the most serious adverse effects of amiodarone [1].\nSeveral forms of the pulmonary disease occur among patients treated with amiodarone, including interstitial pneumonitis, eosinophilic pneumonia, organizing pneumonia, acute respiratory distress syndrome (ARDS), diffuse alveolar haemorrhage (DAH), pulmonary nodules, and (rarely) pleural effusion [2].\nInterstitial pneumonitis usually occurs when the dose of amiodarone exceeds 400 mg per day for 2 months or more, or 200mg/day for more than 2 years [3].\nPathogenesis \u2014. Two major hypotheses have been suggested, a direct toxic injury to lung cells and an indirect immunologic reaction. The mechanism for direct injury involves phospholipid accumulation. Although the mechanism of indirect injury is poorly understood, CD8 lymphocytosis, T cell injury and increased IgM, consistent with hypersensitivity reaction are postulated as a mechanism. [4] \nClinical Perspective\nExertional dyspnoea is usually the dominant symptom. Low-grade fever, anorexia and muscle weakness have also been reported [5].\nRisk factors for pulmonary toxicity include a high cumulative dose, duration of therapy exceeding two months, pre-existing lung diseases, elderly age, surgery, and pulmonary angiography [6-10].\nLung function tests typically show a restrictive pattern. A reduction in diffusing capacity for carbon monoxide (DLCO) of more than 15% is a reliable indicator for amiodarone-induced pulmonary toxicity, with high sensitivity and specificity. Lung biopsy, alveolar cytogram and bronchoalveolar lavage are used to formulate the diagnosis [6].\nImaging Perspective \nChest radiography usually shows peripheral consolidation. High-resolution CT (HRCT) is the imaging modality of choice with typically bilateral and asymmetrical involvement of predominantly the lung bases. Findings include consolidation, patchy ground-glass opacities, and reticulonodular opacities. In addition, the liver (80% of cases) and sometimes the heart (20%) show high attenuation [11].\nOutcome \nThe preliminary therapeutic management involves the replacement of Amiodarone with another anti-arrhythmic agent, followed by corticosteroid therapy. All patients taking amiodarone should perform a chest radiograph and liver function tests before starting therapy and should be followed up and monitored appropriately [12]. Our patient, unfortunately, succumbed to septic shock and congestive cardiac failure shortly after admission before the amiodarone toxicity could be addressed. \nTake Home Message / Teaching Points\nIn conclusion, diagnosis of Amiodarone pulmonary toxicity is challenging owing to the multiform clinical aspects of this complication. We must consider it among the differential diagnoses in patients undergoing amiodarone therapy who present with progressive or acute respiratory symptoms or who present with radiological interstitial lesions in the absence of symptoms. With a prompt diagnosis, appropriate therapeutic management can be started to achieve a favourable outcome [12].",
    "differential_diagnosis": "Pulmonary, tuberculosis, Pulmonary, fibrosis, Amiodarone, toxicity, Calcified, atelectasis, Metastatic, Pulmonary, calcification",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-02/Figure%201_small_2.jpg?itok=tjDzL0OM",
            "caption": "Chest X-ray AP view shows inhomogeneous opacities in the right mid zone, bilateral basal zones and left pleural effusion"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-02/Figure%202A_small.jpg?itok=Ei31rC0i",
            "caption": "Axial CT chest in the mediastinal window shows high attenuation dense consolidation in the bilateral basal segments with peripheral predominance and bilateral moderate pleural effusion"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-02/Figure%202B_small.jpg?itok=LlMOJf4d",
            "caption": "Axial CT chest in lung window shows high attenuation dense consolidation in the bilateral basal segments with peripheral predominance, patchy ground glass opacities, septal thickening, and bilateral moderate pleural effusion"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-02/Figure%203_small.jpg?itok=koyXBXlw",
            "caption": "Axial CT abdomen shows diffuse hyper attenuation of the liver"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-11//17951_4_1.png?itok=tf2KczlQ",
            "caption": "Coronal CT chest in the mediastinal window shows high attenuation dense consolidation bilaterally with moderate pleural effusion"
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-02/Figure%205A_small.png?itok=34hYC7dI",
            "caption": "Sagittal CT of the right lung in the mediastinal window shows high attenuation dense consolidation in the basal segments with moderate pleural effusion"
          },
          {
            "number": "Figure 5b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-02/Figure%205B_small.png?itok=feo7G9qW",
            "caption": "Sagittal CT of the left lung in the mediastinal window shows high attenuation dense consolidation in the apico - posterior and basal segments, and pleural effusion"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT-High Resolution"
    ],
    "link": "https://www.eurorad.org/case/17951",
    "time": "29.11.2022"
  },
  "17965": {
    "case_id": 17965,
    "title": "Dyspnea after trauma?",
    "section": "Chest imaging",
    "age": "61",
    "gender": "male",
    "diagnosis": "Fat Pulmonary Embolism",
    "history": "A 61-year-old male with no known past medical history presented to the emergency department after a ground level fall. The patient was admitted for management of his fractures and over the next few hours developed progressively worsening shortness of breath. Upon arrival he was afebrile, normotensive, and had an O2 saturation of 92% on room air. Neurologic evaluation revealed a Glascow Coma Score of 15 and no focal neurologic deficits. Physical examination revealed deformities of his left lower and right upper extremities.",
    "image_finding": "Given the patient\u2019s history of trauma, physical exam findings of obvious fracture deformities, and symptoms of dyspnea, initial imaging included radiographs of the chest and left lower extremity.\u00a0\nIn our patient\u2019s case, the initial chest radiograph revealed predominantly upper lobe bilateral alveolar opacities. These findings of ill-defined patchy airspace opacities are nonspecific and can be seen with pulmonary oedema, aspiration, or infection [2].\u00a0\nChest CT is often the next imaging acquired when radiographic findings are nonspecific and the diagnosis is still unknown. Our patient\u2019s CT showed no filling defects in the pulmonary trunk, left or right main pulmonary artery, or lobar arteries. \u00a0 It did show bilateral pleural effusions. Lung parenchymal windows showed patchy ground glass opacities with interlobular septal thickening in the bilateral upper and left middle lung fields.\u00a0\nGiven the patient\u2019s history of fracture and dyspnea, pulmonary fat embolism was a consideration. The most common CT findings associated with pulmonary fat embolism include focal or diffuse ground glass opacities, patchy or diffuse areas of consolidation, and small [< 10 mm] nodules of various sizes. Fat attenuating filling defects within the pulmonary arteries can also be seen, although this is a rare finding. While these findings can be seen with pulmonary fat embolism, they can also be seen in interstitial haemorrhage, diffuse alveolar oedema, and pneumonitis produced by fat ischemia and cytotoxicity [1,2,3,4,5].",
    "discussion": "Fat embolism is the presence of fat in the pulmonary or peripheral circulation. Fat embolism syndrome is the combination of this finding with symptomatology; it can result in the triad of respiratory distress, neurological symptoms, and petechial rash.\nFat embolism can be a complication of pelvic and long bone fractures and polytrauma with soft tissue involvement. Most patients with pulmonary fat emboli are asymptomatic with only 1-5% of patients presenting with symptoms and signs of multiple organ dysfunction. These symptoms usually involve the brain, lung, and skin and often manifest as triad of respiratory distress, neurological symptoms and petechial rash [1,5]. Five percent of fat embolism syndrome cases are non-traumatic and can result from severe pancreatitis, prolonged treatment with corticosteroids or sickle cell anaemia.\nThere are two theories on the pathophysiology of fat embolism syndrome. The first is that fracture of a bone causes an increase in intramedullary pressure resulting in leakage of intramedullary fat into the circulation through the vessels severed by the fracture. Embolization of the fat particles clogs the pulmonary capillaries, leading to impaired ventilation/perfusion which then results in decreased oxygen saturation and dyspnea. The second theory is that a toxic reaction is induced by free fatty acids and glycerol within the fat emboli. It is this toxic reaction that produces an inflammatory reaction that damages vascular endothelium, causing oedema and haemorrhage and ultimately diffuse alveolar damage. [1,5]\nRadiological imaging prior to clinical manifestations is normal. However, when symptomatology begins, bilateral alveolar opacities can be seen in the chest X-ray. Nevertheless, while a chest radiograph is often the initial imaging obtained for patients with respiratory distress, its utility is somewhat limited. Unfortunately, various pathologic processes can have overlapping imaging features. In the computed tomography [CT] can be seen as an extensive patchy pattern of ground-glass attenuation that depending on the stage of evolution can be associated with thickened interlobular septa, suggesting airspace occupation and also in rare occasions a low-density repletion defect can be seen inside the pulmonary arterial tree. Given its variable imaging presentation and its nonspecific findings, it can be difficult to establish a definitive diagnosis of pulmonary fat embolism. As a result, the diagnosis of pulmonary fat embolism is determined by clinical, analytical, and imaging correlation. [1,2,3,4,5].\u00a0\nTreatment of fat embolism syndrome consists of ensuring good arterial oxygenation. High-flow oxygen is administered to maintain the arterial oxygen level in the normal range. In addition, it is important to maintain intravascular volume, as shock may exacerbate the lung injury caused by fat embolism. Albumin and balanced electrolyte solution are recommended for volume resuscitation, as in addition to restoring blood volume, they also bind fatty acids, thus preventing further extension of lung injury. Mechanical ventilation and PEEP are commonly used for oxygenation. Steroids, heparin, alcohol and dextran are useless[6].",
    "differential_diagnosis": "Fat, Pulmonary, Embolism, Acute, Pneumonia, Aspiration, pneumonia, Diffuse, alveolar, haemorrhage",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-11//17965_1_1.JPG?itok=rTQCjnBP",
            "caption": "Radiograph of the left lower extremity at the time of diagnosis. Displaced fracture (fx) of fibula and fx of tibia with external fixator (yellow arrow)"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-11//17965_2_1.JPG?itok=-hqTae7K",
            "caption": "Chest X-ray (portable) anteroposterior projection, clinical worsening (respiratory). Bilateral alveolar opacities predominantly in upper lobes (white arrows) and compacted humeral fracture (blue arrow)"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-11//17965_3_1.JPG?itok=fkQbB9pu",
            "caption": "Axial CT with intravenous contrast. Adequate repletion of the truncal, main and lobar pulmonary arteries. Bilateral pleural effusion (yellow arrow)"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-11//17965_4_1.JPG?itok=8wQ6iTqf",
            "caption": "Coronal CT with intravenous contrast. Lung parenchymal window. Patchy groundglass pattern with thickening of interlobular septa located in both upper lung fields and in the left middle lung field (white arrows)"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Emergency"
    ],
    "imaging_technique": [
      "Trauma"
    ],
    "link": "https://www.eurorad.org/case/17965",
    "time": "29.11.2022"
  },
  "17970": {
    "case_id": 17970,
    "title": "Primary Pulmonary Synovial Sarcoma, a high complexity case in a young male adult.",
    "section": "Chest imaging",
    "age": "26",
    "gender": "male",
    "diagnosis": "Primary Pulmonary Synovial Sarcoma",
    "history": "A 26-year-old man, cigarette smoker with no relevant medical history, presented to hospital emergency unit\u00a0 for fever, cough mild-productive for 2 weeks and right chest pain.",
    "image_finding": "Chest X-ray showed opacification of the lower third right lung with pleural effusion. Ultrasonography showed a solid mass with anechoic areas inside. A contrast-enhanced Computed Tomography confirmed a large heterogeneous density lesion, neither obstructing nor infiltrating the right stem bronchus, a small amount of pleural effusion and no mediastinal and axillary lymphadenopathies. The US-guided fine-needle biopsy result was: \u201cepitheliomorphic neoplasm with a rabdoid component, not necrosis, mitotic index up to 5 mitosis/10HPF. CD56 positivity with the relatively low proliferation index is compatible with neuroendocrine neoplasm\u201d. PET-CT\u00a0 showed pathological expression of somatostatin receptors, compatible with neuroendocrine pathology in cohesistence with an undifferentiated component. A second biopsy, aimed to detect genetic alterations for targeted therapy, found ASXL1 G967 del \u2013 CTNNA1 loss. The control CECT showed enlargement of the lesion. A new biopsy revealed a spindle cell malignant mesenchymal neoplasm with morphological and immunophenotypic characters consistent with the diagnosis of monophasic synovial sarcoma.",
    "discussion": "Synovial sarcoma is a malignant tumour affecting primarily young adults and can hit any anatomic site[1]. Primary Pulmonary synovial sarcoma (PPSS) is very rare, accounting for less than 0,5% of all lung tumours [2]. It may originate from lung parenchyma, bronchial tree or pulmonary arteries; it is supposed to originate from the pluripotent mesenchymal cells in the pulmonary system [3]. \nMost patients are asymptomatic at presentation. Anyway, when symptoms arise, they are aspecific, the most common being cough, chest pain, hemoptysis and an enlarging pleural-based mass [4].\nPPSS diagnosis relies on clinical manifestations, imaging, histopathology and immunochemistry. There is a knowledge gap for early recognition, and physicians cannot foresee the tumor pattern [6].\nTumours appear well circumscribed ranging within 0,6-31 cm, with or without a capsule. Histologically, the monophasic spindle cell type is the most common pattern [7].\nClinically PPSS cannot be differentiated from other tumours, and cytology, especially in enormous pulmonary sarcomas, might not be exhaustive [8]. Cytogenetic analysis can detect the translocation t(X; 18) (p11.2;q11.2) which leads to SS18 (formerly SYT)-SSX gene fusion which characterizes synovial sarcoma [5,6,7,8].\nThe prognosis of PPSS is very poor and depends on tumour size (>5 cm), sex (male>female), age (>20y), extension of necrosis, mitotic rate (more than 10 mitotic figures/10 high-power fields), neurovascular invasion, and presence of SYT-SSX1 gene fusion [5,9]. Currently, there is no standardized therapy for PPSS and the primary treatment approach is wide surgical excision with removal of the tumour with free surgical margins and possible radiotherapy if deemed helpful [1]. Unfortunately, surgical excision is not always possible, depending on the tumour size.\nIn advanced or unresectable tumours, doxorubicin- and ifosfamide-based chemotherapy gives an overall rate response of around 24% [10,11]. However, the efficacy of chemotherapy is still controversial and improves survival only in high-risk patients [12]. PPSS is very malignant, with the 5-year overall survival significantly worse than soft tissue sarcomas of the extremities (35% versus 71%) [13].\nAll patient data have been completely anonymised throughout the entire manuscript and related files.\nTake Home Message / Teaching Points\nPrimary pulmonary synovial sarcoma is a very rare tumour that appears as a mass on chest X-ray and Computed Tomography and whose diagnosis relies on histologic analysis and immunostaining,",
    "differential_diagnosis": "Primary, Pulmonary, Synovial, Sarcoma, Lung, neoplasm, Mesothelioma, Metastasis, from, extrapulmonary, sarcomas",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-12//17970_1_1.gif?itok=IW_6OO3L",
            "caption": "Chest X-ray (PA and LL) showed opacification of the lower right hemithorax, with a pleural effusion component"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-12//17970_2_1.gif?itok=p6Ry1UrZ",
            "caption": "Ultrasound of the right lung showed a mainly solid-echogenic mass with some anechoic areas inside"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-12//17970_3_1.gif?itok=PoVeLdGV",
            "caption": "Contrast-enhanced CT revealed  in the right lung inhomogeneous mass with lobated and sharp margins, widely in contact with the chest wall and the mediastinum"
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-12//17970_3_2.gif?itok=kg3qKuno",
            "caption": "At the upper level, the lesion displayed contact with the mediastinum, while the right main bronchus was patent"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-12//17970_4_1.gif?itok=ZSgU8v5v",
            "caption": "Coronal Contrast-enhanced CT MPR reconstruction showed progressive  enlargement of the mass"
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-12//17970_4_2.gif?itok=gGNW7k9A",
            "caption": "Sagittal Contrast-enhanced CT MPR reconstruction of the right hemithorax"
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-12//17970_5_1.gif?itok=kGVkWran",
            "caption": "CT scan displayed the presence of calcifications in the mass"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Oncology",
      "Thorax"
    ],
    "imaging_technique": [
      "CT",
      "Ultrasound"
    ],
    "link": "https://www.eurorad.org/case/17970",
    "time": "01.12.2022"
  },
  "17971": {
    "case_id": 17971,
    "title": "Large solitary fibrous tumor of the ple",
    "section": "Chest imaging",
    "age": "81",
    "gender": "female",
    "diagnosis": "Solitary fibrous tumour of the pleura",
    "history": "An elderly female patient referenced to the emergency department of our institution complaining of shortness of breath and left side chest pain.",
    "image_finding": "Chest radiograph showed a well-defined large lesion in the middle third of the left lung (Fig.1).\nContrast-enhanced CT scan revealed a well-defined, lobulated, pleural-based, solid mass, measuring 9x8 cm, with heterogeneous enhancement, and areas suggestive of recent bleeding (Fig.2). No hilar or mediastinal lymphadenopathy were detected.\nBiopsy revealed the presence of inflammatory and fibrotic cells, and the patient was referred for surgery, with no other adjuvant treatment being performed. The final pathological diagnosis was of a solitary fibrous tumour. \nPostoperative chest radiograph, performed 1 month after surgery, showed good end result, with no signs of residual tumour and only minor left lung volume decrease (Fig.3).",
    "discussion": "Solitary fibrous tumours of the pleura (SFTP) are thought to arise from the non-committed mesenchymal cells\u00a0 in\u00a0 the\u00a0 areolar\u00a0 tissue\u00a0 subjacent\u00a0 to\u00a0 the mesothelial-lined pleura [1]. SFTP are a rare neoplasm, often benign (80%), predominantly occurring in the sixth and seventh decades of life, affecting both sexes equally [1]. There is no apparent genetic predisposition and no known relationship to any environmental exposure [1,2].\nMost patients present with some symptoms, commonly cough, chest pain or dyspnea [1,3]. Hypertrophic pulmonary osteoarthropathy is the most common paraneoplastic syndrome in SFTP, especially in larger tumors ( up to 22%\u00a0 of patients), and generally resolves after removal of the tumour [2].\nChest radiograph is non-specific, usually revealing a\u00a0 mass with well-circumscribed margins, located near the lung periphery or in the projection of an interlobar fissure.\u00a0 The chest CT scan is very important, showing the precise location of the tumor and aiding in surgical planning. SFTP usually appear as well-delineated, lobulated masses with heterogeneous attenuation and contrast enhancement (usually intense due to rich vascularization). It can have areas of myxoid or cystic degeneration, haemorrhage, central necrosis and calcifications (up to 26% of tumours) [1-4].\u00a0 Rarely chest wall invasion or rib notching can be seen [1]. Magnetic resonance imaging is occasionally used to determine potential invasion of the chest wall [1,3].\nThe preferred method of treatment of SFTP is surgical resection in\u00a0both\u00a0the\u00a0benign\u00a0and\u00a0malignant types. Larger tumours might require a major lung resection such as a lobectomy or, rarely a\u00a0pneumonectomy. Due to the rarity of these tumours, there are no guidelines for adjuvant therapy [1-4]. \nSFTP can metastasize, with the pleura being the most common site (75%), followed by lung, liver, bones and peritoneum. Metastases to the brain or chest/abdominal wall are rare [5].\nFollow-up for recurrence should include a chest CT every 6 months for the first 2 years since most recurrences, particularly of the\u00a0sessile malignant\u00a0tumours,\u00a0 occur\u00a0within\u00a0 24\u00a0 months of surgery.\u00a0\u00a0 However, patients need long-term follow-up (usually yearly CT) due to the possibility of late recurrences (reported as long as 17 years after initial surgery) [1].",
    "differential_diagnosis": "Solitary, fibrous, tumour, of, the, pleura, Pleural, mesothelioma, Peripheral, lung, cancer, Intercostal, nerve, neurilemmomas, Primary, thoracic, sarcomas",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-12//17971_1_1.png?itok=A60nC35g",
            "caption": "Chest radiography showing a well-defined large lesion in the middle third of the left lung"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-12//17971_2_1.jpg?itok=azpgfD20",
            "caption": "Unenhanced axial CT (a) revealed a large, well-delineated mass in the left lung, with zones of spontaneous high attenuation corresponding to haemorrhage (*). The mass exhibited smoothly tapering margins at the junction with visceral pleura (arrows). Post-contrast axial (b) and coronal (c) reconstructions showing heterogeneous enhancement"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-12//17971_2_2.png?itok=GM2YvTmx",
            "caption": "Unenhanced axial CT (a) revealed a large, well-delineated mass in the left lung, with zones of spontaneous high attenuation corresponding to haemorrhage (*). The mass exhibited smoothly tapering margins at the junction with visceral pleura (arrows). Post-contrast axial (b) and coronal (c) reconstructions showing heterogeneous enhancement"
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-12//17971_2_3.png?itok=--jiXl1T",
            "caption": "Unenhanced axial CT (a) revealed a large, well-delineated mass in the left lung, with zones of spontaneous high attenuation corresponding to haemorrhage (*). The mass exhibited smoothly tapering margins at the junction with visceral pleura (arrows). Post-contrast axial (b) and coronal (c) reconstructions showing heterogeneous enhancement"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-12//17971_3_1.png?itok=tUHbWDoH",
            "caption": "Post-surgical chest radiography showing a good end result, with only minor left lung volume reduction. No signs of local recurrence"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/17971",
    "time": "01.12.2022"
  },
  "17988": {
    "case_id": 17988,
    "title": "A case of non-resolving pneumoni",
    "section": "Chest imaging",
    "age": "85",
    "gender": "female",
    "diagnosis": "Mid-thoracic oesophageal carcinoma with mediastinal invasion (T4b)",
    "history": "An 85 year old lady presented with generalised abdominal pain, confusion and a productive cough. Following a chest X-ray and blood tests she was treated for community acquired pneumonia. Despite treatment with 6 days of IV Tazocin, there was no significant clinical improvement.",
    "image_finding": "An initial chest x-ray revealed extensive consolidation in the right perihilar region with peripheral interstitial shadowing in the right hemithorax. This was likely due to infection rather than simple pulmonary oedema. The large volume of the lung fields was consistent with background airway obstruction (Figure 1).\nSubsequently a post-contrast Computerised Tomography of the Thorax, Abdomen and Pelvis (CT TAP) was conducted. This demonstrated dilatation of the proximal thoracic oesophagus extending down to a concentric tumour above the level of the left atrium invading the mediastinum and enveloping the left and right main bronchus (Figure 2). Perforation of the tumour into a large peripherally-enhancing cavity (6.6cm x 8cm) in the right lung base containing gas, food and debris was also demonstrated (Figures 3, 4, 5). In addition there was a pleural effusion and nodular lymphangitis carcinomatosis in the right lower lobe (Figure 6). Abdominal and skeletal assessment did not reveal anything sinister.",
    "discussion": "There are a number of possibilities that need to be considered when patients with presumed pneumonia fail to respond to typical antibiotic therapy. Possible causes for non-resolving pneumonia include atypical microbes, complications secondary to infection (i.e. abscess or empyema), a compromised immune system (i.e. HIV) or non-infective diseases such as inflammatory disorders, pulmonary embolism and malignancy [1]. \nIn this case, 7 days after initial presentation, a CT TAP was requested. The rationale for requesting a CT TAP was that it could identify the majority of the differentials listed above for non-resolving pneumonia.\nFollowing the findings of the CT TAP a number of diagnostic procedures could have been used to confirm the diagnosis histologically including an endoscopic procedure with tissue biopsies. In this case however, due to the poor prognosis, further diagnostic tests were not carried out. \nOesophageal pulmonary fistulas are relatively rare. The development of a fistula between the oesophagus and the pulmonary system has been reported to happen in just 5% of oesophageal malignancies [2]. The majority of oesophageal-respiratory fistulas are either oesophageal-tracheal (50%) or oesophageal-bronchial (40%) with oesophageal-pulmonary fistulas being the most uncommon (6%) [2,3]. In this case, the tumour invaded the right and left bronchus, as well as the right lung parenchyma. This case was therefore a particularly rare and advanced case which neither the requesting Medical Consultant or the Consultant Radiologist had ever seen before in their careers.\nManagement of oesophageal-respiratory fistulas includes endoscopic stenting as well as oesophageal bypass. These interventions, while not curing the disease, aim to minimise respiratory complications and improve the patient\u2019s quality of life [4]. In this particular case the patient presented at a late stage and had a number of comorbidities. Palliative care was therefore deemed the most appropriate option and the patient was moved to hospice care and died a short time later. \nThis case highlights the importance of further investigation for conditions that do not respond as expected to standard management. While the majority of pneumonias are simple to manage, atypical presentations do need careful consideration and prompt recognition of this may improve patient care, subsequent recovery and quality of life. In this case, while identification of the cause through further investigations did not lead to prolongation of life, it did lead to a more appropriate level of care and a more dignified end of life. \nConsent: Written informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Mid-thoracic, oesophageal, carcinoma, with, mediastinal, invasion, (T4b), Atypical, pneumonia, resistant, to, antibiotics, of, choice, Foreign, body, aspiration, Empyema, Interstitial, lung, disease, Malignancy",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-12//17988_1_1.jpg?itok=Lx3WYaOa",
            "caption": "This anterio-posterior chest radiograph shows evidence of consolidation in the right peri-hilar region and changes consistent with chronic airway obstruction"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-12//17988_2_1.jpg?itok=NiftPEwh",
            "caption": "This cross-sectional CT TAP image shows invasion of the mediastinum and the left and right main bronchus (white arrow)"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-12//17988_3_1.jpg?itok=h9SEAoiN",
            "caption": "This cross-sectional CT TAP image shows a peripherally enhancing cavity measuring 6.6cm x 8cm containing gas, food and debris (white arrow). The oesophageal tumour can be seen directly next to the gas in the cavity representing the likely connection between the two (black arrow)"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-12//17988_4_1.jpg?itok=k4kg8Sof",
            "caption": "This sagittal section of the CT TAP demonstrating the peripherally enhancing cavity (white arrow) and an area of gas where it communicates with the oesophageal tumour (black arrow)"
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-12//17988_5_1.jpg?itok=mJ78XiUo",
            "caption": "This cross-sectional CT TAP image demonstrates the oesophageal tumour containing food debris (white arrow) and the adjacent fluid and debris-filled cavity (black arrow)"
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2022-12//17988_6_1.jpg?itok=UO578Cmc",
            "caption": "This cross-sectional image from the CT TAP shows nodular lymphangitis carcinomatosis (white arrow) in the right lower lobe and a shallow pleural effusion (black arrow)"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/17988",
    "time": "13.02.2023"
  },
  "18000": {
    "case_id": 18000,
    "title": "Mounier-Kuhn syndrome in an old patient",
    "section": "Chest imaging",
    "age": "69",
    "gender": "male",
    "diagnosis": "Mounier-Kuhn syndrome",
    "history": "A 69-year-old male presented with a recent onset fever and worsening cough for 2 weeks. He had a history of chronic cough for 40 years and had been repeatedly treated for infections without any cross-sectional imaging performed earlier because of a lack of referral to a specialist center.",
    "image_finding": "The patient was admitted to our hospital as a case of community-acquired pneumonia (CAP) requiring further investigations. A High-resolution CT scan of the chest showed widened and deformed tracheobronchial tree [Fig.1,2] with extensive bilateral cylindrical bronchiectasis and reticular and cystic changes particularly affecting bilateral lower lung lobes, right middle lobe, and to lesser degrees both upper lobes. In addition to bronchial and bronchiolar wall thickening, centrilobular and peripheral subpleural nodular shadowing, ground glass opacities, and consolidative changes were present at both the lower lobes and the right middle lobe. \nSubsequent bronchoscopy revealed a distorted tracheobronchial tree [Fig.3,4] with absent tracheal cartilages with exaggerated collapsibility upon coughing or expiration. Mucoid secretions were seen within the tracheobronchial lumens on both sides with no diverticula noted. The reported cytology of the bronchial wash revealed acute inflammatory cells along with squamous and ciliated cells. The patient was therefore diagnosed to have CAP and underlying Mounier-Kuhn syndrome.",
    "discussion": "Mounier-Kuhn syndrome or tracheobronchomegaly, is a rare disease mostly reported in middle-aged men. It is characterized by significant dilatation, weakness, and diverticulosis of the trachea and main bronchi secondary to complete or partial deficiency or atrophy of the elastic fibers of both the cartilaginous and membranous parts [1,2]. Such tracheobronchomegaly manifests as excessive dilatation on inspiration and enhanced collapsibility on expiration, predisposing the patient to recurrent respiratory tract infections due to stagnation of infected intraluminal secretions. The likelihood of it being congenital is supported by the fact that not all reported cases are symptomatic, and that the histology reveals the absence or deficiency of elastic fibers rather than damage secondary to inflammation. It has also been argued that it is an acquired condition because most of the reported cases are of adults with chronic pulmonary suppuration or infections [3,4]. Chronic inhalation of irritants such as cigarette smoking or occupational exposure may contribute to the development of tracheobronchomegaly. The clinical presentation is heterogeneous ranging from completely asymptomatic to severely complicated disease with chronic lung infections and respiratory failure. The diagnosis mandates a CT scan of the chest to demonstrate tracheobronchomegaly, while the modality of choice is bronchoscopy. Treatment is largely supportive and non-specific. Smoking cessation and limiting exposure to airway irritants are encouraged. Infectious exacerbations are treated with antibiotics and postural drainage. \nOther causes of tracheomalacia (or dilated trachea) need to be considered in differential diagnoses of Mounier-Kuhn syndrome that can be either be congenital (certain connective tissue disorders like Marfan syndrome and Ehlers-Danlos syndrome) or acquired (prolonged intubation, chronic obstructive pulmonary disease). Imaging finding of lunate trachea with increased ratio of coronal-to-sagittal tracheal diameter is characteristic. Tracheal dilatation (coronal or sagittal widening), tracheal cartilage calcification, wall thickening, and mediastinal lymphadenopathy need to be looked for to exclude these other causes. Clinicians should consider the diagnosis in cases with recurrent chest infections and opt for imaging.\u00a0 \nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Mounier-Kuhn, syndrome, Connective, tissue, disorder, Dilated, trachea, (or, tracheomalacia)",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-01//18000_1_1.jpg?itok=Gs--0u-Z",
            "caption": "Selected axial CT image showing widened and flattened tracheal lumen"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-01//18000_2_1.jpg?itok=Spe1ubPE",
            "caption": "Selected coronal CT image showing tracheobronchomegaly with widened and ectatic contours of trachea and both major bronchi"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-01//18000_3_1.jpg?itok=4PYHJ749",
            "caption": "Bronchoscopic image showing flattened and widened tracheal lumen"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-01//18000_4_1.jpg?itok=GnQkai2A",
            "caption": "Bronchoscopic image through the left bronchus showing similar widening and flattening of bronchial lumen"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Anatomy",
      "Lung"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/18000",
    "time": "06.02.2023"
  },
  "18001": {
    "case_id": 18001,
    "title": "Macklin effect: What is behind spontaneous pneumomediastinum?",
    "section": "Chest imaging",
    "age": "17",
    "gender": "male",
    "diagnosis": "Spontaneous pneumomediastinum",
    "history": "A 17-year-old man complains of a 24-hour history of sudden thoracic and cervical pain. He reports a self-limited viral process with strong coughing attacks during the past week. No record of fever, vomits, or anorexia. Physical exam showed a slightly erythematous oropharynx and crepitation in the supraclavicular region.",
    "image_finding": "Initial chest x-ray on PA view (Figure 1a) shows linear lucencies along pulmonary hila and paratracheal regions with subcutaneous tissue involvement. These findings are suspicious for pneumomediastinum associated with subcutaneous emphysema. Lateral x-ray view (Figure 1b) shows areas of lucency anterior to the heart and ascending aorta.\nA thoracic contrast-enhanced CT on venous phase was performed (Figure 2):\nAxial views confirm the presence of air within the supraclavicular region (Figure 3a) and mediastinum (Figure 3b). \nCoronal multiplanar reconstruction shows linear bands of air parallel and adjacent to the bronchovascular sheaths (Figure 3c).",
    "discussion": "Background\nPneumomediastinum is a radiological finding depicted by air in the mediastinal space. There are three mechanisms described [1]: \n1] Mucosal barrier disruption [tracheobronchial tree or oesophagus] allows unrestrained air passage towards the mediastinum.\n2] Gas produced by microorganisms in the mediastinum or adjacent areas.\n3] Rupture of alveolar acini.\nAetiologies are varied, among which infection, trauma or iatrogenesis must be ruled out. When there is no apparent explanation, pneumomediastinum is considered spontaneous [Hamman syndrome].\nIn 1937, Charles Macklin first studied the physiopathology of spontaneous pneumomediastinum [SPM] through experimental works. The release of air into the interstitium secondary to acini rupture causes distension of the secondary pulmonary lobule. As this progresses, the air dissects the central arteriobronchial sheath until reaching the pulmonary hilum [Figure 4], entering the mediastinal compartment [2].\nClinical and Imaging Perspective\nAlthough relatively rare, SPM can occur at any age and must be suspected, especially if there is diagnostic uncertainty. Patients usually consult with non-specific chest pain and dyspnea. During a physical examination, one may observe crepitus due to soft tissue gas and a pulse-synchronous rasping sound during cardiac auscultation [Hamman sign].\nDue to its unspecific clinical presentation, radiological evaluation is paramount. Chest radiographs on PA and lateral projections are generally the first assessment based on availability and rapidness. Cardiac silhouette and mediastinal contours must be carefully assessed, looking for linear or curvilinear lucencies [3]. A lateral view sometimes shows a radiolucent delineation of the pulmonary artery [Ring-around-the-Artery Sign] [4]. Peripheral soft-tissue margins might show subcutaneous emphysema.\nCT key findings include linear air bands along the bronchovascular sheats from the distal bronchi to the hilum [Macklin effect]. Pneumopericardium appears confined below the aortic arch as opposed to pneumomediastinum, which usually extends cranially towards subcutaneous tissues. Hence, pneumomediastinum displays slim and linear soft-tissue partitions within the air corresponding to connective tissue.\nOutcome\nEven though it may seem an ominous diagnosis, retrospective cohort studies support self-limitation of SPM, opting for conservative management when concomitant factors, injuries, or underlying diseases are not present [5,6], like it was done in our case with excellent clinical course.\nTake Home Message\n\nAlveola rupture generates emphysematous distension within the secondary pulmonary lobule provoking dissection of the arteriobronchial sheat [Macklin effect]. Finally, air migrates cranially and accumulates within the mediastinum.\n\n\u00a0\nSPM displays poor specific symptoms. Chest x-ray is the first approach, and CT is mandatory to rule out treatable and ominous aetiologies.",
    "differential_diagnosis": "Spontaneous, pneumomediastinum, Oesophageal, rupture, [Boerhaave, syndrome], Mediastinitis, Tracheobronchial, rupture, Pneumopericardium",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-01//18001_1_1.jpg?itok=Zu7Q7UsN",
            "caption": "Chest x-ray on PA view (a) shows linear lucencies along pulmonary hila and paratracheal regions (red arrows) with subcutaneous emphysema (yellow arrowheads). Lateral view (b) shows linear lucencies anterior to the heart, ascending aorta and hilum (red arrows)"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-01//18001_1_2.jpg?itok=ZHQwKi4c",
            "caption": "Chest x-ray on PA view (a) shows linear lucencies along pulmonary hila and paratracheal regions (red arrows) with subcutaneous emphysema (yellow arrowheads). Lateral view (b) shows linear lucencies anterior to the heart, ascending aorta and hilum (red arrows)"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_video/2023-02/CTpulmofino-thumbnail.png?itok=24Xhlx3G",
            "caption": "Contrast-enhanced CT on lung (a) and soft tissue (b) window"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_video/2023-02/CTpartesblandasfino3-thumbnail.png?itok=0u9nX-OH",
            "caption": "Contrast-enhanced CT on lung (a) and soft tissue (b) window"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-01//18001_3_1.jpg?itok=AF7q1x81",
            "caption": "Axial views of contrast-enhanced CT through the lower neck (a) and mediastinum (b) and coronal view (c) show subcutaneous emphysema (yellow arrowheads), pneumomediastinum (yellow arrow), and linear air bands along the bronchovascular sheats (blue arrowheads)"
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-01//18001_3_2.jpg?itok=wP0Y3yhj",
            "caption": "Axial views of contrast-enhanced CT through the lower neck (a) and mediastinum (b) and coronal view (c) show subcutaneous emphysema (yellow arrowheads), pneumomediastinum (yellow arrow), and linear air bands along the bronchovascular sheats (blue arrowheads)"
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-01//18001_3_3.jpg?itok=JHDlinLY",
            "caption": "Axial views of contrast-enhanced CT through the lower neck (a) and mediastinum (b) and coronal view (c) show subcutaneous emphysema (yellow arrowheads), pneumomediastinum (yellow arrow), and linear air bands along the bronchovascular sheats (blue arrowheads)"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-01//18001_4_1.jpg?itok=k5ShGUkP",
            "caption": "Macklin effect depiction: from the secondary pulmonary lobule to the mediastinum"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Anatomy",
      "Lung",
      "Mediastinum",
      "Respiratory system"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/18001",
    "time": "06.02.2023"
  },
  "18008": {
    "case_id": 18008,
    "title": "Inflammation or tumor? A case report of primary pulmonary choriocarcinom",
    "section": "Chest imaging",
    "age": "27",
    "gender": "female",
    "diagnosis": "Primary pulmonary choriocarcinoma",
    "history": "A 27-year-old woman with two children presented to the hospital with a cough, blood-stained sputum and a fever for one month. The patient reported that she had regular menstruation, and there were no hereditary diseases in her family.",
    "image_finding": "A chest computerized tomography (CT) scan at a local hospital showed space-occupied lesions in the lower lobe of the left lung. She was prescribed anti-infective treatment but the response to this medication was poor. A second chest CT scan showed an enlarged space-occupying lesion in the lower lobe of the left lung (Figure 1), which was diagnosed as an infected pulmonary cyst.",
    "discussion": "A chest computerized tomography [CT] scan at a local hospital showed space-occupied lesions in the lower lobe of the left lung. She was prescribed anti-infective treatment but the response to this medication was poor. A second chest CT scan showed an enlarged space-occupying lesion in the lower lobe of the left lung (Figure 1), which was diagnosed as an infected pulmonary cyst.\nDiscussion\nThis report presents a difficult case in which the diagnosis of primary pulmonary choriocarcinoma [PPC] was unexpected in women. Although she was not pregnant, her \u03b2-hCG levels were elevated. As seen in this case, no specific features pointed to the diagnosis of PPC, and the disease was confirmed by postsurgical biopsy. Analysis of the present case and those reported previously, \u00a0preoperative diagnosis of PPC [1], and doctors should pay close attention to the patient's serum HCG level when they suspect the possibility of PPC.\nThe patient\u2019s preliminary laboratory examination revealed that the level of non-small cell lung cancer [NSCLC]-associated antigen was 6.62 ng/ml and that of neuron-specific enolase was 16.73 ng/ml, indicating a malignant lung tumour. The tumour size was 7 \u00d7 6 \u00d7 6 cm and there was no evidence of distant metastasis. Therefore, video-assisted thoracoscopic surgery was proposed to remove the space-occupied lesion in the left lower lobe of the lung.\nThe tumour had invaded the chest wall and the frozen section examination showed a poorly differentiated malignant tumour with a reproductive system origin. Because laparoscopic resection was difficult, it was converted to an axillary small incision, left lower lobectomy, and systematic lymph node dissection.\nImmunohistochemical examination of the diseased tissues revealed that the tumour cells were strongly positive for cytokeratin [CK] 8/18, CD10, GATA-3, \u03b2-hCG, Ki-67, and human placental lactogen [HPL] (Figure 2). Based on these results, a diagnosis of PPC was made.\nThe\u00a0patient\u2019s\u00a0vital signs were normal, and\u00a0she\u00a0recovered well after the operation.\nGiven the rarity of PPC, there is no standard treatment for the disease. Treatment strategies for PPC in published cases include complete excision, chemotherapy, radiation therapy, and supportive care, which are the same as those for gestational choriocarcinoma [2, 3]. Surgical resection is an effective treatment for PPC, particularly for isolated lung lesions, when combined with postoperative chemotherapy to prevent tumour metastasis to other sites [4, 5]. Etoposide, carboplatin, bleomycin, and methotrexate are examples of the commonly used chemotherapy drugs [2, 6]. Furthermore, patients with choriocarcinoma who are resistant to chemotherapeutic drugs can be treated with a combination of toripalimab and individualized chemotherapies [7].\nEthics Statement\nThe studies involving human participants were reviewed and approved by the Institutional Review Board of Shandong Provincial Hospital Affiliated to Shandong First Medical University Subcommittee on Human Studies. The patient provided written informed consent to participate in this study. Written informed consent was obtained from the individual to publish any potentially identifiable images or data included in this article.",
    "differential_diagnosis": "Primary, pulmonary, choriocarcinoma, Giant, cell, carcinoma, of, the, lung, Pulmonary, cyst, Pulmonary, inflammatory, pseudotumor, Organizing, pneumonia",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-01//18008_1_1.jpg?itok=V53OQIwz",
            "caption": "A chest CT scan revealed a large round lesion, approximately 6 cm in diameter, in the lower lobe of the left lung, with a well-defined border and homogeneous density. Following the enhancement scan, the edge of the lesion showed obvious ring enhancement, but no enhancement was observed in the central part. Villous enhancement protruding inward can be clearly seen on the endodorsum of the mass with blurred demarcation from the pleura"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-01//18008_1_2.jpg?itok=lSx0eBf4",
            "caption": "A chest CT scan revealed a large round lesion, approximately 6 cm in diameter, in the lower lobe of the left lung, with a well-defined border and homogeneous density. Following the enhancement scan, the edge of the lesion showed obvious ring enhancement, but no enhancement was observed in the central part. Villous enhancement protruding inward can be clearly seen on the endodorsum of the mass with blurred demarcation from the pleura"
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-01//18008_1_3.png?itok=mE1R97Fv",
            "caption": "A chest CT scan revealed a large round lesion, approximately 6 cm in diameter, in the lower lobe of the left lung, with a well-defined border and homogeneous density. Following the enhancement scan, the edge of the lesion showed obvious ring enhancement, but no enhancement was observed in the central part. Villous enhancement protruding inward can be clearly seen on the endodorsum of the mass with blurred demarcation from the pleura"
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-01//18008_1_4.jpg?itok=3-a8p3Ic",
            "caption": "A chest CT scan revealed a large round lesion, approximately 6 cm in diameter, in the lower lobe of the left lung, with a well-defined border and homogeneous density. Following the enhancement scan, the edge of the lesion showed obvious ring enhancement, but no enhancement was observed in the central part. Villous enhancement protruding inward can be clearly seen on the endodorsum of the mass with blurred demarcation from the pleura"
          },
          {
            "number": "Figure 1e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-01//18008_1_5.jpg?itok=YzoBGI6t",
            "caption": "A chest CT scan revealed a large round lesion, approximately 6 cm in diameter, in the lower lobe of the left lung, with a well-defined border and homogeneous density. Following the enhancement scan, the edge of the lesion showed obvious ring enhancement, but no enhancement was observed in the central part. Villous enhancement protruding inward can be clearly seen on the endodorsum of the mass with blurred demarcation from the pleura"
          },
          {
            "number": "Figure 1f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-01//18008_1_6.jpg?itok=jSK9o1Vq",
            "caption": "A chest CT scan revealed a large round lesion, approximately 6 cm in diameter, in the lower lobe of the left lung, with a well-defined border and homogeneous density. Following the enhancement scan, the edge of the lesion showed obvious ring enhancement, but no enhancement was observed in the central part. Villous enhancement protruding inward can be clearly seen on the endodorsum of the mass with blurred demarcation from the pleura"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-01//18008_2_1.jpg?itok=jbKOPXEu",
            "caption": "HE staining: Figure (B) is a partial enlargement of Figure (A). (B): Cellulose-like material is present in the upper left corner, and neoplastic trophoblasts with highly atypical hyperplasia are present in the lower right corner, with large hyperchromatic nuclei and no villi. Strongly positive immunohistochemical staining of the tumor at 40x magnification: (C) \u03b2-hCG; (D) CK 8/18; (E) Ki-67; and (F) HPL; and at 20x magnification: (G) CD10; (H) GATA-3. The pathological diagnosis was chorionic epithelial carcinoma of the left lower lobe of the lung, and the diameter of the lesion was approximately 10 cm. Most of the lesion was necrotic, and only a few tumor cells were visible"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-01//18008_2_2.png?itok=gq4A6kpD",
            "caption": "HE staining: Figure (B) is a partial enlargement of Figure (A). (B): Cellulose-like material is present in the upper left corner, and neoplastic trophoblasts with highly atypical hyperplasia are present in the lower right corner, with large hyperchromatic nuclei and no villi. Strongly positive immunohistochemical staining of the tumor at 40x magnification: (C) \u03b2-hCG; (D) CK 8/18; (E) Ki-67; and (F) HPL; and at 20x magnification: (G) CD10; (H) GATA-3. The pathological diagnosis was chorionic epithelial carcinoma of the left lower lobe of the lung, and the diameter of the lesion was approximately 10 cm. Most of the lesion was necrotic, and only a few tumor cells were visible"
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-01//18008_2_3.jpg?itok=JKT3z4ju",
            "caption": "HE staining: Figure (B) is a partial enlargement of Figure (A). (B): Cellulose-like material is present in the upper left corner, and neoplastic trophoblasts with highly atypical hyperplasia are present in the lower right corner, with large hyperchromatic nuclei and no villi. Strongly positive immunohistochemical staining of the tumor at 40x magnification: (C) \u03b2-hCG; (D) CK 8/18; (E) Ki-67; and (F) HPL; and at 20x magnification: (G) CD10; (H) GATA-3. The pathological diagnosis was chorionic epithelial carcinoma of the left lower lobe of the lung, and the diameter of the lesion was approximately 10 cm. Most of the lesion was necrotic, and only a few tumor cells were visible"
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-01//18008_2_4.jpg?itok=huYVNOGq",
            "caption": "HE staining: Figure (B) is a partial enlargement of Figure (A). (B): Cellulose-like material is present in the upper left corner, and neoplastic trophoblasts with highly atypical hyperplasia are present in the lower right corner, with large hyperchromatic nuclei and no villi. Strongly positive immunohistochemical staining of the tumor at 40x magnification: (C) \u03b2-hCG; (D) CK 8/18; (E) Ki-67; and (F) HPL; and at 20x magnification: (G) CD10; (H) GATA-3. The pathological diagnosis was chorionic epithelial carcinoma of the left lower lobe of the lung, and the diameter of the lesion was approximately 10 cm. Most of the lesion was necrotic, and only a few tumor cells were visible"
          },
          {
            "number": "Figure 2e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-01//18008_2_5.jpg?itok=i7aIKnL9",
            "caption": "HE staining: Figure (B) is a partial enlargement of Figure (A). (B): Cellulose-like material is present in the upper left corner, and neoplastic trophoblasts with highly atypical hyperplasia are present in the lower right corner, with large hyperchromatic nuclei and no villi. Strongly positive immunohistochemical staining of the tumor at 40x magnification: (C) \u03b2-hCG; (D) CK 8/18; (E) Ki-67; and (F) HPL; and at 20x magnification: (G) CD10; (H) GATA-3. The pathological diagnosis was chorionic epithelial carcinoma of the left lower lobe of the lung, and the diameter of the lesion was approximately 10 cm. Most of the lesion was necrotic, and only a few tumor cells were visible"
          },
          {
            "number": "Figure 2f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-01//18008_2_6.jpg?itok=dZ_ef1hh",
            "caption": "HE staining: Figure (B) is a partial enlargement of Figure (A). (B): Cellulose-like material is present in the upper left corner, and neoplastic trophoblasts with highly atypical hyperplasia are present in the lower right corner, with large hyperchromatic nuclei and no villi. Strongly positive immunohistochemical staining of the tumor at 40x magnification: (C) \u03b2-hCG; (D) CK 8/18; (E) Ki-67; and (F) HPL; and at 20x magnification: (G) CD10; (H) GATA-3. The pathological diagnosis was chorionic epithelial carcinoma of the left lower lobe of the lung, and the diameter of the lesion was approximately 10 cm. Most of the lesion was necrotic, and only a few tumor cells were visible"
          },
          {
            "number": "Figure 2g",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-01//18008_2_7.jpg?itok=HsxcDPio",
            "caption": "HE staining: Figure (B) is a partial enlargement of Figure (A). (B): Cellulose-like material is present in the upper left corner, and neoplastic trophoblasts with highly atypical hyperplasia are present in the lower right corner, with large hyperchromatic nuclei and no villi. Strongly positive immunohistochemical staining of the tumor at 40x magnification: (C) \u03b2-hCG; (D) CK 8/18; (E) Ki-67; and (F) HPL; and at 20x magnification: (G) CD10; (H) GATA-3. The pathological diagnosis was chorionic epithelial carcinoma of the left lower lobe of the lung, and the diameter of the lesion was approximately 10 cm. Most of the lesion was necrotic, and only a few tumor cells were visible"
          },
          {
            "number": "Figure 2h",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-01//18008_2_8.jpg?itok=Ew9MYDQb",
            "caption": "HE staining: Figure (B) is a partial enlargement of Figure (A). (B): Cellulose-like material is present in the upper left corner, and neoplastic trophoblasts with highly atypical hyperplasia are present in the lower right corner, with large hyperchromatic nuclei and no villi. Strongly positive immunohistochemical staining of the tumor at 40x magnification: (C) \u03b2-hCG; (D) CK 8/18; (E) Ki-67; and (F) HPL; and at 20x magnification: (G) CD10; (H) GATA-3. The pathological diagnosis was chorionic epithelial carcinoma of the left lower lobe of the lung, and the diameter of the lesion was approximately 10 cm. Most of the lesion was necrotic, and only a few tumor cells were visible"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/18008",
    "time": "06.02.2023"
  },
  "18009": {
    "case_id": 18009,
    "title": "Allergic Bronchopulmonary Aspergillosis (ABPA) with High Attenuation Mucus (HAM)",
    "section": "Chest imaging",
    "age": "64",
    "gender": "female",
    "diagnosis": "Allergic Bronchopulmonary Aspergillosis (ABPA)",
    "history": "A 64-year-old female presented to the outpatient department with a history of breathlessness and cough for the last 1 week. No history of fever, haemoptysis, or weight loss. She is a known case of bronchial asthma on medication for the past 28 years. Her vitals were stable and had bilateral wheeze on auscultation.",
    "image_finding": "Frontal Radiograph chest: shows non-homogenous radio opacities involving bilateral upper zones in the paratracheal location with a V-shaped configuration. The right hilum appears enlarged with similar radio opacities seen in the right para hilar location involving predominantly right mid-zone showing typical finger-in-glove appearance.\u00a0\nComputed tomography(non-contrast) Thorax: Dilatation of central segmental bronchi (cylindrical bronchiectasis) with uniformly hyperdense areas/collection seen within the dilated bronchi possibly representing hyperattenuating mucus (HAM) of average HU ~ 112 with surrounding areas of resorptive /obstructive atelectasis are seen involving bilateral upper lobes and right middle lobe.\u00a0\nNarrowing of the proximal aspect of central segmental bronchi in the perihilar region (possibly secondary due to mucus plugging) is noted with few areas of small centrilobular nodules of varying sizes seen in bilateral upper lobes.",
    "discussion": "Background\nAllergic bronchopulmonary aspergillosis (ABPA) is a pulmonary disorder characterised by a hypersensitivity reaction to Aspergillus sp, involving type I (IgE-mediated) and type III (IgG-mediated) immunologic responses [1,2,3]\u00a0\u00a0\u00a0\u00a0\u00a0 \nClinical perspective\nThis entity is most commonly encountered in adults before the age of 40 years, with longstanding asthma, which is the most important contributing factor (occurs in 0.25-11% of asthmatic patients). It is seen occasionally associated with cystic fibrosis and other underlying bronchiectatic diseases [2]. Patients generally experience symptoms of recurrent asthma exacerbations (wheezing, cough and dyspnoea). Occasionally, chest pain, fever, expectoration of dark mucous plug and haemoptysis may be associated [3,4].\nImaging Perspective\nOn chest radiograph, ABPA shows tubular branching radio opacities extending from the\nhilum with the appearance of a \u201cfinger in glove\u201d, which may be associated with air-fluid levels in dilated bronchi.\u00a0\nOn HRCT Thorax, Central bronchiectasis (cystic or varicose) and mucoid impaction of underlying bronchiectatic airway, forming large bronchoceles, typically with involvement of the upper lobes. Hyperattenuating mucus on CT scans has been reported as a diagnostic criterion for ABPA, corresponding to an attenuation superior to 70 Hounsfield Unit (denser than the para-spinal muscles). The presence of hyperdense mucous plugging impaction has been shown as a 100% specific criterion of ABPA and thus may be considered pathognomonic [2,6,7].\u00a0\nPulmonary collapse may be seen as a consequence of endobronchial mucoid impaction [1,2,5].\nOther CT findings in acute exacerbation of ABPA include bronchial wall-thickening, centrilobular nodules (as a tree-in-bud pattern), consolidation and mosaic pattern with air trapping [1,2,5,6].\nAccording to Patterson et al. ABPA was classified based on HRCT chest findings as ABPA-CB and ABPA-S, depending on the presence or absence of bronchiectasis [8].\nThe classification scheme was revised by studies done by Ritesh et al. based on HAM was the most consistent, with the progressive increase in immunological severity from ABPA-S (mild) through ABPA-CB (moderate) at diagnosis not only representing immunologically severe disease but also identifies the patient at risk for recurrent relapses.\u00a0\nOutcome\nThe established major criteria for the diagnosis of ABPA include history of asthma, immediate skin reactivity to Aspergillus, elevated total serum IgE (>1000 ng/ml), elevated IgE or IgG to Aspergillus and central bronchiectasis [2,4]. Treatment of ABPA aims to control inflammation and prevent further injury to the lungs, based on the combination of oral corticosteroids and anti-fungal medications. Moreover, the presence of HAM at diagnosis not only represents immunologically severe disease but also identifies the patient at risk for recurrent relapses [9].\nTake\u00a0home message\nABPA can present with a variety of clinico-radiologic manifestations, among which patients with a history of bronchial asthma and HRCT thorax findings of central bronchiectasis with high attenuating mucus (HAM) have high diagnostic accuracy. Patients with a strong suspicion of ABPA should be confirmed with bronchoalveolar lavage, serological and immunological tests for clinical confirmation.",
    "differential_diagnosis": "Allergic, Bronchopulmonary, Aspergillosis, (ABPA), Bronchocele, -, secondary, to, obstructive, causes, like, bronchial, atresia/stricture,, bronchial, tumour,, endobronchial, foreign, body, Bronchocele, -, secondary, to, non-obstructive, causes, like, bronchial, asthma,, and, cystic, fibrosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-01//18009_1_1.JPG?itok=TzdgjMij",
            "caption": "Ill-defined non-homogenous radio opacities in bilateral upper zones (white arrows) involving paratracheal regions with the medial aspect of the opacities abutting the mediastinal pleura with the tip of densities showing a V-shaped configuration. The right hilum appears enlarged with an Ill-defined non-homogenous radio opacities seen in the right para hilar location (yellow arrows) with the medial aspect of the opacities abutting the mediastinal pleura with the tip of densities showing a V-shaped configuration"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-01//18009_2_1.JPG?itok=hqhDWewo",
            "caption": "Non-contrast CT Thorax axial section lung window at the level of arch of aorta shows dilatation of central segmental bronchi(cylindrical bronchiectasis) (white arrow)"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-01//18009_2_2.JPG?itok=rilt3w7c",
            "caption": "Non-contrast CT Thorax axial  section at the level of arch of the aorta and coronal reconstructed sections mediastinal window shows dilatation of bilateral  upper lobe central segmental(apical and apico-posterior) bronchi with uniformly hyperdense areas/collection seen within the dilated bronchi(white arrows) - possibly representing hyperattenuating mucus (HAM)"
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-01//18009_2_3.JPG?itok=GgZGjMov",
            "caption": "Non-contrast CT Thorax axial  section at the level of arch of the aorta and coronal reconstructed sections mediastinal window shows dilatation of bilateral  upper lobe central segmental(apical and apico-posterior) bronchi with uniformly hyperdense areas/collection seen within the dilated bronchi(white arrows) - possibly representing hyperattenuating mucus (HAM)"
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-01//18009_2_4.JPG?itok=RTp7-Uj2",
            "caption": "Non-contrast CT Thorax axial section mediastinal window at the level of right pulmonary artery shows hyperattenuating mucus of average HU ~ 112 within the dilatated central right upper lobe anterior segmental bronchi"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-01//18009_3_1.JPG?itok=3UvH-xYs",
            "caption": "Axial sections of Non-contrast CT thorax in lung and mediastinal windows showing narrowing of proximal aspect of central segmental(anterior) bronchi in the perihilar region(white arrows)  (possibly secondary due to mucus plugging)"
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-01//18009_3_2.JPG?itok=H6cB_qvE",
            "caption": "Axial sections of Non-contrast CT thorax in lung and mediastinal windows showing narrowing of proximal aspect of central segmental(anterior) bronchi in the perihilar region(white arrows)  (possibly secondary due to mucus plugging)"
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-01//18009_3_3.JPG?itok=Mij8KMmE",
            "caption": "Axial section of Non-contrast CT thorax in lung window at the level of arch of aorta showing multiple areas of small centrilobular nodules (white arrows) of varying sizes with surrounding mild subpleural ground-glass opacities(Black arrow)  involving bilateral upper lobes"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Abdomen",
      "Respiratory system"
    ],
    "imaging_technique": [
      "CT",
      "Ultrasound"
    ],
    "link": "https://www.eurorad.org/case/18009",
    "time": "06.02.2023"
  },
  "18018": {
    "case_id": 18018,
    "title": "A woman with cough",
    "section": "Chest imaging",
    "age": "61",
    "gender": "female",
    "diagnosis": "Lung adenocarcinoma associated with cystic airspaces",
    "history": "A 61-year-old woman with a previous history of Hashimoto\u2019s thyroiditis and bilateral breast augmentation presented to the pulmonologist with complaints of persistent cough. She is a current smoker with 25 pack years. Both bronchoscopy and broncho-alveolar lavage were normal. Furthermore, laboratory findings were unremarkable. A chest CT was performed.",
    "image_finding": "Contrast-enhanced Computed Tomography (CT) with intravenous contrast showed a multilocular cystlike lesion of 2,4 cm in the right lower lobe, partially surrounded by ground glass, some small nodular components and fine intralesional septations (Fig. 1A-B). There were no pathological lymph nodes detected. \u00a0A 18F\u00a0fluorodeoxyglucose-positron emission tomography-CT (FDG-PET/CT) was performed and showed very little uptake of 18F-FDG in the wall of the cystic lesion and in the septations (Fig 2). Follow-up chest CT (not shown) 3 months later showed persistence of the abnormalities without any further changes. A lobectomy was performed and histopathology showed a well-differentiated lepidic predominant adenocarcinoma with no signs of angiolymphatic nor perineural invasion.",
    "discussion": "\u201cLung cancer associated with cystic airspaces\u201d was originally described in 1941 [1]. It is still a rare radiological entity; however, with the widespread use of CT it is gaining more attention the last years [2]. The true prevalence of this entity is unknown. The pathogenesis is not yet understood, with different mechanisms been proposed to date. It is unclear if the cystic airspace precedes the development of lung cancer or tumour growth leads to the formation of the cystic lesion. The latter may be explained by a possible check-valve obstruction at the terminal bronchiolar level by the neoplastic process, leading to formation of the cystic airspace. This theory is supported by the fact that the cystic airspace can increase in size when the nodular component increases. \nA strong association between this disease entity and smoking was noted by Kaneda et al. [3]. Patients can be asymptomatic or can present with classic signs associated with lung cancer, including cough and hemoptoe. Adenocarcinoma is the most commonest found associated cancer [67-80%], but squamous and small cell carcinomas is also seen [4-6]. Lung cancer with associated cystic airspaces tends to have a poor prognosis [3]. Early diagnosis is difficult since findings are subtle and often not recognized in the initial stage. Scholten et al. showed that 22.7% of the missed cancers in the NELSON lung cancer screening trial presented as a bulla with wall thickening [7]. The lesions are often misinterpreted as inflammatory or infectious pathology making it an underrecognized and misdiagnosed entity [6].\nThere are 4 different morphologic types described in the modified Maki et al. classification [4, 8]. Type I is a nodule or mass abutting the external wall of the cyst. Type II is a nodule or mass confined to the cystic airspace. Type III is a soft tissue density extending along the wall/wall thickening, sometimes circumferential. Type IV is a multicystic lesion containing areas of soft tissue density [4, 8]. Especially typ I and IV can be misdiagnosed as benign lesions whereas type II and III lesions often have a broader differential diagnosis [infection, inflammatory]. To date, the value of these classification systems is unclear since they do not provide prognostic information [referentie Radiographics]. \nRadiologists should carefully examine the wall of cystic airspaces, especially in patients at risk for lung cancer, since this type of tumour is at risk for delayed diagnosis. Wall thickening and wall irregularities should alert the radiologist to the possibility of an associated cancer. In the short-term follow-up of lesions with ground glass aspect and possible malignant nature, assessment of the density and occurrence of a solid component is more important than the change in size of the ground glass lesion. The evolution of the cystic airspace can be unchanged, increase or decrease in size and may change morphologically [2]. The absence of interval changes over a short period of time does not exclude a malignant aetiology since lesions with lepidic growth can have an indolent evolution. Moreover, due to the lepidic growth pattern [growth along the surface of intact alveolar walls without stromal or vascular invasion], these lesions show only minor 18F-FDG-uptake.\nInformed patient consent for publication has been obtained.",
    "differential_diagnosis": "Lung, adenocarcinoma, associated, with, cystic, airspaces, Emphysema, with, infection, Congenital, pulmonary, airway, malformation, Cystic, bronchi\u00ebctasis, with, infection, Airspace, enlargement, with, fibrosis, [AEF]",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-02//18018_1_1.gif?itok=wuTB4Bf8",
            "caption": "In the apex of the right lower lobe there is a 2.4 cm lucent area, with irregular thin wall, some septae as well as some surrounding (and interspersed) ground glass component"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-02//18018_1_2.gif?itok=zUwGiHpY",
            "caption": "In the apex of the right lower lobe there is a 2.4 cm lucent area, with irregular thin wall, some septae as well as some surrounding (and interspersed) ground glass component"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-02//18018_2_1.png?itok=XYGSK6N5",
            "caption": "Axial fused 18FDG-PET/CT image shows very low FDG uptake (SUVmax 1.6) in the wall of the cystic lesion and in the septations"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/18018",
    "time": "06.03.2023"
  },
  "18040": {
    "case_id": 18040,
    "title": "Mysterious excavated masses of the lung",
    "section": "Chest imaging",
    "age": "37",
    "gender": "male",
    "diagnosis": "Organizing pneumonia related to cannabis consumption",
    "history": "A 37-year-old male presented chest pain evolving for 15 days with cough and haemoptysis. He had stayed in Tunisia for the five previous months. In his background, we found asthma, cannabis consumption for 20 years and tobacco consumption at 10 packets-year. \nOut of the chest symptoms, the clinical exam found only a low-grade fever of 38.3\u00b0c.",
    "image_finding": "The first CT imaging showed two excavated masses in the left upper lobe and the left lower lobe.\nThere were no mediastinal adenomegaly nor lesion of bronchiolitis.\nAnother CT completed four months later showed a regression of the two previous masses but a newly developed excavated masse in the left lower lobe.\nThe third CT realised six months later the first examination showed a complete resolution of the lesions without new lesions.",
    "discussion": "The gastric BK casings and BK sputum were negatives for direct exams and cultures. Bronchoscopy with bronchoalveolar lavage was macrophagic and the biopsies found no granuloma.\n\u00a0The biological exams found a CRP at 200 mg/l. The anti-neutrophil cytoplasm autoantibody (ANCA) was negative. Either was the angiotensin-converting enzyme and the anti-nuclear antibodies and dot-my site. The serum protein electrophoresis was not inflammatory.\nNo biopsy of the pulmonary lesions was made because of their spontaneous resolution.\nThe CT showed a complete resolution of the lesions after cannabis withdrawal.\nThe diagnosis made by internists was organized pneumonia.\nOrganized pneumonia is characterized by the plugging of connective tissue in the distal airspaces, alveoli, alveolar ducts, and bronchioles.\u00a0 This lung pattern may be idiopathic or caused by many injuries, including drugs, infections, connective-tissue diseases, or inhalation injury.\nThe clinical features are not specific, related to dry cough, fever, weight loss and in half to two-thirds of patients\u2019 dyspnoea [1;2].\nHigh-resolution computed tomography of the lung can reveal various patterns: the dominant pattern (70%) is uni or bilateral, peripheral, and multifocal consolidations with or without air bronchogram. The lesions may progress or migrate over time which can be a key in the diagnosis.\u00a0 Nodular forms are described with solitary or multiple nodules or masses that may \u2013 very rarely- be excavated [3].\nOrganizing pneumonia can often be managed without histopathological confirmation and a biopsy should be performed if the clinical follow-up is inconsistent with the diagnosis [1].\nThe treatment consists in removing the triggering factor, along with corticosteroid treatment or macrolide antibiotics.\nAll patient data have been completely anonymised throughout the entire manuscript and related files.",
    "differential_diagnosis": "Organizing, pneumonia, related, to, cannabis, consumption, Tuberculosis, Vasculitis,, specifically, granulomatosis, with, polyangiitis, Lung, cancer, Sarcoidosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-02//18040_1_1.jpg?itok=xRzskRw5",
            "caption": "CT scan of the lungs in a 37-year-old male, showing two excavated masses with peripheral ground glass opacities in the left upper and lower lobes"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-02//18040_2_1.jpg?itok=aIYG1V6f",
            "caption": "CT scan performed in the same individual after four months, showing a regression of the two previous masses with reticular and retractile scars (Fig. 2). Conversely, there was a newly developed excavated masse in the left lower lobe (Fig. 3)"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-02//18040_3_1.jpg?itok=2pO0djwv",
            "caption": "CT scan performed in the same individual after four months, showing a regression of the two previous masses with reticular and retractile scars (Fig. 2). Conversely, there was a newly developed excavated masse in the left lower lobe (Fig. 3)"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-02//18040_4_1.jpg?itok=NDXXWBVG",
            "caption": "CT scan performed in the same individual six months later, showing a complete resolution of the masses and no new lesion"
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-02//18040_5_1.jpg?itok=A2-KT-D1",
            "caption": "CT scan performed in the same individual six months later, showing a complete resolution of the masses and no new lesion"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Thorax"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/18040",
    "time": "06.03.2023"
  },
  "18054": {
    "case_id": 18054,
    "title": "Mediastinal benign mature cystic teratoma in a female patient without calcification",
    "section": "Chest imaging",
    "age": "30",
    "gender": "female",
    "diagnosis": "Anterior mediastinal non-complicated benign mature type of cystic teratoma without calcification",
    "history": "A 30-year-old female presented to the chest clinic with gradual onset of chest pain and discomfort. For an initial evaluation, a frontal chest radiograph was ordered which was showing asymmetrically widened mediastinal borders, especially in the right paramedian location (not available at the moment). Later on, to characterize the lesion, a contrast-enhanced computed tomography scan of the thorax was ordered to rule out differentials of mediastinal widening.",
    "image_finding": "Contrast-enhanced CT scan images were showing a well-defined well marginated encapsulated large cystic lesion, which was situated along the right-sided margins of the anterior and middle mediastinum.\u00a0It appears to be abutting the right atrium, superior vena cava, and reaching up to the hilar region. There is the presence of another well-defined well-marginated\u00a0fat-containing rounded lesion with an internal non-enhancing mural nodule noted within the cystic lesion.\u00a0Few fat densities in scattered areas were noted along the superior aspect of the lesion. No calcification foci were noted within the lesion. The wall of the lesion shows minimal faint enhancement. No enlarged mediastinal lymph nodes or any metastatic thoracic and upper abdominal lesions were noted.\nThe above findings favour a mature type of cystic teratoma without calcification.",
    "discussion": "Benign mature teratomas are tumours that belong to the group of germ cell tumours, typically occur in young patients and have an approximately equal sex ratio. They are derived from primitive cells that fail to migrate completely during early embryonic development. They predominantly consist of ectodermal elements including skin, sebaceous gland, hair and calcification.\nMediastinal teratomas account for 10-20% of all mediastinal tumours and are usually found in the anterior mediastinum [1]. Other anterior mediastinal tumours are thymoma, thymolipoma, lymphoma, thyroid lesions, aneurysm of thoracic aorta. Most patients are completely asymptomatic as the tumour grows slowly. As they enlarge they may cause symptoms by compressing surrounding structures. Extrinsic compression of the heart and great vessels appears to be very rare [2, 3]. Benign teratomas do have the potential to undergo malignant transformation into a variety of malignancies as rhabdomyosarcoma, adenocarcinoma, leukaemia and anaplastic small cell tumours [4].\nDiagnostic assessment of mediastinal tumours is performed with plain chest radiographs and chest CT. Although the presence of fat and calcification within an anterior mediastinal mass suggests a teratoma, the preoperative diagnosis is often difficult on plain films because of the inability to detect the fat or calcification. CT accurately estimates the density of all included tissues, such as soft tissue (in virtually all cases), fluid (88%), fat (76%), calcification (53%) and teeth, which are considered specific imaging findings [5, 2]. MRI is a very valuable tool in detecting the anatomical relations to the mediastinal and the hilar structures, like vessels and airways. A large anterior mediastinal mass with a well-defined wall and predominantly cystic component are highly suggestive of a benign cystic teratoma. With calcifications in the wall of the mass or small spherical or irregular calcifications within the mass, mature cystic teratoma is even more likely. Unequivocal fat within the mass, particularly a fat-fluid level, makes this diagnosis certain.\nComplete surgical resection is the treatment of choice, but also subtotal resection can relieve symptoms. There is a role of transthoracic biopsy only if lesion is adjacent to bronchus but in our case, it was far away and predominantly in anterior mediastinum therefore only excisional biopsy was preferred.\nTeaching points/Take-home message\nFrom the above case, one can learn that; mature teratoma may present without calcification or tooth which along with fat is a very certain finding generally, therefore this case is an exception to general behaviour.\n\u00a0\nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Anterior, mediastinal, non-complicated, benign, mature, type, of, cystic, teratoma, without, calcification, Thymolipoma, Hydatid, cyst",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-02//18054_1_1.png?itok=dijKqfNG",
            "caption": "Coronal scanogram shows homogenous non-calcified large soft tissue density on the right side with asymmetrical mediastinal widening and the lesion does not project above the clavicle. It obliterates the normal silhouette of the SVC and right heart border. Hilar vessels can be seen through the mass. The rest of the lungs and the pleura appear unremarkable. This goes in favour of anterior mediastinal mass. CT scan confirmed the findings."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-02//18054_2_1.png?itok=-4roeTgu",
            "caption": "Contrast-enhanced axial CT scan showing well-defined well marginated encapsulated large cystic lesion noted abutting right margins of anterior and middle mediastinum, prevascular and visceral areas of the mediastinum.  It appears to be abutting the right atrium, superior vena cava, and reaching up to the hilar region. There is presence of another well-defined well-marginated fat-containing rounded lesion with an internal non-enhancing mural nodule noted within the cystic lesion."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-02//18054_2_2.png?itok=V4svIiZn",
            "caption": "Contrast-enhanced axial CT scan showing well-defined well marginated encapsulated large cystic lesion noted abutting right margins of anterior and middle mediastinum, prevascular and visceral areas of the mediastinum.  It appears to be abutting the right atrium, superior vena cava, and reaching up to the hilar region. There is presence of another well-defined well-marginated fat-containing rounded lesion with an internal non-enhancing mural nodule noted within the cystic lesion"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-02//18054_3_1.jpg?itok=MCCYjjnb",
            "caption": "Photograph of the gross specimen shows an opened cystic mass. Note the presence of yellowish fluid, central fat containing internal lesion, surrounding fat and hair."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-02//18054_3_2.jpg?itok=NlWZ5PsX",
            "caption": "Photomicrograph (original magnification, x4; hematoxylin-eosin stain) of the mature pericardial teratoma shows keratinized squamous epithelium, fat, connective tissue and cartilage."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Mediastinum"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/18054",
    "time": "17.03.2023"
  },
  "18082": {
    "case_id": 18082,
    "title": "Persistent left superior vena cava (PLSVC) and possible Partial anomalous pulmonary venous return (PAPVR)",
    "section": "Chest imaging",
    "age": "56",
    "gender": "female",
    "diagnosis": "Persistent Left Superior Vena Cava (PLSVC) and possible co-existing Partial Anomalous Pulmonary Venous Return (PAPVR)",
    "history": "56-years old female was referred to our department for a routine chest CT. Chest X-ray, which was performed in a smaller regional hospital for chronic coughing and possible COVID-19 pneumonia, revealed right hilar enlargement and a central pulmonary mass was suspected (chest X-ray images were not available). No other medical history was available.",
    "image_finding": "Routine post-contrast chest CT images revealed persistent left superior vena cava (LSVC), originating below the junction of the left subclavian and internal jugular veins, coursing inferiorly to the left of the aorta and main pulmonary artery, and finally draining into the right atrium via the dilated coronary sinus. Normal anatomical position of the right superior vena cava (RSVC) was also found. Bridging vein (BV) was not present. Additionally, anomalous drainage of the right upper pulmonary vein into the right SVC was suspected. Dilation of central pulmonary arteries and segmental pulmonary branches indicate pulmonary hypertension.\nLung window analyses revealed prominent mosaic attenuation in both lungs and enlarged pulmonary branches surrounded by the area of hypoperfused lung. No lung or mediastinal masses were found.",
    "discussion": "Persistent left superior vena cava (PLSVC) is the most common congenital anomaly of the thoracic venous system. When accompanied (in up to 90% of the cases) by normal, right sided superior vena cava (RSVC) anomaly is called double SVC (DSVC). Both veins may be connected with the left brachiocephalic vein, which is then known as bridging vein (BV). PLSVC may be detected as an incidental finding in asymptomatic patients when cardiovascular imaging is performed for various reasons, or due to an atypical course of the catheter on a post-procedural chest X-ray [1-3]. When symptomatic, PLSVC is often associated with other congenital cardiovascular anomalies, most frequently ASD, VSD or less frequent variants such as anomalous pulmonary venous drainage (APVD), which was suspected in this case. The clinical significance of PLSVC depends on the drainage site and the type of accompanying anomalies. The most common site of drainage is the right atrium via the often dilated coronary sinus. Dilatation of CS may cause compression of the atrioventricular node and left atrium and lead to cardiac arrhythmias [1-3]. Less frequently the left atrial drainage is found.\nPost-contrast computed tomography (CT) is most commonly used for the diagnosis. It can easily depict anomalous vessel course, diameter and termination.\nPartial anomalous pulmonary vein return (PAPVR), as potential co-existing anomaly shown in this case, could be the main reason for the enlargement of the right hilum. Right upper lobe pulmonary veins draining into RSVC lead to left to the right shunt, increased pulmonary flow and consequently pulmonary hypertension. If the patient is referred to CT for non-specific reasons, and vascular anomaly is not instantly depicted, analyses of pulmonary vasculature and presence of mosaic attenuation in the lungs may become most helpful. Differentiating the vascular causes of mosaic attenuation from more frequently found small airway disease is crucial. Enlarged central pulmonary arteries, increased ratio between segmental bronchi and adjacent pulmonary artery branches are suggestive of pulmonary hypertension. In advanced stage right ventricular hypertrophy and enlargement, flattening and deviation of interventricular septum may be found [4]. However, because biphasic contrast protocol injection was used, which led to equal enhancement of both pulmonary arteries and veins, it became difficult to distinguish margins between these structures. Dedicated ECG-gated cardiac CT for the evaluation of pulmonary veins might be a useful tool for further clarification and final diagnosis. \u00a0In conclusion, this case report highlights the role of a routine chest CT in the assessment of vascular anomalies. A thorough analysis of chest vasculature may become the most helpful tool for the final diagnosis.",
    "differential_diagnosis": "Persistent, Left, Superior, Vena, Cava, (PLSVC), and, possible, co-existing, Partial, Anomalous, Pulmonary, Venous, Return, (PAPVR), Chest, X-ray:, Central, hilar, mass, Chest, X-ray:, Lymphadenopathy, CT:, Anomalous, left, brachiocephalic, vein",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-03//18082_1_1.jpg?itok=jFCpzwka",
            "caption": "Soft tissue window at the level of the aortic arch shows usuall position of the right SVC, (    blue arrowhead) and PLSVC on the left. (white arrowhead)"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-03//18082_2_1.jpg?itok=mk2r5Crf",
            "caption": "Coronal image showing the corase of the PLSVC to the left of tha aorta and draining into the RA via dilated CS. (white arrowheads)"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-03//18082_3_1.jpg?itok=8efCiWwk",
            "caption": "Dilatatet coronary sinus (black *) and RA ( blue *)"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-03//18082_4_1.jpg?itok=qmtTPaAa",
            "caption": "The diameter of the main pulmonary artery ( black *) is greater than that of the ascending aorta. ( white*)"
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-03//18082_5_1.jpg?itok=mKvyIQhA",
            "caption": "Axial CT image at the level of lower lobes show prominent mosaic attenuation in both lungs. (white*). Segmental and  subsegmental arteries are much larger than the adjecent bronchus. ( white arrow). The airways appear normal. ( arrowhead)"
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-03//18082_6_1.jpg?itok=xDTqy7y2",
            "caption": "Axial (a) and coronal oblique (b) reformatted CT images indicate the right upper lobe pulmonary vein (blue arrow) draining into the right SVC (white arrow), consistent with partial anomalous pulmonary venous return"
          },
          {
            "number": "Figure 6b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-03//18082_6_2.jpg?itok=U7iTagmc",
            "caption": "Axial (a) and coronal oblique (b) reformatted CT images indicate the right upper lobe pulmonary vein (blue arrow) draining into the right SVC (white arrow), consistent with partial anomalous pulmonary venous return"
          }
        ]
      }
    ],
    "area_of_interest": [],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/18082",
    "time": "28.03.2023"
  },
  "18103": {
    "case_id": 18103,
    "title": "Pulmonary Langerhans\u2019 Cell Histiocytosis and solitary eosinophilic granuloma in an adult",
    "section": "Chest imaging",
    "age": "32",
    "gender": "female",
    "diagnosis": "Pulmonary Langerhans\u2019 Cell Histiocytosis",
    "history": "A 32-year-old female presented at the emergency department with acute right-sided thoracic pain. She also complained of a chronic dry cough. She was an active smoker with 10 packyears. Clinical examination and laboratory results were unremarkable. The patient was hemodynamically stable and afebrile.",
    "image_finding": "Computed tomography (CT) reveals multiple thick-walled cystic lesions (<10 mm) as well as some micronodules, predominantly in the upper- and middle lung fields (Figure 1). An osteolytic lesion with non-sclerotic margins, cortical breakthrough and adjacent soft tissue swelling is seen on the lateral aspect of the right seventh rib (Figure 2A). Subsequent bone scintigraphy confirms its unique location (Figure 2B). Immunohistochemical diagnosis of Langerhans\u2019 Cell Histiocytosis was made after a surgical lung biopsy.",
    "discussion": "Langerhans\u2019 Cell Histiocytosis (LCH) is a rare systemic disorder caused by (idiopathic) infiltration and proliferation of Langerhans cells or histiocytes in various organs. Manifestations occur most commonly in bones, lungs, liver\u2013spleen, central nervous system, thymus and lymph nodes.\nPulmonary LCH (PLCH) presents in young adults aged 20 to 40 years old, independent of gender. There is an important association with current (or previous) cigarette smoking in 90 to 100% [1]. Clinical presentation includes chronic cough, dyspnoea and constitutional symptoms (asthenia, weight loss). Only a minority of lesions present with pneumothorax. CT is the modality of choice for pulmonary evaluation. The typical manifestation pattern of PLCH is centrilobular lesions that predominate in the upper and middle lung fields. Basal fields are typically spared. The morphology of the lesions differs depending on the stage of disease. In the early or \u201cflorid\u201d stage, (cavitated) nodules are found, followed by cavitation and formation of thick-walled cysts which progressively transform into thin-walled cysts. End-stage is characterized by fibrotic and cystic changes. The key features for diagnosis are patient age, a history of smoking, and the distribution pattern and morphology of the lesions. Cysts with a round shape in random distribution (no basal sparing) and absence of parenchymal nodules favors the diagnosis of lymphangioleiomyomatosis (LAM), while cysts predominate in the lower lobes favors lymphocytic interstitial pneumonitis (LIP). In centrilobular emphysema, destructed parenchyma lacks a visible wall. Overall, pulmonary findings can be confounding, thus biopsy is mandatory especially in young females with a cystic pattern at onset [1-3].\nLCH in a solitary bone was previously referred to as eosinophilic granuloma. It is more commonly seen in children aged 3 to 5 years old, with predilection site of the skull, pelvis and femur. It is rarer in adults, in whom the jaw, skull and vertebra are the preferred locations [4]. Patients present with pain, tenderness and swelling around the lesion. CT is the preferred modality to evaluate matrix and adjacent structures. The osteolytic defect has non-sclerotic margins and is often beveled due to uneven destruction of the inner and outer cortex [5]. Adjacent soft tissue swelling can also be appreciated on CT and ultrasound, which is a good site for biopsy. Bone scintigraphy and PET-CT are useful to evaluate multiplicity [4, 6]. The differential diagnosis for an osteolytic rib lesion with non-sclerotic margins includes metastasis, multiple myeloma, primary bone malignancy, osteomyelitis and lymphoma.\nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Pulmonary, Langerhans\u2019, Cell, Histiocytosis, Lymphangioleiomyomatosis, (LAM), Emphysema, Lymphocytic, interstitial, pneumonitis, (LIP), Usual, interstitial, pneumonia, (UIP), Wegener, granulomatosis, Septic, emboli, Pneumatocoeles, secondary, to, pulmonary, infections, Metastasis, Osteomyelitis, Multiple, myeloma, Primary, bone, malignancy, Lymphoma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-03//18103_1_1.png?itok=bSIO6SL2",
            "caption": "Coronal CT scan of the thorax in lung window. Description: Multiple thick-walled cystic lesions (< 10 mm) in the upper- and middle lung fields, with some micronodules (red arrow). Notice sparing of the lower fields"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-03//18103_2_1.png?itok=ZTkbPJrD",
            "caption": "Coronal CT scan of the thorax in bone window. Description: Ill-defined osteolytic lesion with cortical breakthrough and adjacent soft tissue swelling is seen on the lateral aspect of the seventh rib on the right (red arrow)"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-03//18103_2_2.png?itok=rDaS4VBC",
            "caption": "Bone scintigraphy in the early osteoblastic phase. Description: Bone scintigraphy was used to exclude multifocality of musculoskeletal LCH. Osteoblastic activity is seen on the lateral aspect of the seventh rib on the right (red arrow), correlating with a solitary eosinophilic granuloma"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Musculoskeletal bone",
      "Musculoskeletal soft tissue"
    ],
    "imaging_technique": [
      "CT",
      "SPECT"
    ],
    "link": "https://www.eurorad.org/case/18103",
    "time": "18.04.2023"
  },
  "18116": {
    "case_id": 18116,
    "title": "Intense abdominal pain with some respiratory difficulty after vomiting",
    "section": "Chest imaging",
    "age": "37",
    "gender": "male",
    "diagnosis": "Boerhaave syndrome with left tension hydropneumothorax and pneumomediastinum",
    "history": "A 37-year-old young man with no noteworthy health history presented to the emergency room because he woke up nauseated and started with intense abdominal pain with some respiratory difficulty after vomiting. No prior intake of NSAIDs. The patient was hemodynamically stable, with shallow breathing and marked hypoventilation in the left hemithorax.",
    "image_finding": "Intravenous chest CT scan with coronal reconstruction, with soft tissue, and lung window (Figure 1), showing the perforation of the intrathoracic distal oesophagus, due to a tear in the lower left lateral aspect, upper from the GE junction and left tension hydropneumothorax secondary to the oesophagus perforation, with complete lung collapse, pneumomediastinum, and subcutaneous emphysema.",
    "discussion": "Background\nOesophageal perforation usually occurs after chest trauma, complications of the surgery, and after violent vomiting (Boerhaave Syndrome) [1-3]. Boerhaave syndrome is defined as a dehiscence of the oesophageal wall in an area macroscopically healthy, generally because of a sudden increase in oesophageal pressure combined with intrathoracic negative pressure caused by vomiting. It usually occurs on the left side wall in the lower third oesophagus, 3-5 cm above the gastroesophageal junction (Figures 1A and 1B) [4-5]. In our patient, Boerhaave syndrome was accompanied by a left tension hydropneumothorax (it was not superinfected) probably due to a complex valvular mechanism: mean pleural pressure is usually between -5 to +5 cmH2O, being lower than oesophageal pressure (according to the laws of physics, the air contained in the esophagus is at a higher pressure since the volume in which it is found is smaller). This, added to the emetic efforts of the patient, would cause a continuous passage of air from the digestive tract to the pleural space in the first hours. On the other hand, it must be considered that the patient's pain can reduce the work of breathing and thereby reduce lung expansion and perpetuate the mechanism of air entering the pleural space from the esophagus.\nClinical Perspective\nMain symptoms are vomiting, pain thoracic (the most common), dyspnoea, dysphagia, subcutaneous emphysema, tachycardia, fever, tachypnoea, and epigastric pain. The Mackler triad (vomiting, severe chest pain, and cervical subcutaneous emphysema) is seldom presented in a complete way [4-5]. Diagnostic delays increase morbidity and mortality, so an effective imaging protocol allows rapid identification and excludes other causes of acute chest pain [1].\nImaging Perspective\nChest radiographs can demonstrate indirect findings of oesophageal perforation [4-5], however, the World Society for Emergency Surgery (WSES) recommends the use of CT with intravenous contrast of the chest (Figure 1) or CT oesophagography (using oral contrast) as the initial imaging of choice (Grade 1C) [6]. So when suspected, two issues must be decided before the CT exam; first, determine whether to perform acquisitions without and with intravenous iodinated contrast before oral contrast; second, determine whether the patient can drink oral contrast [1]. CT has a sensitivity of 92\u2013100% and can rule out alternative diagnoses, evaluate the degree of involvement of surrounding structures (air or fluid in the mediastinum, pleural effusion (Figures 1C and 1D)), and guide management of fluid collections that require percutaneous or surgical drainage [5].\nOutcome\nSince mortality can reach up to 80% in the first 24-48 hours, early consultation with appropriate interventionalists is vital (interventional endoscopy and surgery, and critical care). There are several options available for definitive therapy. Primary surgical repair has been the traditional treatment; however, non-operative management is nowadays considered in patients who have been diagnosed early with evidence of a contained leak and without signs of systemic infection. A hybrid approach utilizing stent placement can be used depending on the location and underlying pathologies [5]. In our case, surgeons place a chest tube for drainage of the left hemithorax with significant hydropneumothorax (2L). After that, a median supraumbilical laparotomy was performed. They opened the left and anterior diaphragm pillar for better access to the esophagus. A clear display of linear perforation affecting all esophagus layers was seen, which extended longitudinally for about 5 cm. A simple suture with loose vicryl stitches and a leak test with air and serum were done.\nTake Home Message / Teaching Points\nIt is essential to have an adequate CT protocol that allows rapid identification of oesophageal perforations since this is a serious pathology whose morbidity and mortality increase with diagnosis delay.\n\u00a0\nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Boerhaave, syndrome, with, left, tension, hydropneumothorax, and, pneumomediastinum, Aortic, emergency, Myocardial, infarction, Cardiac, tamponade, and/or, pericarditis, Pulmonary, embolism, Perforated, peptic, ulcer, and/or, pancreatitis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-03//18116_1_1.jpg?itok=DYtxETm8",
            "caption": "A) axial CT with soft tissue window and B) axial CT with lung window (same level) showing lower left lateral perforation of the intrathoracic distal oesophagus (arrows), the gas surrounding the oesophagus due to perforation (little stars), pleural effusion on the left hemithorax (triangle) and left pneumothorax with a complete collapse of the lung (small arrows), altogether, left tension hydropneumothorax due to distal intrathoracic oesophagus perforation"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-03//18116_1_2.jpg?itok=dQdhISLt",
            "caption": "A) axial CT with soft tissue window and B) axial CT with lung window (same level) showing lower left lateral perforation of the intrathoracic distal oesophagus (arrows), the gas surrounding the oesophagus due to perforation (little stars), pleural effusion on the left hemithorax (triangle) and left pneumothorax with a complete collapse of the lung (small arrows), altogether, left tension hydropneumothorax due to distal intrathoracic oesophagus perforation"
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-03//18116_1_3.jpg?itok=aiD_zvig",
            "caption": "C) axial CT with lung window in the upper thoracic portion and D) coronal CT reconstruction with modified lung window demonstrating left tension hydropneumothorax (small arrows and triangle) with mediastinum slightly displacement to the right, and gas in the upper mediastinum and subcutaneous emphysema (little stars)"
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-03//18116_1_4.jpg?itok=1pLaGjT7",
            "caption": "C) axial CT with lung window in the upper thoracic portion and D) coronal CT reconstruction with modified lung window demonstrating left tension hydropneumothorax (small arrows and triangle) with mediastinum slightly displacement to the right, and gas in the upper mediastinum and subcutaneous emphysema (little stars)"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Emergency",
      "Gastrointestinal tract",
      "Mediastinum"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/18116",
    "time": "18.04.2023"
  },
  "18118": {
    "case_id": 18118,
    "title": "Lung and parotid gland involvement in Granulomatosis with Polyangiitis",
    "section": "Chest imaging",
    "age": "44",
    "gender": "female",
    "diagnosis": "Granulomatosis with polyangiitis",
    "history": "Female, 44 years old\nSmoker\nNo previous pathologies in patient history\nNo chronic therapy\nNot pregnant",
    "image_finding": "First Rx scan shows hardly distinguishable areas of opacity with a central excavation in both of the apices of the lung. In the second Rx Scan, both apical opacities are easily distinguishable, and also central excavation is well-defined.\nEnhanced CT scan of the head and neck shows an enlarged, inhomogeneous right parotid with hypodense region within the gland parenchyma of several enlarged right-sided peri-parotid and cervical lymph nodes are also present.\nIn maxillofacial CT scan, we can appreciate the maxillary sinus mucosa thickening; we can also notice a slight right-convex deviation of the nasal septum.\nThe Chest CT scan indicates cavitating lesions of the lung at both apices, further solid-nodular lesions with central cavitation are evident in the lung bases, and some small mediastinal lymph nodes are evident.\nIn the MRI scan the parotid gland is enlarged with inhomogeneous post-contrast enhancement and diffuse signal restriction on DWI.",
    "discussion": "Granulomatosis with polyangiitis (GPA), previously known as Wegener granulomatosis, is a vascular antineutrophil cytoplasmic antibody\u2013associated disease that involves medium and small-sized vessels with evidence of vascular wall inflammatory infiltrations and granulomas.\nGPA may involve any organ, but most frequently the upper airways, lungs and kidneys. On histology, the typical findings are granulomas with central necrosis and cavitation, which are usually found in the small artery wall, capillaries and venules of the airways and lung as in the renal glomeruli.\nClinical presentation is variable, and nose involvement is often the first sign in most people [1, 2].\nInvolvement of the upper respiratory tract is seen in nearly all people with GPA [3]. Upper respiratory tract involvement includes cough, fever, dyspnea, asthenia, chest pain, persistent rhinorrhea, epistaxis, hemoptysis, sinusitis, weight loss, arthralgia, otitis, arthritis, and mucosal ulceration.\nImaging findings in the parotid gland are nonspecific and consist of heterogeneous gland enlargement and hyper and heterogeneous enhancement after contrast injection; the evidence of high signal intensity on T2-weighted MR images, related to necrosis.\nImaging findings in nose and paranasal sinuses include bone involvement in paranasal sinuses, sphenoid bone, osseous erosions due to granulomas and mucosal thickening.\nLung is the organ most commonly involved, mainly bilaterally, with multiple pulmonary nodules and masses, from a few millimeters to 10 cm in diameter. In larger lung lesions, it is more common to find cavitation.\nPeripheral hemorrhage around lung nodules appears on HRCT images as ground-glass opacity surrounding the nodule, which is known as the \u201chalo\u201d sign\u00a0[4]. Consolidation and spots within ground glass opacities can be seen in perihilar areas and in the middle lower lung.\nThe final diagnosis was made by increased PCR value, c-ANCA antibody positivity and biopsy result.\nThe therapy consists in corticosteroids, immunosuppressants and cyclophosphamide. New therapies have been tested, such as methotrexate, etanercept and rituximab.\nIf no renal complications occur, 5 years after diagnosis, the current survival rate for patients is 100%, while at 10 years, it drops to 75-88%.\nGPA disease can mimic different infectious diseases including tuberculosis. Is important to evaluate all these findings and consider autoimmune disease as alternative diagnosis when cavitary lesions are discovered. Manifestations are often identified at chest CT, and the radiologist may be the first to suggest GPA diagnosis. CT is the imaging modality of choice for diagnosis, surveillance, and follow-up in patients with GPA [5].\n\u00a0\nAll patient data have been completely anonymised throughout the entire manuscript and related files.",
    "differential_diagnosis": "Granulomatosis, with, polyangiitis, Parotid, gland, abscess, with, septic, embolism, Tuberculosis, Lung, abscess, Pulmonary, metastases, GPA",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-03//18118_1_1.JPG?itok=dfbKgUZ2",
            "caption": "Shows the first rx scan, which was performed with incorrect placement of the patient, this leads the sternal ends of the clavicles to cover the apical lesions, which, in this case, are hard to detect"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-03//18118_1_2.JPG?itok=0o5-wie0",
            "caption": "RX scan, performed with a correct patient placement, shows the cavitary lesions in a more definite way, this rx scan was also perform 15 days after the first one, probably one of the reasons why the lesions are more evident is also their progression"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-03//18118_2_1.JPG?itok=w-L6By8E",
            "caption": "CT scan, show a thickening of the maxillary sinus in his medial and basal area. In this image we can also notice a subtle nasal sept deviation"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-03//18118_2_2.JPG?itok=hRKTTG99",
            "caption": "Head and neck CT scan shows the parotid gland. The scan is performed in enhanced-venous phase. We can notice the inhomogeneous enhancement of the parotid gland , which is very enlarged compared to the contralateral one . The central area is hypointense and it does not have contrast enhancement"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-03//18118_3_1.JPG?itok=rs0zrJh9",
            "caption": "Evidences two apical cavitary lesions with their characteristics wall thickness and the central area filled with gas, which can be easily recognized by the lack of the parenchymal lung. Also, nodular lesions with a cavitary center area"
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-03//18118_3_2.JPG?itok=NFiaifzM",
            "caption": "Nodular lesions with a cavitary center area"
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-03//18118_3_3.JPG?itok=p6ao-sIt",
            "caption": "Nodular lesions with a cavitary center area"
          },
          {
            "number": "Figure 3d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-03//18118_3_4.JPG?itok=TMIanY5H",
            "caption": "Nodular lesions with a cavitary center area"
          },
          {
            "number": "Figure 3e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-03//18118_3_5.JPG?itok=BA6QG-W2",
            "caption": "The same apical lesions in enhanced venous phase"
          },
          {
            "number": "Figure 3f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-03//18118_3_6.JPG?itok=yxF5Rnl9",
            "caption": "The same apical lesions in enhanced venous phase"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-03//18118_4_1.JPG?itok=0P7KZyyg",
            "caption": "MRI scan is a T2 weighted image where we can recognize the central parotid area as fluid"
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-03//18118_4_2.JPG?itok=nz6M2oSG",
            "caption": "DWI sequence which shows a signal restriction"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Head and neck",
      "Salivary glands",
      "Thorax"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT",
      "MR"
    ],
    "link": "https://www.eurorad.org/case/18118",
    "time": "18.04.2023"
  },
  "18121": {
    "case_id": 18121,
    "title": "Venous hemangioma of the anterior mediastinum",
    "section": "Chest imaging",
    "age": "70",
    "gender": "male",
    "diagnosis": "Venous hemangioma of anterior mediastinum",
    "history": "A 70-year-old male incidentally found a large mass of the anterior mediastinum without dyspnea and chest pain.",
    "image_finding": "Contrast-enhanced CT scan showed a lobulated, solid mass under the left anterior mediastinal pleura, measuring 6.5x5.3cm, with round smooth calcifications scattered randomly.\nArterial phase images were collected 30 seconds after beginning of contrast injection, most of the tumor showed slight enhancement (CT value increased by less than 10HU), while patchy obvious enhancement (CT value increased by 40HU) was detected in the venous phase (50 seconds after the beginning of contrast injection). The left cephalobrachial vein was obviously displaced. No hilar or mediastinal lymphadenopathy was detected.\nAfter excluding surgical contraindications, surgical resection was performed. the postoperative pathological results confirmed that it was venous hemangioma and there was no special discomfort after the operation.\nNo evidence of recurrence at 15 months after surgery was detected.",
    "discussion": "Mediastinal hemangiomas, which account for approximately 0.5% or less of all mediastinal tumors, are almost benign tumors made up of abundant vascular [1, 2]. Histologically, hemangioma is characterized by increased endothelial cell turnover and proliferation of normal vascular components and have various amounts of interposed stromal elements (e.g., fat, myxoid, and fibrous tissue) [2, 3]. Usually appearing after birth, growing rapidly, and then involuting over time [2]. There is a wide range of ages at the time of diagnosis (26 days\u201376 years), and the peak incidence is in the first decade of life [2]. There is no sex predilection [1]. The tumors are categorized according to the size of their vascular spaces as capillary, cavernous, or venous hemangiomas. Venous hemangiomas (VH) are extremely rare and they only account for 1% of all mediastinal hemangiomas [2].\nOne-third to one-half of the patients had no symptoms at presentation; the rest of the patients had non-specific symptoms such as cough, chest pain, and dyspnea caused by larger mass compression or, less likely, invasion of adjacent structures [2].\nThe mass is located behind the sternum, and the chest radiograph can not show clearly and locate the tumor accurately. Contrast-enhanced CT scans can show the exact location and adjacent structures of the tumor, which is of key importance to operation planning. Hemangiomas are usually round or lobulated, with smooth margins. Calcified small round phleboliths are of great significance in indicating the vascular nature of the mass, although phleboliths can be detected in only 10% of cases [2]. In our case, we could observe this finding. According to Seline et al., central \u201cpuddling\u201d of contrast material also indicates the diagnosis of mediastinal hemangioma [2, 3], which has also been confirmed in our case. We noticed an obvious enhancement area caused by contrast media siltation inside the mass in venous phase, which could increase confidence in the diagnosis of hemangioma. Because the symptoms and imaging findings are usually non-specific, the accurate diagnosis of mediastinal hemangioma before an operation is difficult. Surgery is an important way of diagnosis and treatment. Because the tumor may recur after incomplete resection, complete resection of the tumor is recommended [1].\nAlmost all mediastinal hemangiomas are benign, but occasionally, large masses can cause compression or invasion to adjacent structures, requiring multiple operations [4]. Till now, there has no metastasis or recurrence case been reported. Because of abundant vascular of the mass, it is of great significance to indicate the diagnosis of hemangioma before surgery for reducing intraoperative blood loss.",
    "differential_diagnosis": "Venous, hemangioma, of, anterior, mediastinum, Thymoma, Intrathoracic, goiter, Lymphoma, Teratoma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-03//18121_1_1.png?itok=fNAnGjsm",
            "caption": "Unenhanced axial CT (a) revealed a lobulated, solid mass of the anterior mediastinum, with an unclear margin with the mediastinal vessels and the left anterior mediastinal pleura (arrows)"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-03//18121_1_2.png?itok=4cveeXM2",
            "caption": "Unenhanced axial CT (b) revealed the mass with round smooth calcifications scattered randomly (*), which correspond to the phleboliths"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-03//18121_2_1.jpg?itok=boqk6jdk",
            "caption": "Enhanced axial CT revealed most of the tumor showed slight enhancement (CT value increased by less than 10HU) in arterial phase"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-03//18121_2_2.png?itok=LpdsMYSS",
            "caption": "Enhanced axial CT detected an obvious enhancement area (CT value increased by 40HU) in venous phase (*). The left cephalobrachial vein was obviously displaced (arrow)"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-03//18121_3_1.jpg?itok=gsvmWQTI",
            "caption": "Post-surgical chest CT showing a good end result. No signs of local recurrence"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/18121",
    "time": "17.04.2023"
  },
  "18134": {
    "case_id": 18134,
    "title": "Hemangioma \u2013 a rare case of mediastinal mass",
    "section": "Chest imaging",
    "age": "73",
    "gender": "female",
    "diagnosis": "Mediastinal Hemangioma",
    "history": "A 73-year-old woman, non-smoker, with a history of congestive heart failure and several risk factors for cardiovascular disease, presented with a twenty-day history of left chest pain and dyspnea. The physical examination shows diminished left lung sounds in chest auscultation. Pleuracentese of effusion revealed an exudate, where tumor markers and cultures were negative.",
    "image_finding": "Chest X-ray revealed moderate free pleural effusion on the left (Fig. 1). \nUnenhanced thoracic computed tomography (CT) imaging (Fig. 2) showed moderate left pleural effusion and a 5 cm homogeneous soft-tissue oval mediastinal mass in the aortopulmonary window, smoothly marginated and without calcifications or areas of fat attenuation. CT after intravenous administration of iodinated contrast (Fig. 2) revealed marked peripheral enhancement of the mediastinal mass in the arterial phase. The interface of the lesion and adjacent mediastinal structures, namely pulmonary artery trunk, was clear.",
    "discussion": "Hemangiomas are uncommon benign vascular mediastinal lesions (0.5% of mediastinal masses) [1]. \nThe cause of hemangiomas is unclear but can represent either true neoplasm or developmental vascular anomalies [2]. The anterior mediastinal compartment is most commonly involved, but hemangiomas can be located in any compartment of the mediastinum or involve multiple compartments [1,2,3]. This disease has a higher incidence in young adults, with 75% of cases being under 35 years old [1,4]. \nAt histological examination, the lesions are a combination of large interconnecting vascular spaces lined by vascular endothelium, with interposed stromal elements (such as fat, myxoid and fibrous tissues) and focal organized thrombus, which can calcify as phleboliths [1,2,3]. Hemangiomas can be classified based on the size of vascular spaces as capillary, cavernous or venous, the cavernous ones being more common in the mediastinum [1,2]. Up to half of patients are asymptomatic at diagnosis. The symptoms appear due to compression of adjacent mediastinal structures, with a nonspecific clinical presentation, which includes cough, chest pain and dyspnea[2]. \nIn non-enhanced CT scans, the hemangioma is often a heterogeneous and well-defined soft tissue attenuated mass [1,2]. Infiltration of mediastinal structures is uncommon [2]. The presence of calcifications, normally round and ringlike, is a feature that helps in the diagnosis of hemangioma, however they may be present in other mediastinal lesions, such as teratomas or cartilaginous tumors [1,2]. Intralesional fat attenuation is rare but may be present [2]. On single arterial phase CT scan after contrast administration, the enhancement pattern is uncharacteristic: peripheral, central, mixed or homogeneous patterns have been described [2,3]. On delayed images, progressive and centripetal fill-in enhancement or enhancement \u00abfast in and slow out\u00bb are characteristic of hemangiomas, but not always present [1,2,6]. \nIn the magnetic resonance (MR) imaging, hemangiomas are usually presented as heterogeneous lesions on T1 weighted imaging (WI), with isointense and hyperintense nodular areas, the latter attributable to macroscopic fat. Hemangiomas are typically hyperintense on T2 WI fat suppression imaging, similar to the presentation of these lesions in other organs, like the liver, due to the high fluid content [1,6].\nThe association between pleural effusion and mediastinal hemangioma is poorly understood, with few cases described in the literature.\nImagiological diagnosis of mediastinal hemangioma is difficult and the biopsy of hypervascular lesions carries the risk of uncontrolled hemorrhage [1,4,5]. Hemangioma is a benign tumor, its resection with tharoscopy or open thoracotomy has good results, with rare recurrence. Further than that, preoperative interventional embolization may be performed to reduce the risk of intraoperative bleeding or, as a conservative option, if the lesion is asymptomatic, and careful follow-up is an option [3,4].",
    "differential_diagnosis": "Mediastinal, Hemangioma, Mediastinal, Teratoma, Mediastinal, Lymphoma, Mediastinal, Lymphangioma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-03//18134_1_1.png?itok=RO70Or1B",
            "caption": "Frontal chest x-ray shows a left sided moderate pleural effusion"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-03//18134_2_1.png?itok=wSn2Db0G",
            "caption": "Axial (a), coronal (b) and sagittal (c) unenhanced chest CT showing large left-side pleural effusion and homogeneous mass (blue arrow) with soft-tissue attenuation in aortopulmonary window of visceral mediastinal compartment. The tumor does not present calcifications or fat attenuation"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-03//18134_2_2.png?itok=ak7H1a3U",
            "caption": "Axial (a), coronal (b) and sagittal (c) unenhanced chest CT showing large left-side pleural effusion and homogeneous mass (blue arrow) with soft-tissue attenuation in aortopulmonary window of visceral mediastinal compartment. The tumor does not present calcifications or fat attenuation"
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-03//18134_2_3.png?itok=OH72Zbqy",
            "caption": "Axial (a), coronal (b) and sagittal (c) unenhanced chest CT showing large left-side pleural effusion and homogeneous mass (blue arrow) with soft-tissue attenuation in aortopulmonary window of visceral mediastinal compartment. The tumor does not present calcifications or fat attenuation"
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-03//18134_2_4.png?itok=2o_0Rchv",
            "caption": "Axial (d), coronal (e) and sagittal (f) enhanced chest CT in the arterial phase showing nodular peripheral enhancement of the lesion (blue arrow)"
          },
          {
            "number": "Figure 2e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-03//18134_2_5.png?itok=SpafI5wv",
            "caption": "Axial (d), coronal (e) and sagittal (f) enhanced chest CT in the arterial phase showing nodular peripheral enhancement of the lesion (blue arrow)"
          },
          {
            "number": "Figure 2f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-03//18134_2_6.png?itok=hBfmw23Z",
            "caption": "Axial (d), coronal (e) and sagittal (f) enhanced chest CT in the arterial phase showing nodular peripheral enhancement of the lesion (blue arrow)"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Mediastinum"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/18134",
    "time": "10.05.2023"
  },
  "18145": {
    "case_id": 18145,
    "title": "Cervical herniation of an atypical emphysematous bull",
    "section": "Chest imaging",
    "age": "68",
    "gender": "male",
    "diagnosis": "Atypical Emphysematous bulla",
    "history": "A 68-year-old man with a hard lump on his palate was admitted for further evaluation. During the preoperative assessment, an emphysematous bulla was incidentally detected.",
    "image_finding": "Chest X-Ray (Figure 1) performed for routine pre-operative evaluation showed a cystic lesion occupying most of the right apical region. These findings were confirmed on a CT scan (Figure 2) which showed Para-septal emphysema with apical predominance (Right > Left) and a large thin-walled air-containing bulla arising from the right apical lobe extending into the neck space. The large bulla caused mild deviation of the trachea to the left and displacement of the right carotid sheath and its content. There was also passive atelectasis of underlying apical lung parenchyma. The patient had a surgical procedure to remove the hard palate mass and received the appropriate anaesthetic management for an individual with large emphysematous bullae.",
    "discussion": "A bulla is defined as an air-filled region within the lung that is larger than 1 cm in diameter and has developed as a result of emphysematous deterioration of the lung parenchyma. [1] They do not participate in gas exchange and are most frequently found in the hypo-perfused upper lungs. Pulmonary bullae frequently coexist with severe emphysema but can rarely be seen in the healthy lung. The apex of the lung extends into the base of the neck three to four centimetres above the level of the first costal cartilage, allowing such bullae to herniate into the neck from the thoracic cavity. [2] \nA bulla from the lung's apex has been theorised as having a chance to herniate through the Sibson fascia and appear in the neck. [3] Sibson's fascia has a potential weakness on the anteromedial side between the scalenus anterior and sternocleidomastoid muscles. [2,4] There are a few hypotheses about bulla expansion. The most widely accepted explanation states that a one-way valve mechanism results from partial occlusion of the airways in an emphysematous lung, allowing air to enter the bulla during inspiration but become trapped during expiration, slowly leading the bulla to enlarge. [3] \nEnlarged bullae may result in mediastinal displacement, atelectasis, and compression of the nearby lung parenchyma. Bullae enlargement are common, although spontaneous regression is unusual. [3] \nA few major complications due to emphysematous bullae include haemorrhage into the bullae, infection, and spontaneous pneumothorax. [3,5\u20137]. Patients with concomitant bullous lung lesions may present for non-thoracic surgery. The diagnosis of this condition is crucial since these patients are more likely to have complications from the bullae or underlying lung disease while under anaesthesia. [8] \nBullae are easily identifiable on a typical chest x-ray. The precise anatomical location, volume occupied, condition of the underlying lung parenchyma, and presence of complicated characteristics like infection and pneumothorax can all be determined with the aid of a CT scan. [9] Few cases of emphysematous bullae herniation have been reported in the literature, making it a relatively unusual complication.\nIn this case, the patient had a significant history of cigarette smoking for the past 30 years. The patient underwent an excisional biopsy for the palatine mass which turned out to be a lipoma. Due to the presence of a large emphysematous bulla and extreme age, the biopsy was performed using IV sedation. General anaesthesia was avoided because anaesthesia induction and positive-pressure ventilation could lead to the rupture of these bullae and lead to potential life-threatening pneumothorax. Therefore it\u2019s crucial for a radiologist to point out such imaging findings.\nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Atypical, Emphysematous, bulla, Paratracheal, cyst",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-04//18145_1_1.JPG?itok=aLB7aAHj",
            "caption": "Chest radiograph (PA view) showed an encapsulated lesion with air lucency extending from the apical region extending into neck with mild tracheal deviation"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-04//18145_2_1.JPG?itok=POF6UGyf",
            "caption": "Axial CT section in lung window shows bilateral para-septal emphysema with a large right apical bulla dissecting superiorly into the neck spaces"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-04//18145_3_1.JPG?itok=4rBSUibN",
            "caption": "Coronal CT section in lung window shows an air containing Bulla with cervical extension, surrounding mass effect in form of tracheal deviation and passive compressive atelectasis of the surrounding lung"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-04//18145_4_1.JPG?itok=pwuO1Hud",
            "caption": "Axial section in venous phase shows superior herniation of bulla with displacement of surrounding tracheal, oesophagus and carotid space"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Respiratory system"
    ],
    "imaging_technique": [
      "CT-High Resolution"
    ],
    "link": "https://www.eurorad.org/case/18145",
    "time": "12.06.2023"
  },
  "18173": {
    "case_id": 18173,
    "title": "Chemical pneumonitis after a single exposure to bleach",
    "section": "Chest imaging",
    "age": "43",
    "gender": "female",
    "diagnosis": "Chemical pneumonitis with subsequent reactive airways dysfunction syndrome (RADS)",
    "history": "We present a 43-year-old woman that presents with franc dyspnea, non-productive cough and central chest pain with 2 weeks of evolution, with no fever, that she associates with a single inhalative high-concentration exposure to bleach, during normal work. She had no pre-existing atopy or pulmonary problems. Two weeks earlier, she went to the emergency department of a private hospital, having been diagnosed with right community-acquired pneumonia, having been medicated with antibiotics and bronchodilator therapy. She returned to the emergency department a week later with aggravated symptoms, due to lack of response to the prescribed antibiotic and bronchodilators. \nLaboratory tests revealed mildly elevated C-reactive protein (12 mg/dL with normal range being <3.0mg/dL) and leukocytosis (17.8x10^9 with 88% of neutrophils) and the oxygen saturation levels were 92%. On auscultation of her chest, widespread expiratory wheeze was noted.",
    "image_finding": "The patient was subjected to thorax radiograph (figure 1), which revealed areas of \u200b\u200bdiscrete hypotransparency in the uppers thirds of the hemithoraces. A computed tomography (CT) scan of the chest was also performed, revealing peribrochovascular ground glass opacities and some foci of consolidation affecting the upper and middle lobes (figure 2, 3 and 4).\nGiven the known history of exposure and the atypical imaging pattern for community-acquired pneumonia, a diagnosis of chemical pneumonitis was made and treatment with oxygen, bronchodilators and steroids was prescribed. Her condition improved in a few days.",
    "discussion": "Chlorine-containing bleach is commonly used as a household cleaning agent. Although it is safe for household use, it can cause damage to the eyes, skin, gastrointestinal tract, and cardiovascular system[1]. Respiratory complications that develop after acute exposure to chlorine gas include rhinitis, pneumonitis, pulmonary oedema, and acute respiratory distress syndrome [1-4]. Most of the patients who developed respiratory symptoms after exposure to inhaled domestic products normally have pre-existing lung problems or atopy[4-7]. \u00a0However, in our patient, there was no pre-existing atopy or pulmonary problems. \nChemical pneumonitis is an inflammation of the lungs and has been reported after exposure to a variety of industrial chemicals and respiratory irritants. The treatment is usually supportive, although steroids have been administered during the acute phase after exposure.[5] Antibiotics are usually not helpful or needed, unless there is a secondary infection.\nReactive airways dysfunction syndrome (RADS) is a disorder characterized by asthma-like symptoms resulting from a high level of exposure to an irritant gas, smoke, fume or vapour either at the workplace, at home or in the general environment, in patients not previously diagnosed with lung disease[8-10]. The incidence of developing RADS after an inhalational exposure to a chemical product has been difficult to quantify because specific information at the time of an inhalational accident (magnitude and duration of exposure) is often not available.\nThe treatment of RADS is similar to that of asthma. Therapy with nasal oxygen, corticosteroids and bronchodilators are recommended [11], but the response rate to bronchodilators is less than in patients with known asthma [12].\nThe clinical context is of utmost importance for the radiologist to raise the final diagnosis, and therefore, avoiding the use of antibiotics. Also, inhalation of an irritant substance should be considered in a patient who presents with sudden onset of symptoms affecting the eyes, skin or respiratory tract.\nIt is important to take precautions when using chemical products at home as household products may not be totally safe even after going through vigorous testing and approval processes.",
    "differential_diagnosis": "Chemical, pneumonitis, with, subsequent, reactive, airways, dysfunction, syndrome, (RADS), Hypersensitivity, pneumonitis, Acute, eosinophilic, pneumonia, Organizing, pneumonia, Community-acquired, pneumonia",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-04//18173_1_1.jpg?itok=FqKe-eRO",
            "caption": "Plain radiograph of the thorax showing areas of discrete hypotransparency in the uppers thirds of the hemithoraces (circles)"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-04//18173_2_1.jpg?itok=AT7OZqnx",
            "caption": "Coronal CT image showing ground glass peribrochovascular opacification in the upper lobes"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-04//18173_2_2.jpg?itok=SIZMk9ly",
            "caption": "Axial CT image showing ground glass peribrochovascular opacification in the right upper lobe"
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-04//18173_2_3.jpg?itok=4BJjgAwg",
            "caption": "Axial CT image showing ground glass peribrochovascular opacification in the middle lobe and lingular segments of right upper lobe"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Respiratory system"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/18173",
    "time": "13.06.2023"
  },
  "18174": {
    "case_id": 18174,
    "title": "Bronchoalveolar adenocarcinoma masquerading as diffuse pneumoni",
    "section": "Chest imaging",
    "age": "64",
    "gender": "male",
    "diagnosis": "Broncho alveolar carcinoma",
    "history": "A 64-years old male presented with complaint of severe cough with sputum since three months and progressive breathlessness. \u00a0On examination, there were abnormal bronchial breath sounds in bilateral upper and mid zones of lung fields.\nA provisional diagnosis of consolidation was made and imaging investigations were ordered.",
    "image_finding": "Chest radiograph showed diffuse markedly radiodense opacification involving bilateral upper and mid lung zones and few nodular radiodense opacities in bilateral lower zones. (FIGURE 1)\nHigh-resolution Computed Tomography (CT) of chest revealed diffuse segmental and subsegmental dense consolidations with few air bronchograms and well-defined mild lobulated contours in bilateral upper lobes, right middle lobe, left lingular segments with peripheral preponderance (FIGURE 2) and few other focal nodular/patchy consolidations in bilateral lower lobes and left upper lobe. (FIGURES 3, 4). Few prominent mediastinal lymph nodes were also noted.\nIn view of pattern of distribution with lobulated contours of consolidation, patient\u2019s age and normal leukocyte count inconsistent with infective aetiology, contrast study was suggested for any underlying neoplastic aetiology. \nContrast-enhanced CT (CECT) showed mild patchy post-contrast enhancement (FIGURES 5, 6) suggestive of neoplastic aetiology concerning for consolidation type of bronchoalveolar carcinoma. No bone or visceral metastases were noted. Further CT-guided biopsy was done and the histopathology report confirmed it as lepidic pattern adenocarcinoma of lung.",
    "discussion": "Background \nLung cancer is one of the most common malignancies in the world, with high mortality and adenocarcinoma is the most common histological type. [1]\nBronchoalveolar carcinoma (BAC) is classified as one of the subtypes of adenocarcinoma according to the WHO classification of lung and pleural tumours. [2]\nIt is believed that atypical adenomatous hyperplasia with certain mutations including k-ras, TTF-1, 8q, 17p and epidermal growth factor tyrosine kinase favouring stem cells to proceed towards pure BAC pathway are precancerous for adenocarcinoma and bronchoalveolar carcinoma. [3]\nHistologically, bronchoalveolar carcinoma is classified as non-mucinous and mucinous types. Non-mucinous BAC originates from Clara cells or type-II pneumocytes and on immuno-histochemical staining they are positive for TTF-1, CK-7 and negative for CK-20. The patients with mucinous type of tumour are often asymptomatic and usually show a better prognosis. [4] Invasive lung adenocarcinoma can manifest in five histological architectural patterns -lepidic, acinar, papillary, solid, and micropapillary. Histology showing malignant cells proliferating along the alveolar and bronchiolar walls is characteristically known as lepidic growth. [5]\nClinical Perspective \nBronchoalveolar carcinoma shows a peak incidence in sixth and seventh decades of life with a mild male predominance and in smokers. Scarred lung due to previous infection, occupational factors like construction, wood and paper mill works, sugar cane farming are potential risk factors. [6] Clinically cough, dyspnoea and chest pain are the presenting complaints. Respiratory failure is seen commonly because of the underlying shunt physiology.\nImaging Perspective \nRadiologically, the recognized patterns are single mass/ nodular form(50%), local consolidative form(20%), bilateral diffuse consolidation (20%)and multinodular form(10%). [7,8] The patient, in this case, had predominantly bilateral diffuse consolidation form of bronchoalveolar carcinoma.\nStudies to differentiate between neoplastic and inflammatory etiologies indicate that patients with lung cancers belonged to relatively older age groups than those with infective and inflammatory lesions. Irregular air bronchograms, ground-glass opacity (GGO) component, and pleural retraction were more commonly seen in neoplastic aetiology, while necrotic component, bronchial wall thickening proximal to the lesion, interlobular septa thickening and pleural thickening were more commonly seen in inflammatory aetiology.\nPATHOPHYSIOLOGY BEHIND THE FINDINGS:\nPleural retraction occurs due to the infiltration of fibrous tissue produced by tumour cells along the subpleural stroma or tumour mesenchyme contraction. Pleural thickening is attributed to inflammatory exudation from alveoli easily disseminating to the subpleural area and leading to an inflammatory response in the pleura.\nInflammatory necrosis is due to inflammatory responses by microbial infection and is usually seen at an early stage, whereas tumoral necrosis results from chronic ischemic injury or hypoxia and is generally observed in large tumours and is rarely seen in adenocarcinomas involving localized areas. \nAdjacent bronchial wall and interlobular septal thickening commonly observed in inflammatory aetiology are associated with the spread of inflammation along adjacent alveoli, bronchi, and interstitium. \nA follow-up scan of CT after 8\u201312\u00a0weeks with or without empirical antibiotic treatment may be useful in determining the malignant potential. [9, 10]\nOutcome \nMultifocal disease with involvement of bilateral lungs, mucinous histology and mediastinal lymphadenopathy suggests poor prognosis. [11]\nSurgery is the definitive treatment for stage I and II disease. Chemotherapy is used for multifocal disease, which however has poor response in bronchoalveolar carcinomas. [12]\nTake Home Message \n\nDense or increased attenuation consolidations with fewer air bronchograms, lobulated contours, peripheral predominance, GGO component and pleural retraction should raise a suspicion of neoplastic aetiology and warrant further evaluation with contrast scans. \nChronicity , unresponsiveness to antibiotics and normal leucocyte count also point towards possible non-infective or neoplastic aetiology\n\n\nCT-guided biopsies are advised in case of peripheral lesions where bronchoscopy-guided interventions fail to address the need.\n\nImaging also plays an important role in follow-up with or without management. Enlargement in the size of consolidation, gradually disappearing air bronchograms and ground glassing components, increasing attenuation are some of the red flag signs favouring malignancy over infection.",
    "differential_diagnosis": "Broncho, alveolar, carcinoma, Aspiration, pneumonia, Bilateral, infectious, pneumonia",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-05//18174_1_1.jpg?itok=ozKqxv_E",
            "caption": "Plain chest radiograph frontal view showing diffuse homogenous radiodense opacifications involving predominantly peripheral right upper, mid and left mid zone with haziness and few other nodular radiodense opacifications in right lower zone"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-05//18174_2_1.jpg?itok=ln9Jq75y",
            "caption": "HRCT chest axial section in lung window at subcarinal level showing bilateral dense homogenous consolidations in right middle lobe, left lingular segments with lobulated contours (orange curved arrows) and fewer air bronchograms (green arrows)"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-05//18174_3_1.jpg?itok=Y0mVM4tQ",
            "caption": "HRCT chest axial section in lung window showing dense nodular consolidations in left lingular segments and diffuse lobar consolidation in right middle lobe"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-05//18174_4_1.jpg?itok=1c307_z1",
            "caption": "HRCT chest coronal section in lung window showing dense lobar consolidation in right upper lobe and focal patchy consolidations in bilateral lower lobes"
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-05//18174_5_1.jpg?itok=_T5U2jW3",
            "caption": "Post contrast CT chest axial section in mediastinal window showing mild patchy enhancement in the consolidations"
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-05//18174_6_1.jpg?itok=VxNYsxKf",
            "caption": "Pre (A) and Post (B) contrast CT chest axial sections in mediastinal window showing mild patchy enhancement in the consolidations on post contrast (B) image, shown with a difference in Hounsfield Units (HU)"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Respiratory system",
      "Thorax"
    ],
    "imaging_technique": [
      "CT",
      "CT-High Resolution"
    ],
    "link": "https://www.eurorad.org/case/18174",
    "time": "13.06.2023"
  },
  "18185": {
    "case_id": 18185,
    "title": "Pulmonary sequestration with tuberculous infection of the sequestrated lung",
    "section": "Chest imaging",
    "age": "8",
    "gender": "female",
    "diagnosis": "Extralobar pulmonary sequestration with superadded tuberculous infection and broncho-cutaneous fistula",
    "history": "An eight-month-old female child presented with fever, left anterior chest wall swelling and discharging abscess in the left supraclavicular region since one month of age. On physical examination, there was decreased air entry on the left side. Her white blood cell counts were elevated (44,000/\u00b5L).",
    "image_finding": "The chest radiograph showed a large homogenous soft tissue opacity in the left lung field (Figure 1). A contrast-enhanced CT of the chest was done. There was a large soft tissue lesion occupying the left hemithorax in the upper and mid portions. Within the lesion, there were fluid-filled dilated bronchi which showed no communication with the bronchial tree of the residual aerated lung (Figure 2 a, b).\nThe lesion had its arterial supply via a branch from the left subclavian artery and the venous drainage was into the left brachiocephalic vein (Figure 3 a, b).\nThere was a fistulous tract opening on the skin surface communicating with one of the dilated fluid-filled bronchus in the lesion suggestive of broncho cutaneous fistula (Figure 4).",
    "discussion": "Background\nPulmonary\u00a0sequestration (PS)\u00a0is dysplastic lung tissue without any communication with the tracheobronchial tree. The arterial feeder is mostly through the aorta and variable venous drainage. This was initially described by Pryce et al in 1946 and divided into intralobar and extralobar types. In 2008 Lee et al classified pulmonary sequestration under bronchopulmonary vascular malformations which includes concurrent abnormalities of the airway, arteries, veins and associated gastrointestinal tract and diaphragmatic anomalies. [1] The incidence of PS is 0.29% accounting for 0.15\u20136.4% of all congenital pulmonary malformations.[2]\nClinical Perspective\nIntralobar sequestration is more common (75-85%) and presents in late childhood or adolescence with recurrent pulmonary infections, whereas extralobar sequestration presents in newborns or infants as respiratory distress, cyanosis and feeding difficulty. [3]\nImaging Perspective\nThe left lower lobe is the most common location of PS.\nIntralobar type does not have a separate pleura and the venous drainage is usually to the\u00a0pulmonary circulation. Extralobar type has a separate visceral pleura and can sometimes be extra thoracic with venous drainage usually into the\u00a0systemic circulation.\nOn Chest radiographs,\n\nThe lesion is seen as triangular opacity in the affected bronchopulmonary segment.\n\nOn Ultrasonography,\n\nThe lesion appears as a solid well-defined triangular intra-thoracic or extra-thoracic echogenic mass\nIn-utero cases may show a feeding vessel from the aorta on colour Doppler [4]\n\nOn CT,\n\nThe lesion is seen as a focal enhancing area of consolidation.\nCT Angiography study shows arterial blood supply mostly from the aorta but less frequently, it can be from intercostal, subclavian, internal thoracic or pericardial arteries\nFluid or air bronchograms are seen within if the lesion is infected or as a part of a hybrid lesion with a foregut communication [5]\n\nDSA Angiography\u00a0is the gold standard procedure for the diagnosis\u00a0of PS [6]\nOutcome\nSurgery with\u00a0thoracotomy\u00a0or\u00a0video-assisted thoracoscopic surgery (VATS)\u00a0approach is the standard care for these patients.\u00a0[7] In our case, VATS with lobectomy of left lung sequestration was performed. The sequestered lung was broken into pieces with a harmonic scalpel and tissue was sent for histopathology.\nHistopathology revealed necrotizing granulomatous inflammation suggestive of tuberculosis involving the sequestered lung. \nTake Home Message / Teaching Points\nThe differential diagnosis of pulmonary sequestration must be kept in mind when evaluating non-resolving consolidation in children. CT angiography is the mainstay in the diagnosis of pulmonary sequestration.\nAfter the diagnosis of the sequestrated lung is confirmed, the possibility of superadded infection like tuberculosis should be considered.",
    "differential_diagnosis": "Extralobar, pulmonary, sequestration, with, superadded, tuberculous, infection, and, broncho-cutaneous, fistula, Pulmonary, tuberculosis, Bacterial, pneumonia, Congenital, pulmonary, airway, malformation",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-05//18185_1_1.jpg?itok=HNGUXgaz",
            "caption": "Frontal chest radiograph shows a well-defined large homogenous soft tissue opacity in the left lung field sparing a part of the left lower zone. There is mediastinal shift to the right"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-05//18185_2_1.jpg?itok=UfOPpV3m",
            "caption": "Coronal images of the CT chest in lung window (a) and post-contrast soft tissue window (b) show a large soft tissue lesion occupying almost the entire left hemithorax. This lesion contains fluid-filled dilated bronchi (white arrow) without any communication with the bronchial tree of the residual aerated left lung"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-05//18185_2_2.jpg?itok=72V9os_s",
            "caption": "Coronal images of the CT chest in lung window (a) and post-contrast soft tissue window (b) show a large soft tissue lesion occupying almost the entire left hemithorax. This lesion contains fluid-filled dilated bronchi (white arrow) without any communication with the bronchial tree of the residual aerated left lung"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-05//18185_3_1.jpg?itok=6Y-lKcEJ",
            "caption": "Coronal reformatted images of the post-contrast CT chest show the lesion with its arterial supply by a branch (white arrow) from the left subclavian artery and the venous drainage (black arrow) into the left brachiocephalic vein"
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-05//18185_3_2.jpg?itok=e2NYAgeh",
            "caption": "Coronal reformatted images of the post-contrast CT chest show the lesion with its arterial supply by a branch (white arrow) from the left subclavian artery and the venous drainage (black arrow) into the left brachiocephalic vein"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-05//18185_4_1.jpg?itok=Wg7_GVoz",
            "caption": "Sagittal image of post-contrast CT chest shows a fistulous tract (black arrow) arising from one of the dilated fluid-filled bronchus (white arrow) extending up to the skin surface suggestive of a broncho-cutaneous fistula"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Paediatric"
    ],
    "imaging_technique": [
      "CT",
      "Ultrasound"
    ],
    "link": "https://www.eurorad.org/case/18185",
    "time": "13.06.2023"
  },
  "18202": {
    "case_id": 18202,
    "title": "Hampton hump and Palla sign: Radiographic signs of pulmonary embolism",
    "section": "Chest imaging",
    "age": "40",
    "gender": "male",
    "diagnosis": "Pulmonary embolism with Hampton Hump and Palla sign",
    "history": "A male patient in his 40s presents with right-sided pleuritic pain. He has no fever or abnormal inflammatory parameters. He has a history of Achilles tendon surgery two months prior to presentation. His oxygen saturation is normal, and there is no evidence of hypercapnia.",
    "image_finding": "The chest X-ray (figure 1) shows a wedge-shaped pleural-based opacity in the right lower lung field (Hampton hump). Additionally, at the middle lung field, there is engorgement of the right descending pulmonary artery (Palla sign). These findings were absent on the preoperative chest X-ray taken two months prior (figure 2). Given the radiographic findings and the presence of pleuritic pain, a CT pulmonary angiogram (CTPA) was performed to exclude the condition. The CTPA (figure 3) revealed bilateral PE, specifically in the right branch of the pulmonary artery, lower lobar branch, and segmental branches, as well as in some segmental branches of the lower lobe of the left lung. It also confirmed the presence of a pleural-based consolidation in the right lower lobe, with a ground glass halo (figure 4), indicating a pulmonary infarction, corresponding to the Hampton hump already detected on the chest X-ray.",
    "discussion": "The Hampton hump and Palla sign are two radiographic findings that can be seen in patients with pulmonary embolism (PE) [1-5].\nIt is important to note that while the Hampton hump and Palla sign can be suggestive of PE, they are not present in all cases. These signs are often subtle and not visible in most cases, particularly in patients with small or subsegmental PEs [5]. Studies have shown that these findings are relatively rare [6]. It is common that the chest x-ray shows no abnormalities in a patient with PE, even in patients with clinically severe PE [7]. \nThe Hampton hump is a radiographic finding that appears as a pleural-based, wedge-shaped opacity on the chest radiograph. The hump is typically seen in the lower lung fields and corresponds to infarcted lung tissue distal to the embolus. A Hampton hump is highly suggestive of PE, although it can also be seen in other causes of pulmonary infarction [3; 4]. Studies have shown that wedge-shaped consolidations were found in only 36% of the patients with massive PE in CTPA [8].\nThe Palla sign is another radiographic finding seen in patients with PE. It is characterised by a characteristic \u2018sausage-shaped\u2019 appearance in the right middle lung field that corresponds to right descending pulmonary artery enlargement as a potential sign of pulmonary embolism [1; 2].\nAnother described sign is the Westermark sign, which corresponds to a focal peripheral hyperlucency secondary to oligemia [6].\nDespite the relatively low sensitivity of the chest radiograph for the detection of pulmonary embolism (PE), it is still an important tool in the evaluation of patients with suspected PE. The chest radiograph can help to identify other potential causes of symptoms such as pneumonia or pneumothorax, and may also show findings such as those signs, pleural effusion or atelectasis that may be associated with PE [5-7]. \nIn this case, despite the clinical finding were not the most typical of PE, due to the recent surgery and the radiographical findings, the patient did CTPA that confirmed the diagnosis of PE.\nIn conclusion, the Hampton hump and Palla sign are relatively rare findings in patients with PE, and the chest radiograph is not sensitive to exclude it. Despite the low sensitivity of the chest radiograph for detecting PE, the radiologist should be aware of these signs. CT angiography is the gold standard in its detection, and V/Q scintigraphy is also more sensitive for detecting the condition [5].",
    "differential_diagnosis": "Pulmonary, embolism, with, Hampton, Hump, and, Palla, sign, Right, lower, lobe, atelectasis, Pneumonia, Pulmonary, hemorrhage",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-06//18202_1_1.jpg?itok=S1nqAVt6",
            "caption": "Chest x-ray, posteroanterior view, at the time of the symptoms: There is a wedge-shaped pleural-based opacity in the right lower lung field. Additionally, at the middle lung field, there is engorgement of the right descending pulmonary artery"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-06//18202_1_2.jpg?itok=wl3GMw0W",
            "caption": "Chest x-ray, posteroanterior view at the time of the symptoms: There is a wedge-shaped pleural-based opacity in the right lower lung field (Hampton hump \u2013 blue arrow). Additionally, at the middle lung field, there is engorgement of the right descending pulmonary artery (Palla sign \u2013 white arrow)"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-06//18202_2_1.jpg?itok=PCBg_ebI",
            "caption": "Chest x-ray, posteroanterior view, two months before the symptoms as preoperative scan, shows no abnormalities"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-06//18202_3_1.jpg?itok=-ikaqjGr",
            "caption": "CTPA in the axial plane with mediastinal window shows a bilateral PE, specifically in the right branch of the pulmonary artery (arrow), lower lobar branch, and segmental branches, as well as in some segmental branches of the lower lobe of the left lung"
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-06//18202_3_2.jpg?itok=8DRUHzhr",
            "caption": "CTPA in the axial plane with mediastinal window shows a bilateral PE, specifically in the right branch of the pulmonary artery, lower lobar branch, and segmental branches, as well as in some segmental branches of the lower lobe of the left lung"
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-06//18202_3_3.jpg?itok=73ay9d9B",
            "caption": "CTPA in the axial plane with mediastinal window shows a bilateral PE, specifically in the right branch of the pulmonary artery, lower lobar branch, and segmental branches, as well as in some segmental branches of the lower lobe of the left lung (arrow)"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-06//18202_4_1.jpg?itok=lLPhgw5B",
            "caption": "Thoracic CT in the sagittal plane in lung window shows a wedge-shaped opacity in the right lower lobe, corresponding to an area of pulmonary infarction"
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-06//18202_5_1.jpg?itok=sG0SxaCI",
            "caption": "Radiographic signs of PE and its tomographic correlation \u2013 Chest radiography: White arrow \u2013 Palla sign; blue arrow \u2013 Hampton Hump"
          },
          {
            "number": "Figure 5b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-06//18202_5_2.jpg?itok=7O6Qp_Bv",
            "caption": "Radiographic signs of PE and its tomographic correlation \u2013 Thoracic CT in the sagittal plane in lung window: blue arrow \u2013 Hampton Hump"
          },
          {
            "number": "Figure 5c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-06//18202_5_3.jpg?itok=eMk1IGYW",
            "caption": "Radiographic signs of PE and its tomographic correlation \u2013 Thoracic CTPA in the sagittal plane: White arrow \u2013 Palla sign; Blue arrow \u2013 Hampton Hum"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT-Angiography"
    ],
    "link": "https://www.eurorad.org/case/18202",
    "time": "14.06.2023"
  },
  "18228": {
    "case_id": 18228,
    "title": "Symptomatic radiation recall pneumonitis induced by immunotherapy",
    "section": "Chest imaging",
    "age": "77",
    "gender": "male",
    "diagnosis": "Radiation recall pneumonitis induced by immunotherapy",
    "history": "A 77-year-old man was diagnosed with lung adenocarcinoma in right lower lobe with mediastinal and cervical lymphadenopathies. He was treated with chemotherapy and sequential radiotherapy. 21 months after the diagnosis, due to progression, he was treated with anti-PD-L1 Atezolizumab. Three months later, the patient developed a process of respiratory failure.",
    "image_finding": "Axial chest CT images at diagnosis revealed a solid lobulated mass in right lower lobe that corresponds to primary lung neoplasm with cervical and subcarinal lymphadenopathies. \nThree months after immunotherapy initiation, the patient was admitted at hospital with acute respiratory symptoms and a chest CT was performed showing signs of lung fibrosis from previous radiotherapy and new ground glass opacities in paramediastinal region, localised within the previously irradiated area.\nPulmonary infection was ruled out by blood and sputum culture and the images were not suggestive of neoplasm recurrence. The clinical evolution was good just with supportive care. Based on the above facts, it was suggested that the patient had radiation recall pneumonitis induced by Atezolizumab, and prednisolone was administered.",
    "discussion": "Radiation recall pneumonitis (RRP) manifests as acute inflammation confined to previously irradiated lung tissue, which can occur months or even as late as 5 years after radiotherapy in response to treatment [1]. Several studies reported that chemotherapy agents and molecular target-agents could cause RRP [2], and lately there are reported cases with immunotherapy. Currently, the specific pathophysiological mechanism of RRP still remains unclear. There are some hypotheses suggested, including idiosyncratic drug hypersensitivity reactions, changes in the function of stem cells in the irradiated field, vascular injuries or inflammatory cascades [3]. \nThe clinical manifestation varies from completely asymptomatic to severely symptomatic with non-productive cough and dyspnea on exertion [2].\nThe radiologic images show ground-glass or consolidative opacities confined to prior radiation field, as opposed to ICI-related pneumonitis, which is typically diffuse [1]. The most common radiologic pattern is organizing pneumonia (OP) [4].\nThe treatment for RRP includes discontinuation of the systemic anti-tumour agents, administration of corticosteroids and supportive medical care [2].\nIn conclusion, RRP is a delayed complication of radiotherapy triggered by antineoplasm treatments including immunotherapy that can be easily misdiagnosed. In the future, with the increasing use of ICIs in advanced lung cancer, we can expect that previously irradiated patients will be more exposed to radiation recall pneumonitis, enhancing the importance of understanding and recognizing it [1].",
    "differential_diagnosis": "Radiation, recall, pneumonitis, induced, by, immunotherapy, ICI-related, pneumonitis, Radiation, pneumonitis, Infectious, processes",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-08/figure_1a.png?itok=51CgYtis",
            "caption": "Disseminated lung neoplasm with solid lobulated mass in right lower lobe that corresponds to primary lung neoplasm (Figure 1a; Figure 1b) and subcarinal (Figure 1c) and cervical (Figure 1d) lymphadenopathies"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-08/figure_1b.png?itok=tAdp7YkA",
            "caption": "Disseminated lung neoplasm with solid lobulated mass in right lower lobe that corresponds to primary lung neoplasm (Figure 1a; Figure 1b) and subcarinal (Figure 1c) and cervical (Figure 1d) lymphadenopathies"
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-08/figure_1c.png?itok=nxhtRMXs",
            "caption": "Disseminated lung neoplasm with solid lobulated mass in right lower lobe that corresponds to primary lung neoplasm (Figure 1a; Figure 1b) and subcarinal (Figure 1c) and cervical (Figure 1d) lymphadenopathies"
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-07//18228_1_1.png?itok=2kBgmjus",
            "caption": "Disseminated lung neoplasm with solid lobulated mass in right lower lobe that corresponds to primary lung neoplasm (Figure 1a; Figure 1b) and subcarinal (Figure 1c) and cervical (Figure 1d) lymphadenopathies"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-07//18228_2_1.jpg?itok=U8d50Wo0",
            "caption": "Signs of paramediastinal lung fibrosis with bronchiectasis and right pleural effusion from previous radiotherapy (Figure 2a-b-c-d) and new ground glass opacities in paramediastinal region, localised within the previously irradiated area after immunotherapy (Figure 2c; Figure 2d)"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-07//18228_2_2.jpg?itok=MXbUce-r",
            "caption": "Signs of paramediastinal lung fibrosis with bronchiectasis and right pleural effusion from previous radiotherapy (Figure 2a-b-c-d) and new ground glass opacities in paramediastinal region, localised within the previously irradiated area after immunotherapy (Figure 2c; Figure 2d)"
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-07//18228_2_3.jpg?itok=f14TUltK",
            "caption": "Signs of paramediastinal lung fibrosis with bronchiectasis and right pleural effusion from previous radiotherapy (Figure 2a-b-c-d) and new ground glass opacities in paramediastinal region, localised within the previously irradiated area after immunotherapy (Figure 2c; Figure 2d)"
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-07//18228_2_4.jpg?itok=XorF5cbP",
            "caption": "Signs of paramediastinal lung fibrosis with bronchiectasis and right pleural effusion from previous radiotherapy (Figure 2a-b-c-d) and new ground glass opacities in paramediastinal region, localised within the previously irradiated area after immunotherapy (Figure 2c; Figure 2d)"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/18228",
    "time": "12.08.2023"
  },
  "18273": {
    "case_id": 18273,
    "title": "A case of Pulmonary Mucormycosis with classic imaging findings",
    "section": "Chest imaging",
    "age": "60",
    "gender": "male",
    "diagnosis": "Pulmonary mucormycosis",
    "history": "A 60-year-old male patient arrived complaining of worsening fever, breathlessness and non-productive cough for the past 1 month. There was no history of weight loss, chills, hemoptysis, diabetes mellitus, steroid use or malignancy. Physical examination revealed bilateral scattered crepitation. His fasting blood sugar was found to be 286 mg/dl.",
    "image_finding": "Computed tomography (CT) revealed 3 nodules with irregular margins noted in the lateral segment of right middle lobe, superior segment of right lower lobe and superior lingular segment of left lower lobe. These lesions showed central ground glass shadows with a peripheral rim of consolidation giving the appearance of a reverse halo sign (RHS) (Figure 1). All lesions showed secondary cavitation and, irregular, intersecting strands within it, giving it the classic appearance of a bird\u2019s nest sign (Figure 3a & 3b).\nAnother 8.1* 6.2 * 11.9 cm cavity was noted in the superior segment of left lower lobe with thick walls and an air-fluid level within, indicating a lung abscess (Figure 2a & 2b). Following contrast administration, there is very minimal enhancement of the cavity wall seen. The rest of the lesions were non-enhancing. A few enlarged paratracheal lymph nodes were seen within the mediastinum.",
    "discussion": "Pulmonary mucormycosis (PM) is an uncommon, opportunistic angioinvasive infection caused by a fungus belonging to the order Mucorales [1][2]. PM is the second most common manifestation of mucormycosis after rhino-orbital-cerebral infection. Prognosis of PM is poor with mortality approaching 75% [3]. Common risk factors include hematologic malignancies, organ and stem cell transplant, prolonged steroid therapy and diabetes. Symptoms comprise fever, dyspnoea, cough and haemoptysis [4][5]. \nRadiological features in PM are nonspecific. Lobar and segmental consolidation is the most common imaging finding in a chest radiograph followed by single or multiple nodules and masses which may have a surrounding ground glass halo [6]. The extent of PM is best determined by HRCT. Mark M Hammer et al who reviewed CT studies of 30 patients concluded that nodules were present in 20%, consolidations were present in 57%, RHS in 60%, perilesional halo in 53% and cavitation in 10% of patients [7].\nThe clinical and radiologic manifestations of PM resemble those of invasive pulmonary aspergillosis (IPA) [8]. However, it is important to distinguish between the two as the treatments involved are different. Various studies have identified a RHS to be associated with PM than with IPA [6] [9-11]. J Vogel conducted a study in which bird\u2019s nest sign could be identified in CT in 22% of patients [12]. Abscess formation was noted in 13% of PM cases in a study conducted by Murphy and Miller [13]. The case presented here showed RHS, bird\u2019s nest sign and abscess formation, all favouring a diagnosis of PM. \nCommon bacterial infections such as staphylococcus aureus, Klebsiella and mycobacterium, septic emboli, granulomatosis with polyangitis, rheumatoid nodules also present as cavitary pulmonary lesions [14]. Unless surgery is contraindicated, the recommended therapy for PM is early surgical debridement in conjunction with early amphotericin B therapy [15]. Finding of characteristic hyphae in the biopsy specimen remains the gold standard for diagnosis of PM. The patient in this case underwent bronchoscopy and BAL specimen was sent for culture which confirmed the presence of zygomycetes species. The patient was started on injection liposomal Amphotericin B 350 mg in 5 % dextrose over 3 hours following radiological diagnosis. \nTeaching points: Imaging findings of PM are nonspecific. However, radiologists should look out for RHS, bird\u2019s nest sign, features of hyphal invasion of arteries along with immunocompromised status of the patient which are more often associated with PM.\nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Pulmonary, mucormycosis, Invasive, pulmonary, aspergillosis, Pulmonary, candidiasis, Granulomatosis, with, polyangiitis, Septic, emboli",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-08//18273_1_1.jpg?itok=4mGn01Ng",
            "caption": "Axial non contrast CT image (lung window). Heterogeneous lesion with central ground glass opacity surrounded by consolidation forming a complete ring giving a classic reverse halo sign (yellow arrow) in superior segment of right lower lobe."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-08//18273_2_1.PNG?itok=NFdyS5B3",
            "caption": "Axial non contrast CT. (Lung window -2a). (Mediastinal window \u20132b) 8.1 * 6.2 * 11.9 cm well defined, thick walled cavitary lesion noted in superior segment of left upper lobe with an air fluid level within it indicating abscess formation (red star)."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-08//18273_2_2.PNG?itok=v24nDYET",
            "caption": "Axial non contrast CT. (Lung window -2a). (Mediastinal window \u20132b) 8.1 * 6.2 * 11.9 cm well defined, thick walled cavitary lesion noted in superior segment of left upper lobe with an air fluid level within it indicating abscess formation (red star)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-08//18273_3_1.jpg?itok=FeBKaxok",
            "caption": "Axial non contrast CT (lung window). Cavitary lesions noted in (3a) apicoposterior segment of left upper lobe (blue arrow) and, (3b) lateral segment of right middle lobe (green arrow) with irregular and interesting strands within the cavitary lesions with surrounding consolidation giving a bird\u2019s nest appearance."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-08//18273_3_2.jpg?itok=8F2vaeb8",
            "caption": "Axial non contrast CT (lung window). Cavitary lesions noted in (3a) apicoposterior segment of left upper lobe (blue arrow) and, (3b) lateral segment of right middle lobe (green arrow) with irregular and interesting strands within the cavitary lesions with surrounding consolidation giving a bird\u2019s nest appearance."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT",
      "CT-High Resolution"
    ],
    "link": "https://www.eurorad.org/case/18273",
    "time": "24.08.2023"
  },
  "18290": {
    "case_id": 18290,
    "title": "xtension of non-small cell lung carcinoma into left atrium: a case report",
    "section": "Chest imaging",
    "age": "75",
    "gender": "female",
    "diagnosis": "Poorly differentiated non-small cell carcinoma lungs",
    "history": "A 75 years old female, ex-smoker for 50 years (40 to 50 pack years) and previously diagnosed with chronic obstructive pulmonary disease presented to the emergency of a tertiary centre with a history of significant weight loss, anorexia and blood in sputum for 3 months and shortness of breath, bipedal oedema and palpitation for 1 week.",
    "image_finding": "A plain radiograph of chest was done which showed moderate right pleural effusion and a well-defined relatively homogeneous opacity in the right mid-zone. Cardiomegaly was present and prominent bronchovascular markings were seen in the bilateral lung fields. In contrast-enhanced CT chest, a relatively well-defined heterogeneously enhancing mass measuring 9.7 x 7.7 x 5.7 cm was seen in lower lobe of right lung. The lesion was extending into left atrium through right inferior pulmonary vein forming a figure of eight pattern. The lesion in left atrium was 5.4 x 4.4 x 3.9 cm in size. Smooth interlobular septal thickening was seen in the bilateral lungs. Mild centriacinar emphysematous changes were seen in rest of the bilateral lungs. Moderate right pleural effusion was seen. Cardiomegaly and tortuous course of descending thoracic aorta were also seen. Mild pericardial effusion was also seen. The main pulmonary artery was dilated measuring 35 mm in diameter.",
    "discussion": "Background\nExtension of pulmonary neoplasms through pulmonary vein into left atrium has been sparsely documented in the literature. In a study by Riquet et al, the involvement of pulmonary vein and left atrium in pulmonary malignancies was seen in 0.7% and 0.5% of patients [1]. Extension of pulmonary malignancies into left atrium is seen in T4 disease which is advanced inoperable stage [2]. Usually, palliative treatment is done in T4 disease. But, with recent advances, possibility of surgical resection is an option and long-term survival is seen in some of the studies [3].\nClinical Perspective\nExtension of primary lung malignancies into heart through pulmonary veins are mostly discovered in imaging. Sometimes, it presents with features of cardiac failure and embolism in a known case of primary lung malignancy. Risk of myocardial infarction, stroke, mesenteric ischemia etc. is substantially increased [2]. Extension of malignant mass into heart is more common with sarcomas than bronchogenic carcinoma. Both small and non-small cell lung carcinomas can extend to heart via pulmonary veins [4,5].\nImaging Perspective\nExtension of pulmonary malignancies into heart is mostly discovered in CT or echocardiography. Large, often necrotic mass is seen in lung extending into left atrium through pulmonary vein, forming figure of eight pattern due to the small caliber of pulmonary vein. In case of direct extension of the lesion, figure of eight pattern may not be seen. In echocardiography, mobile mass similar to myxoma is seen in left atrium [2].\nOutcome\nCT chest was done on the day of presentation. Therapeutic US-guided tapping of right pleural effusion was also done immediately. After that, US-guided biopsy was done the next day from malignant lung mass which showed the lesion to be poorly differentiated non-small cell carcinoma. Possibilities of cardiopulmonary bypass and surgical resections were considered in order to prevent embolism and cardiac failure. However, the patient's party opted for palliative treatment. On day 3 of admission, patient deteriorated suddenly and died, which we hypothesize was due to massive embolism.\nTake Home Message / Teaching Points\n\nCardiac extension of lung malignancies via pulmonary veins is sparsely documented.\nIn CT, a heterogeneously enhancing mass may be seen extending into left atrium via pulmonary vein forming a figure of 8.\nCardiac extension of pulmonary malignancy is T4 disease and indicates poor prognosis.\nRisk of death is high due to cardiac failure and embolism.",
    "differential_diagnosis": "Poorly, differentiated, non-small, cell, carcinoma, lungs, Bland, thrombus, Tumour, extension, Atrial, myxoma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-09//18290_1_1.jpg?itok=0SyoNx7u",
            "caption": "Postero-anterior chest radiograph of the patient shows a well-defined relatively homogeneous opacity in the right mid zone (shown by arrow). There is blunting of the right costophrenic angle suggestive of pleural effusion. There is mild cardiomegaly. Prominent bronchovascular markings are seen in the rest of bilateral lung fields. Descending thoracic aorta shows a tortuous course"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-09//18290_2_1.jpg?itok=ByHBkyBm",
            "caption": "Axial contrast-enhanced CT image of the chest at the level of left atrium in arterial phase. Heterogeneous mass is seen in the right lower lobe (red arrow). The lesion extends into the left atrium (green arrow) via inferior pulmonary vein to form a figure of 8 pattern"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-09//18290_2_2.jpg?itok=kocobh4U",
            "caption": "Coronal contrast enhanced CT image of chest at the level of left atrium in venous phase. Heterogeneous mass is seen in right lower lobe (red arrow). The lesion extends into left atrium (green arrow) via the inferior pulmonary vein to form a figure of 8 pattern. Moderate right pleural effusion is also seen (blue arrow)"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-09//18290_3_1.jpg?itok=HCYDLs2_",
            "caption": "Axial lung window images of chest. Mild centriacinar emphysematous changes are seen in the bilateral lungs (red arrows)"
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-09//18290_3_2.jpg?itok=0ovi-7mv",
            "caption": "Axial lung window images of chest. Mild smooth interlobular septal thickening is seen in the bilateral lungs (blue arrows)"
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-09//18290_3_3.jpg?itok=iyKZfxw_",
            "caption": "Axial contrast-enhanced arterial phase image of chest at the level of main pulmonary artery. The main pulmonary artery is dilated suggesting pulmonary arterial hypertension"
          },
          {
            "number": "Figure 3d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-09//18290_3_4.jpg?itok=i6SSucJv",
            "caption": "Axial contrast-enhanced venous phase image of chest at the level of heart. There is mild cardiomegaly (yellow arrow). Mild pericarial effusion is also seen (white arrows)"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-09//18290_4_1.jpg?itok=1J3i2GkT",
            "caption": "Histology of lung mass biopsy. The section shows tumour tissue composed of loose nets and sheets of pleomorphic cells with moderate to abundant amount of cystoplasm and round to oval nuclei. Nuclei show coarse granular chromatin and prominent nuceoli. Few multinucleated cells are also seen. Mitotic figures constitute 4/ high power field. Marked tumour necrosis is also seen. Histologically, the mass was diagnosed to be poorly differentiated non-small cell carcinoma which was further confirmed in IHC"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Cardiac",
      "Mediastinum",
      "Oncology"
    ],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/18290",
    "time": "03.10.2023"
  },
  "18298": {
    "case_id": 18298,
    "title": "ndobronchial metastases in renal cell carcinom",
    "section": "Chest imaging",
    "age": "50",
    "gender": "male",
    "diagnosis": "Endobronchial metastases with pulmonary metastases and metastatic mediastinal lymph nodes",
    "history": "A 50-year-old man, a reformed smoker, with past history of left nephrectomy for renal cell carcinoma 6 years back, presented to the hospital with fresh complaints of cough for 8 months, loss of appetite and weight. He also complained of coughing out tissue-like material multiple times.",
    "image_finding": "Contrast-enhanced CT scan of the thorax was done which showed intensely enhancing soft tissue density intraluminal branching type masses within the right lower lobe bronchus and its segmental branches, resulting in distal lung collapse and consolidation. \nMultiple other intensely enhancing rounded pulmonary nodules of varying sizes were seen in both lungs. Multiple enlarged hyperenhancing mediastinal nodes were seen in subcarinal, lower paratracheal and aortopulmonary window locations. \nVisualized upper abdomen showed absence of left kidney, consistent with past history of nephrectomy. Visualized right kidney was unremarkable. No liver or adrenal lesions seen.",
    "discussion": "Endobronchial lesions can have various causes, most common ones being primary lung malignancy (squamous cell and small cell carcinomas) and neuroendocrine tumours (carcinoid tumour) [1]. Some benign causes of endobronchial lesions include fungal infections, inflammatory pseudopolyp, lipoma and broncholith [2]. Endobronchial metastases (EBM) are very rare accounting for only 1.1% of the endobronchial masses [3].\nLung metastases from extrathoracic malignancies are common, however, endobronchial metastasis is extremely rare. Common sources of EBM include colorectal, renal and breast malignancies [4,5].\nEndobronchial metastases need to be differentiated from bronchogenic carcinoma as treatment and prognosis varies. However, clinically, radiologically and on bronchoscopy these two entities are indistinguishable and need histopathological confirmation. \nEBM are known to present late in the course of cancer progression with average duration between diagnosis of primary malignancy and detection of EBM being around 50 months [5]. Studies have shown that EBM may not indicate poor prognosis and should not be thought of as a bad prognostic sign in choosing treatment modality [6].\nOur patient underwent rigid bronchoscopy and electrosurgical excision of the endobronchial mass. Histopathological analysis showed metastases from clear cell carcinoma. Patient was referred to a higher cancer centre for further management.\nWritten informed consent for publication has been obtained.",
    "differential_diagnosis": "Carcinoid, tumour, Primary, lung, malignancy, Endobronchial, metastases, with, pulmonary, metastases, and, metastatic, mediastinal, lymph, nodes",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-09//18298_1_1.jpg?itok=JsAed-56",
            "caption": "Contrast-enhanced CT scan of thorax axial (1a), coronal (1b) and sagittal (1c) images show intensely enhancing branching type luminal mass in right lower lobe bronchus and its segmental branches (yellow arrows) with post obstructive atelectasis and consolidation (red arrow)"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-09//18298_1_2.jpg?itok=BkudGcXo",
            "caption": "Contrast-enhanced CT scan of thorax axial (1a), coronal (1b) and sagittal (1c) images show intensely enhancing branching type luminal mass in right lower lobe bronchus and its segmental branches (yellow arrows) with post obstructive atelectasis and consolidation (red arrow)"
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-09//18298_1_3.jpg?itok=rJuyBEkc",
            "caption": "Contrast-enhanced CT scan of thorax axial (1a), coronal (1b) and sagittal (1c) images show intensely enhancing branching type luminal mass in right lower lobe bronchus and its segmental branches (yellow arrows) with post obstructive atelectasis and consolidation (red arrow)"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-09//18298_2_1.jpg?itok=Yveyi6J1",
            "caption": "Contrast-enhanced CT scan of thorax coronal images in mediastinal (2a) and lung (2b) windows show multiple rounded hyperenhancing pulmonary nodules in left lung (red arrows)"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-09//18298_2_2.jpg?itok=nKPgZmNL",
            "caption": "Contrast-enhanced CT scan of thorax coronal images in mediastinal (2a) and lung (2b) windows show multiple rounded hyperenhancing pulmonary nodules in left lung (red arrows)"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-09//18298_3_1.jpg?itok=P_IDy0nD",
            "caption": "Contrast-enhanced CT scan of thorax coronal (3a) and axial (3b) images showing intensely enhancing subcarinal and aortopulmonary nodes respectively (red arrows)"
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-09//18298_3_2.jpg?itok=aQ4ypyfl",
            "caption": "Contrast-enhanced CT scan of thorax coronal (3a) and axial (3b) images showing intensely enhancing subcarinal and aortopulmonary nodes respectively (red arrows)"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-09//18298_4_1.jpg?itok=sGD8U2vc",
            "caption": "Visualized upper abdomen shows absence of left kidney"
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-09//18298_5_1.jpg?itok=nd0w4iKc",
            "caption": "Image showing endobronchial tumour removed via rigid bronchoscopy"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Oncology",
      "Thorax"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/18298",
    "time": "04.10.2023"
  },
  "18309": {
    "case_id": 18309,
    "title": "The benign pulmonary nodules - so it&#039;s not cancer, what could be?",
    "section": "Chest imaging",
    "age": "71",
    "gender": "female",
    "diagnosis": "Nodular pulmonary amyloidosis",
    "history": "We report a case of a 71-year-old woman with a history of bronchiectasis and Sjogren's syndrome who reported anorexia, weight loss, and a productive cough.",
    "image_finding": "The X-ray revealed multiple nodular opacities of varying dimensions scattered throughout the lung fields, with irregular margins and random distribution (Figure 1). A subsequent computed tomography (CT) was then performed for further evaluation, which also showed the presence of mediastinal adenomegalies and confirmed the ill-defined nodular densities occupying both lungs with variable sizes.\u00a0There were no observed calcification or cavitation lesions (Figure 2). PET-CT showed an increase in FDG uptake in the pulmonary lesions (Figure 3). Resection of the pulmonary nodule was performed by thoracotomy and the material was sent for pathological anatomy demonstrating the presence of amyloidosis (Figures 4 and 5). Research on amyloid substance on abdominal wall biopsy was negative, so we concluded that this is a case of localized amyloidosis in the lung. The patient remained asymptomatic and under surveillance. After two years of follow-up, the lesions are stable.",
    "discussion": "Amyloidosis is a disease of protein metabolism with extracellular deposition of the amyloid substance in different organs and tissues [1].\nThe overall incidence of amyloidosis is about ten cases per million per year, estimated if the incidence of pulmonary amyloidosis reaches about 20% [2].\nPulmonary involvement is rare and can occur in isolation or in association with systemic disease. Three patterns of pulmonary amyloidosis are described: nodular pulmonary amyloidosis, tracheobronchial/laryngeal amyloidosis, and diffuse/septal-alveolar parenchymal amyloidosis [3,4].\nNodular pulmonary amyloidosis is a rare, benign, and indolent disease. It has a variable presentation and imaging studies show nonspecific findings that can simulate other more common pathologies such as neoplasms. Localized forms of amyloidosis progress slowly and rarely require treatment, unlike systemic amyloidosis forms [1,3].\nPET-CT, performed in the differential diagnosis of neoplasms, shows that amyloid deposits have high activity, like other metabolically active lesions, and should therefore be carefully interpreted. F-FDG is recognized for being absorbed by not only cells engaged in inflammation and infection (leukocytes), but also by cells participating in the clearance response, such as macrophages, monocytes, and giant cells. In cases of localized AL amyloidosis, the presence of giant cells is believed to be attributed to their involvement in amyloid production [5].\nThis case emphasizes how crucial it is for the radiologist to be familiar with pulmonary amyloidosis, allowing for a prompt clinical approach with the optimization of its final diagnosis.",
    "differential_diagnosis": "Granulomatous, lung, disease, Nodular, pulmonary, amyloidosis, Pulmonary, malignancy, with, widespread, metastatic, disease",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-09//18309_1_1.png?itok=ammOykx6",
            "caption": "Chest X-ray showing multiple differently sized nodular opacities in both lung fields, which were suspected for metastases"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-09//18309_2_1.png?itok=pJAMfH10",
            "caption": "Axial chest CT showing bilateral, prominent, ill-defined nodular densities of varying sizes and lobulated contours. They are distributed randomly throughout both lungs (red arrow). There were mediastinal and hilar adenopathy (green arrow)"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-09//18309_3_1.png?itok=7EGPwleM",
            "caption": "The PET-CT scan revealed a significant increase in FDG uptake in the pulmonary lesions"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-09//18309_4_1.png?itok=T7UBKMz1",
            "caption": "The pathology image revealed multiple foci of nodular amyloidosis within the alveolar space, associated with stromal fibrosis, and patchy perivascular and septal amyloid deposition (H&E, 40x)"
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-09//18309_5_1.png?itok=0SiActrd",
            "caption": "Congo-red stain showing apple-green birefringence confirming the diagnosis of pulmonary amyloidosis (Congo Red, 40x)"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Management"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT",
      "PET-CT"
    ],
    "link": "https://www.eurorad.org/case/18309",
    "time": "09.10.2023"
  },
  "18321": {
    "case_id": 18321,
    "title": "Bronchiolitis obliterans secondary to chronic graft-versus-host disease",
    "section": "Chest imaging",
    "age": "18",
    "gender": "male",
    "diagnosis": "Bronchiolitis obliterans from pulmonary graft-versus-host disease",
    "history": "18-year-old male patient with acute myeloid leukemia was treated with induction therapy followed by consolidation therapy. Finally, he received allogeneic hematopoietic stem cell transplantation (HSCT).\nNine months later, routine Pulmonary Functional Tests (PFTs) revealed a FEV1 of 63% that pointed to an obstructive pulmonary disease.",
    "image_finding": "Chest radiograph was normal in this case. The chest radiographic findings associated to BO are nonspecific and include mild hyperinflation, central bronchial wall thickening and reticulonodular markings.\nNon-contrast low-dose inspiratory high-resolution CT (HRCT) chest\u00a0with a 1.50 mm slice thickness demonstrated a bilateral patchy mosaic attenuation pattern with areas of low attenuation with paucity and reduced calibre of pulmonary vessels compared with the normal parenchyma. An expiratory CT was performed that showed persistence of the low attenuation areas, indicating air trapping.\nOther CT features include bronchial wall thickening and bronchiectasis, absent in this patient.",
    "discussion": "Chronic graft-versus-host disease (cGVHD) is a multisystem disease with high morbidity and mortality that occurs as a complication in 30-70% of allogeneic HSCT [1].\nThe lungs are frequently affected after allogeneic HSCT, both in infectious and non-infectious complications. Bronchiolitis obliterans (BO), also known as constrictive bronchiolitis, is the most common pulmonary manifestation of cGVHD. BO is an irreversible obstructive disease that appears around 6-12 months after HSCT. The incidence is estimated at 2-5% in patients receiving allogeneic HSCT and at 6% in patients already diagnosed with cGVHD, although recent publications suggest a higher incidence [1,2].\nAfter allogeneic HSCT, BO can be secondary to drug toxicity or cGVHD. Other less frequent causes of BO include toxic inhalation exposure, previous infection, small vessel vasculitis and collagen vascular disease [1,2].\nHistologically, it is characterized by concentric stenosis of the bronchiolar lumen secondary to inflammation and fibrosis of the terminal bronchioles leading to airway obstruction and air trapping.\nAt an early stage, pulmonary cGVHD is asymptomatic in 20% of patients or could manifest with nonspecific symptoms such as dyspnea, exercise intolerance or non-productive cough [3]. This represents a challenge because reaching the diagnosis before the disease evolves into an advanced stage with irreversible structural changes is crucial for patient morbidity and mortality.\nThe detection of BO relies on PFTs and high resolution CT (HRCT) with inspiratory and expiratory images.\nAccording to the 2015 National Institutes of Health (NIH) guidelines the diagnostic criteria for BO are [4]:\n\nAbsence of active respiratory tract infection.\nNegative microbiological tests.\nFEV1<70 % in PFTs.\nEvidence of air trapping in PFT or one of the following findings on HRCT (air trapping, bronchiectasis, or small airway wall thickening).\n\nAlthough diagnostic approaches remain challenging, early diagnosis may improve clinical outcome and regular post-transplant follow-up PFTs should be considered [5,6].\nSystemic first-line treatment consists of high doses of corticosteroids and optional addition of azithromycin.\nTake Home Messages\n\nTransplant-related complications are common after allogeneic HSCT, including GVHD. \nBO is a non-reversible obstructive lung disease with high morbidity and mortality that affects the terminal bronchioles, and it is the most frequent manifestation of pulmonary cGVHD.\nCT findings include mosaic attenuation pattern due to air trapping secondary to bronchiolar obstruction and bronchial wall thickening. \nExpiratory HRCT acquisition is required to demonstrate the evidence of air trapping when the diagnosis is suspected.\nEarly treatment before structural irreversible changes have developed is crucial for patient morbidity and mortality.\n\nAll patient data have been completely anonymised throughout the entire manuscript and related files.",
    "differential_diagnosis": "Non, transplant-related, bronchiolitis, obliterans, Post-transplant, lymphoproliferative, disorder, Bronchiolitis, obliterans, from, pulmonary, graft-versus-host, disease, Drug, toxicity, Infectious, bronchiolitis, Collagen, vascular, disease",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-09//18321_1_1.jpg?itok=zbLIwH8n",
            "caption": "Normal PA film"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-09//18321_1_2.jpg?itok=wvnS0jN8",
            "caption": "Normal lateral radiograph"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-09//18321_2_1.jpg?itok=fKFoH6uL",
            "caption": "Axial plane image with standard lung window settings depicts interspersed areas of low and high attenuation"
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-09//18321_2_2.jpg?itok=S-RNA-dg",
            "caption": "Regions of interest avoiding vessels quantify de attenuation differences"
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-09//18321_2_3.jpg?itok=wpEY9ZER",
            "caption": "Same axial plane image with specific narrow lung window settings highlights the differences between the high and low attenuation zones"
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-09//18321_2_4.jpg?itok=Xq_rkivo",
            "caption": "Sagittal plane with narrow window settings showing the mosaic attenuation pattern"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-09//18321_3_1.jpg?itok=QWD1rk01",
            "caption": "Axial plane expiratory image shows persistence and magnification of the low attenuation areas, indicating air trapping"
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-09//18321_3_2.jpg?itok=pUBUoR52",
            "caption": "Sagittal plane expiratory image clearly manifests the same findings"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Thorax"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT-High Resolution"
    ],
    "link": "https://www.eurorad.org/case/18321",
    "time": "09.10.2023"
  },
  "18322": {
    "case_id": 18322,
    "title": "Breath-taking surprises: Tracheobronchopathia osteochondroplastica unveile",
    "section": "Chest imaging",
    "age": "79",
    "gender": "male",
    "diagnosis": "Tracheobronchopathia osteochondroplastica",
    "history": "A 79-year-old male with no significant medical history, except for previous COVID-19 infection, and a history of smoking, presents with chronic cough with sputum and dyspnea that had worsened in the past 6 months. A chest x-ray was normal, and he was referred for further evaluation with Computed Tomography (CT).",
    "image_finding": "CT revealed scalloping and irregular thickening of the tracheal wall, with scattered calcified and non-calcified submucosal nodules, arising from the anterolateral walls of the trachea and also extending down to the proximal portion of the left main stem bronchus. Sparing of the posterior wall was noticed and these findings caused only mild distortion and narrowing of the airway lumen.",
    "discussion": "Tracheobronchopathia osteochondroplastica (TO) is a rare and idiopathic benign condition characterized by the development of multiple osseous and cartilaginous sessile submucosal nodules of variable sizes, along the lower two-thirds of trachea and central bronchi, typically sparing the membranous portion of the trachea (posterior wall). These nodules project into the tracheobronchial lumen, causing varying degrees of airway narrowing [1,2].\nThe aetiology remains unclear, although chronic inflammation of the airways, such as in COPD or smoking, is believed to contribute to its development [3-5].\nThe prevalence of TO is not well established, as it is often undiagnosed due to similar clinical presentation with other conditions such as asthma or COPD [6]. Three large retrospective studies reported its incidence around 0,11% among patients undergoing bronchoscopy [7-9]. TO is typically diagnosed in the sixth/seventh decade of life [1,10], with no gender preference [3,5,11].\nThe disease is usually asymptomatic and progresses slowly, often discovered incidentally during intubation or bronchoscopy [12-14].\nClinical manifestations of airway obstruction can develop, such as chronic cough, suppuration, dyspnea, or hemoptysis due to ulceration of the nodules, as well as recurrent respiratory infections, due to impaired mucociliary clearance [4,7,15,16].\nThe severity of symptoms and pulmonary function tests depend on the degree of obstruction, ranging from a normal spirometry to an obstructive pattern in patients with extensive disease [13,15].\nCT is considered the most reliable imaging method to screen tracheal disorders, being very sensitive in showing the submucosal nodules, with or without calcification. It allows the distinction from other conditions with overlapping findings, but which instead present with posterior wall involvement and circumferential thickening such as amyloidosis and granulomatosis with polyangiitis. Conversely, if sparing of the posterior wall is also seen but instead of tracheal submucosal nodules/focal coarse calcification, CT shows smooth tracheal thickening, relapsing polychondritis requires consideration [2,10,17-20]. Besides, CT can demonstrate disease extension and detect complications such as post-obstructive pneumonia/collapse [2,21,22].\nAlthough bronchoscopy is the gold standard for diagnosis, some authors consider that pathognomonic tomodensitometric findings may be sufficient if bronchoscopy is not feasible [23,24].\nTO may be more prevalent than initially believed, and due to the resemblance in presentation to common conditions, it is likely to be misdiagnosed. Therefore, it\u2019s important to increase the awareness of this entity among radiologists, who should consider this diagnosis in patients with chronic respiratory symptoms and recurrent pulmonary infections. CT is the main method for tracheal evaluation, and the presence of calcified nodules with sparing of the posterior wall is the key to diagnosis.",
    "differential_diagnosis": "Tracheobronchopathia, osteochondroplastica, Relapsing, polychondritis, Tracheobronchial, amyloidosis, Tracheolaryngeal, papillomatosis, Granulomatosis, with, polyangiitis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_video/2023-10/video1a%20-%20frame%20at%200m0s.jpg?itok=MWxfskfu",
            "caption": "Axial chest CT in mediastinal window (a) and in lung window (b) showing irregular scalloping of the tracheal wall, with multiple calcified and non-calcified sessile submucosal nodules, arising from the anterolateral walls of trachea and proximal portion of the left main stem bronchus and projecting into the tracheobronchial lumen, notably sparing the posterior wall"
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_video/2023-10/video1b%20-%20frame%20at%200m2s.jpg?itok=rYBFrRpP",
            "caption": "Axial chest CT in mediastinal window (a) and in lung window (b) showing irregular scalloping of the tracheal wall, with multiple calcified and non-calcified sessile submucosal nodules, arising from the anterolateral walls of trachea and proximal portion of the left main stem bronchus and projecting into the tracheobronchial lumen, notably sparing the posterior wall"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-09//18322_2_1.jpg?itok=h6YguaI7",
            "caption": "Coronal CT image in mediastinal window demonstrates scalloping of the tracheal wall, with multiple calcified and non-calcified sessile submucosal nodules, arising from the lateral walls of trachea"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Respiratory system",
      "Thorax"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/18322",
    "time": "09.10.2023"
  },
  "18342": {
    "case_id": 18342,
    "title": "A rare case of persistent cough caused by an unusual mediastinal tum",
    "section": "Chest imaging",
    "age": "34",
    "gender": "male",
    "diagnosis": "Mediastinal yolk sac tumour",
    "history": "The patient presented with dyspnea and cough that had been ongoing for four months, accompanied by bloody sputum and a 10% (8 kg) weight loss. Seeking medical attention, they consulted a private pulmonologist who ordered a chest X-ray and CT scan. Later, the patient presented to the emergency department with continuous dyspneic chest pain that was non-oppressive, along with general discomfort, a fever of 37.9\u00b0C, and vomiting, requiring urgent medical attention.",
    "image_finding": "The posteroanterior chest radiograph reveals a sizable lesion encompassing the left lung with contralateral displacement of the trachea and a negative silhouette sign along the cardiac border, also an elevated left hemidiaphragm due to compensatory hyperinflation of the contralateral lung. The lateral projection demonstrates occupation of the retrosternal space accompanied by the presence of the spine sign. In the contrast-enhanced computed tomography, we can observe the previously identified lesion which exhibits heterogeneity with predominantly peripheral enhancement, as well as central hypodense areas, likely indicative of necrosis. It is located within the anterior mediastinum and does not infiltrate adjacent tissues, but it displaces the broncho-vascular structures towards the contralateral side. Additionally, compression of the right pulmonary artery can be observed, along with the presence of pleural effusion and left basal atelectasis.",
    "discussion": "Yolk sac tumours (YST) are aggressive primitive germ cell tumours that can develop both within and outside the gonads, more frequently seen in men. In adults, YST are frequently found alongside other types of germ cell tumours, unlike in infants, where they usually occur as a pure form. Mediastinal germ cell tumours (GCTs) predominantly occur in males, with a notable rise in frequency during puberty, potentially attributed to hormone-mediated stimulation of neoplastic cells arising from embryonic development [1].\nThese tumours originate from cells that have the capacity to differentiate into various tissues found in the yolk sac during embryonic development. Yolk sac tumours can synthesize alpha-fetoprotein (AFP) [2].\nThe majority of mediastinal masses are located in the anterior region. Chest radiography is a crucial initial study for evaluating mediastinal lesions. The silhouette sign is a helpful tool in differentiating specific mediastinal spaces based on the loss of normal borders. After identifying an abnormality on chest radiography, further evaluation is necessary using computed tomography (CT).\nCT is used to understand the characteristics of the lesion, identify any accompanying abnormalities, and provide guidance for subsequent treatment strategies. MRI is employed in cases where a cystic mass is present, there is vascular involvement, or when contrast-enhanced CT is contraindicated.\nTo differentiate between seminoma and non-seminomatous germ cell tumours (NSGCTs), specific factors need to be considered. When examining a substantial, lobular, and homogeneous mass in the anterior mediastinum, it raises suspicion of seminoma. To distinguish NSGCTs, it is important to note that they present with elevated levels of AFP or \u03b2-human chorionic gonadotropin (\u03b2-HCG). These markers are observed in approximately 90% of patients with NSGCTs [3].\nThe treatment for these tumours typically involves a combination of surgery and chemotherapy. However, it is important to note that these tumours commonly exhibit resistance to cisplatin-based chemotherapy, resulting in a generally unfavourable prognosis [4].\nIn conclusion, YST predominantly occur in young men and are potentially influenced by hormonal factors. These tumours have the capacity to produce an AFP. Chest radiography serves as an initial study for the differentiation of mediastinal compartments when evaluating mediastinal masses. CT and MRI are utilized for tumour characterization and therapeutic decision-making. While imaging plays a valuable role, the use of specific markers such as AFP and \u03b2-HCG aids in distinguishing between these lesions. A definitive diagnosis is established through histopathological examination, in our case the diagnosis was confirmed through excisional biopsy and treatment can be challenging due to the frequent cisplatin resistance observed in many NSGCT cases [1\u20134].\nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Yolk, sac, tumour, Mediastinal, yolk, sac, tumour, Thymoma, Lymphoma, Seminoma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-10//18342_1_1.png?itok=LZnGoQqX",
            "caption": "The PA chest radiograph reveals a significant lesion involving the left mediastinum. A positive silhouette is noted with the left upper border of the hearth with preservation of the borders of the left hemidiaphragm, which suggests that the mass does not extend posteriorly. Obtuse angles can be visualized in relation to the lung. There is a discrepancy in lung volume probably due to secondary diaphragmatic paralysis caused by tumour compression. Left hilar point preservation is observed as the mass displaces the hilium posteriorly. There is obliteration of the left costophrenic angle, indicating the presence of a pleural effusion."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-10//18342_2_1.jpg?itok=5Md3O5T7",
            "caption": "A lateral view was requested to delineate the tumour\u00b4s location, confirming it to be in the anterior mediastinum, there is evidence of occupation within the retrosternal space."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-10//18342_3_1.jpg?itok=MJVDDB8u",
            "caption": "On axial imaging, we can see the previously identified lesion. That demonstrates a heterogeneous appearance, characterized by predominantly enhanced peripheral regions, as well as central areas of lower density, suggestive of necrosis. Additionally, compression of the right pulmonary artery can be observed."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-10//18342_3_2.png?itok=rZe0-giQ",
            "caption": "On coronal view, the mass does not extend to the section of the heart border that shapes the cardiac silhouette, and this observation serves as a notable example of how a preserved silhouette can potentially be misleading. It is also noted the presence of pleural effusion which correlates with the X-ray."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-10//18342_3_3.png?itok=svtPI5hz",
            "caption": "On the sagittal plane, we observe findings that align with those seen in the lateral radiograph. The retrosternal space appears to be occupied. Furthermore, these findings help explain the loss of the left hemidiaphragmatic silhouette on the X-ray."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Mediastinum"
    ],
    "imaging_technique": [
      "CT",
      "Digital radiography"
    ],
    "link": "https://www.eurorad.org/case/18342",
    "time": "13.10.2023"
  },
  "18343": {
    "case_id": 18343,
    "title": "A rare case of a persistent and isolated superior vena cava in an adult patient",
    "section": "Chest imaging",
    "age": "60",
    "gender": "male",
    "diagnosis": "Persistent and isolated superior vena cava",
    "history": "A 60-year-old apyretic man presents with dyspnea and increased D-Dimeres levels on blood tests. He underwent an angio-CT.",
    "image_finding": "No pulmonary embolism was found. However, the angio CT displayed on mediastinal view an aberrant vessel left to the aortic arch which drains into the right atrium, corresponding to an aberrant left superior vena cava. The right superior vena cava was absent. No other associated vascular abnormalities were found.",
    "discussion": "Background\nPersistent superior vena cava (PLSVC) is rare as it is seen in only 0.3 to 0.5% of the population. Yet, it is the most common thoracic veinous abnormality.\nThe primitive veinous system consists of the cardinal veins, umbilical veins and vitelline veins. PLSVC is seen when the left superior cardinal vein and its continuity with the left common cardinal vein\u00a0fail to regress. The presence of a left superior vena cava along with a right superior vena cava is much more frequent, and the condition is called the double superior vena cava. Isolated PLSVC without a right vena cava is very rare.\nRight atrial drainage is the most frequent and is associated with a large coronary sinus. Left atrial drainage causes a left to right shunt but it was however sometimes reported without cardiac defects.\nClinical perspective\nThe clinical relevance of this entity depends on its drainage and cardiac-associated abnormalities. When asymptomatic, it is discovered incidentally on chest examinations. In most cases, the PLSVC drains into the right atrium and the patients are asymptomatic. But in 10-20% of cases, it can drain into the left atrium, causing a right to left shunt, leading to clinical symptoms such as cardiac arrhythmia, chest discomfort, palpitation, and cyanosis.\nImaging\nOn plain radiographs, LSVC can be detected as a vertical left upper mediastinal vertical limit superimposed to the aortic arch. Sometimes, it is not directly seen on plain radiographs and it can be suspected if a central catheter is in an unexpected left para mediastinal situation.\nCT with contrast media administration is the modality of choice for the characterization of this anomalous vessel in the left mediastinum. It is suspected in the presence of a dilated coronary sinus on cross-sectional imaging.\nMost cases encounter a PLSVC draining into the right atrium through the coronary sinus. The vessel begins its course at the junction of the left subclavian and internal jugular veins, passes through the left side of the mediastinum, at the left of the ductal arch, passes anteriorly to the left hilum, and terminates in most cases in the right atrium via the coronary sinus.\nCT on axial plane displays a \u201cfour vessels\u201d image instead of a three-vessel image. On an axial slice at the level of the main left bronchus, in the case of PLSVC, two veins are seen anteriorly to the bronchus. In the case of a vertical vein, no vein can be seen next to the anterior wall of the left main stem bronchus.\nThe sagittal plane can show the \u201c pipe sign\u201d.\nIn up to 20% of cases, the drainage is into the left atrium directly, through an unroofed coronary sinus, or into the left superior coronary vein.\nIn 90% of cases, it is associated with a right superior vena cava, making it a superior vena cava duplication, and in those cases, a bridging vein may be seen (left brachiocephalic vein). Sometimes, the left brachiocephalic vein is absent leaving both superior vena cava not connected. Sometimes, the left superior intercostal vein may form a communication between the PLSVC and the accessory hemiazygos vein, forming a left-sided azygos arch.\nIf PLSVC is isolated (absence of right superior vena cava in 10% of cases), it is either seen with a normal heart or with congenital heart abnormalities: tetralogy of Fallot, atrioventricular canal defect, mitral atresia, atrial/septal ventral defect, transposition of the great arteries, aortic arch abnormalities, etc. It is also present in 50-70% of heterotaxy syndrome cases.\nThe incidence of congenital heart disease is increased in the absence of the right superior vena cava.\nOutcome\n\nDilation of the coronary sinus may cause stretching of the arteriovenous node and bundle of his, causing arrhythmia.\nThe patient\u2019s outcome depends on the other malformations associated with this condition.\n\nTeaching points\n\nA vessel on the left side of the aorta in the mediastinum is not always a PSLVC. The beginning, the course, and the end of this vessel must be carefully evaluated to make the correct diagnosis.\nRadiologists must specify on their report if there is a PLSVC even if the patient is asymptomatic. This information might be useful in the case of placement of a central venous device or an eventual cardiac surgery.\n\nAll patient data have been completely anonymised throughout the entire manuscript and related files.",
    "differential_diagnosis": "Left, superior, intercostal, vein, Aberrant, left, brachiocephalic, vein, Persistent, and, isolated, superior, vena, cava, Levoatriocardinal, vein, The, vertical, vein",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-10//18343_1_1.png?itok=G5Eddrm_",
            "caption": "Axial CT pulmonary angiogram at the level of the aortic arch displaying persistent left superior vena cava (PLSVC) ipsilateral to the aortic arch (arrow). The right SVC is absent."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-10//18343_2_1.jpg?itok=zgWibEvd",
            "caption": "Coronal reconstruction of the same CT-PA showing the course of the left SVC."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-10//18343_2_2.jpg?itok=pw1PbI0j",
            "caption": "Sagittal reconstruction of the same CT-PA showing the course of the left SVC."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-10//18343_3_1.png?itok=T6ne39DK",
            "caption": "Axial CT pulmonary angiogram at the level of the main bronchus showing two main vessels located anteriorly to the left bronchus: the left superior vena cava (white arrow) and the left superior pulmonary vein (blue arrow)."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-10//18343_4_1.jpg?itok=4gjMwLHm",
            "caption": "Axial CT pulmonary angiogram displaying the course of the PLSVC into the right atrium through the coronary sinus."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-10//18343_4_2.jpg?itok=59tBa10M",
            "caption": "Axial CT pulmonary angiogram at a different level displaying the course of the PLSVC into the right atrium through the coronary sinus."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Anatomy",
      "Mediastinum",
      "Thorax"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/18343",
    "time": "13.10.2023"
  },
  "18367": {
    "case_id": 18367,
    "title": "heim\u2013Chester disease with extensive aortic involvement",
    "section": "Chest imaging",
    "age": "66",
    "gender": "male",
    "diagnosis": "Erdheim\u2013Chester disease with extensive aortic involvement",
    "history": "A 66-year-old man with no past medical follow-up for decades came to our emergency department complaining of worsening fatigue, dyspnea, orthopnea and paroxysmal nocturnal dyspnea. He referred to having these symptoms for years and that they became unbearable over the last couple of days. Blood scan showed normal leucocytes and elevated C-reactive protein.",
    "image_finding": "A thoracoabdominal angioscan was performed to look for a cause for these symptoms. It showed extensive circumferential soft tissue sheathing of the thoracic and abdominal aorta (\u201ccoated aorta\"), as well as its branches. The aortic arch was also involved. A bilateral pleural effusion was also noted.\nWe could also see bilateral symmetric peri-nephric fat stranding (\"hairy kidney\").\nThe inferior vena cava is spared.\nErdheim\u2013Chester disease and lymphoma were the suggested differential diagnoses at this point.\nA biopsy of the periaortic tissue was performed in order to confirm the diagnosis.",
    "discussion": "Erdheim\u2013Chester disease (ECD) is a rare form of non-Langerhans' cell histiocytosis, originally described in 1930 as \"Lipid Granulomatosis\" [1]. It is a systemic disorder characterized by diffuse histiocytic infiltration of the bones and various organs [1].\nIt primarily affects adults between their 5th and 7th decades of life, with a slight male predominance [1]. Patients with ECD have a variable clinical course, ranging from an indolent focal disease to life-threatening organ failure [2].\nHistologically, it is characterized by the presence of lipid-laden histiocytes with foamy or eosinophilic cytoplasm, which are positive for CD68 and negative for CD1a [3].\nBone pain represents the most common symptom and usually involves the lower limbs [2]. Other common presenting symptoms include non-specific complaints such as fever, weakness, weight loss, night sweats and fatigue [1].\nImaging plays a key role in diagnosing ECD. The most frequent organ affected are the bones, with bilateral symmetric osteosclerosis of the metadiaphysis of the femur, tibia, and fibula considered pathognomonic [1]. Other common radiological manifestations include periaortic soft tissue encasement, pericardial and pleural effusions, myocardial and CNS infiltration, interstitial lung disease and infiltrative perinephric soft tissue thickening (\u201chairy kidney\") [4].\nThe rarity of ECD coupled with multi-organ involvement can make the diagnosis extremely challenging and often requires integration of descriptive pathology together with clinical and radiographic findings [4]. Tissue biopsy is required in all ECD cases, not only to confirm the diagnosis, but also to identify associated mutations for therapeutic purposes [4].\nVarious therapies for ECD have been reported. FN-\u03b1-based regimens have been shown to improve survival and have been widely used in the therapy of ECD [5]. However, the most promising advances in this disease\u00b4s treatment have been the demonstration of efficacy for BRAF inhibitors and MEK inhibitors [5], as these medications are now recommended as 1st line options depending on mutational testing [4].\nAll patient data have been completely anonymised throughout the entire manuscript and related files.",
    "differential_diagnosis": "Erdheim\u2013Chester, disease, with, extensive, aortic, and, renal, involvement, Erdheim\u2013Chester, disease, with, extensive, aortic, involvement, Lymphoma, IgG4, mediated, disease",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-11//18367_1_1.PNG?itok=U-bu0jk8",
            "caption": "Post-contrast CT showing extensive circumferential soft tissue sheathing of the thoracic aorta (\u201ccoated aorta\u201d). There is also bilateral pleural effusion."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-11//18367_1_2.PNG?itok=vmLzpo1H",
            "caption": "Post-contrast CT showing extensive circumferential soft tissue sheathing of the thoracic aorta (\u201ccoated aorta\u201d). There is also bilateral pleural effusion."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-11//18367_2_1.PNG?itok=Tcw04Vbi",
            "caption": "Contrast-enhanced abdominal CT demonstrates circumferential soft tissue sheathing of the abdominal aorta and its branches. There is also bilateral peri-nephric fat stranding (\u201chairy kidney\u201d)."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Abdomen",
      "Anatomy",
      "Arteries / Aorta"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/18367",
    "time": "07.11.2023"
  },
  "18383": {
    "case_id": 18383,
    "title": "Lady Windermere Syndrome, a rarely considered entity: A case in South Americ",
    "section": "Chest imaging",
    "age": "56",
    "gender": "female",
    "diagnosis": "Chronic pulmonary disease by Mycobacterium avium intracellular infection",
    "history": "A 56-year-old immunocompetent Caucasian woman presented with chronic cough. She was an active smoker (3 pack years) and had no known environmental expositions. She presented basal rales and rhonchi at physical examination.",
    "image_finding": "Computed tomography of the chest showed right middle lobe chronic volume loss with architectural distortion and bronchiectasis, with scattered mucous plugging and endobronchial calcification. There was also similarly distributed scattered tree-in-bud nodularity and ill-defined centrilobular nodules.\nThere was no significant emphysema, focal consolidation, cavitary nodules, or pleural effusion or thickening.\nFindings were in keeping with small-airways disease, possibly due to non-tuberculous mycobacteria (NTM).",
    "discussion": "Lady Windermere Syndrome (LWS) is an atypical presentation of Mycobacterium avium complex (MAC) pulmonary disease. First described in 1992, this NTM lung disease is recognised in the official statement of the American Thoracic Society (ATS) and the Infectious Diseases Society of America (IDSA) regarding its diagnosis and treatment [1,2].\nContrary to the traditional presentation seen in immunocompromised middle-aged males with a smoking history and underlying lung disease, LWS presents in healthy non-smoking elderly white women with no underlying pulmonary disease. It presents as a slowly progressive disease with nonspecific respiratory symptoms such as chronic cough and dyspnoea [1,3\u20135].\nSince it has a nonspecific clinical presentation, clinicians should suspect it as one of the possible differential diagnoses in patients presenting chronic cough. Therefore, it is recommended that the evaluation should include a chest image, preferably a CT scan [2].\nRadiological presentation typically involves the right middle lobe or lingula. This infection is an excellent example of cellular bronchiolitis, which damages the small airways. CT findings are broad, including multiple small peripheral centrilobular nodules, usually in a \u201ctree-in-bud\u201d pattern, diffuse opacities and cylindrical bronchiectasis [2].\nAlthough not always possible, diagnosis is confirmed with positive sputum cultures for MAC. The most recent ATS/IDSA recommendation for treatment consists of a three-drug regimen of clarithromycin or azithromycin, ethambutol and rifampicin given intermittently three times weekly until 12 months of culture-negative sputum [2].\nThis clinical case partially fits the typical patient description of LWS, being a middle-aged immunocompetent Caucasian woman with a history of chronic cough. Although she had a long cigarette smoking history, her lung did not show smoking-related lung damage. Her chest CT shows the classical LWS radiologic pattern, middle lobe compromise with chronic pulmonary atelectasis, traction bronchiectasis and multiple centrolobulillar nodules, confirmed with sputum cultures positive for MAC.\nIn recent years, NTM diseases such as LWS have received an unprecedented level of interest. Improvements in diagnostic techniques have shown this disease in patients with different characteristics as the ones typically described in literature. Because of that, there needs to be a high index of suspicion when dealing with patients presenting nonspecific chronic pulmonary symptoms, relying on radiological and CT findings in the evaluation process of these kinds of patients [2].\nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Chronic, pulmonary, disease, by, Mycobacterium, avium, intracellular, infection, Chronic, obstructive, pulmonary, disease, (COPD), Chronic, respiratory, infection, by, Mycobacterium, Tuberculosis, Chronic, respiratory, infection, by, other, nontuberculous, Mycobacterium",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-11//18383_1_1.jpg?itok=-pKGjux7",
            "caption": "In this slice, middle lobe volume loss is depicted (arrowheads), almost completely replaced by cystic-like images (arrows) which at close examination could be followed to the main pulmonary airways, characteristic of traction bronchiectasis."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-11//18383_2_1.jpg?itok=E71pjfQZ",
            "caption": "In this slice, at a higher level, we can identify small airways disease damaging only the middle lobe (arrowheads), sparing the rest of the lung parenchyma. A \u201ctree in bud\u201d pattern (arrows) can be seen in the periphery of the lobe, with centrilobular nodules sparing the pleura and minor fissure."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Respiratory system",
      "Thorax"
    ],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/18383",
    "time": "21.11.2023"
  },
  "18388": {
    "case_id": 18388,
    "title": "Primary pulmonary MALT lymphom",
    "section": "Chest imaging",
    "age": "69",
    "gender": "male",
    "diagnosis": "Primary pulmonary MALT lymphoma",
    "history": "A 69-year-old man presented with dry cough and dyspnea. He had a history of chronic obstructive pulmonary disease and rectal cancer, successfully treated with surgical resection and chemoradiotherapy. He was an ex-smoker. Physical examination revealed weak vesicular breath sounds and normal vital signs. Laboratory findings were unremarkable.",
    "image_finding": "X-ray (Figure 1) shows bilateral airspace consolidations.\nCT (Figure 2) shows multiple well-delineated soft-tissue masses with air bronchogram and halo sign, the largest one measuring 9 cm in the inferior left lobe. There are also multiple lung cysts, with mid to lower-lobe predominance. No evidence of hilar or mediastinal lymphadenopathy.\nPET-CT (Figure 3) shows pulmonary consolidation areas with 18FDG uptake in both lungs (SUVmax 9.9).\nCT-guided transbronchial biopsy was performed. The histopathology of the tissues revealed a small to intermediate-sized B lymphocyte cell population with towel-like growth and hyalinized areas. On immunohistochemistry, the tumour showed positivity for CD20, CD79, Bcl2 and CD43 and negativity for Bcl6, CD3, CD5, CD10 and cyclin D1. There was focally positivity for MUM1. The proliferation index (Ki67) was 20%. This was compatible with a pulmonary mucosa-associated lymphoid tissue (pMALT) lymphoma.\nHe also underwent a bone marrow aspirate and upper endoscopy, which were normal.",
    "discussion": "Background\nPulmonary MALT lymphoma is the most frequent primary pulmonary lymphoma, which is a rare clinical entity [1]. It is a low-grade B-cell extranodal lymphoma characterized by a proliferation of clonal marginal zone lymphocytes and is associated with chronic antigenic stimulation and autoimmune diseases, such as systemic lupus erythematosus, Hashimoto\u2019s thyroiditis, and Sj\u00f6gren\u2019s syndrome [2].\nClinical Perspective\nPulmonary MALT lymphoma usually occurs in sixth and seventh decade. Patients might be asymptomatic or present with unspecific symptoms and signs with a slow and insidious course. Most common symptoms are cough, dyspnea, expectoration, chest pain, hemoptysis, and B symptoms [3].\nImaging Perspective\nOn imaging, it typically manifests as solitary or multiple consolidations with air bronchograms, nodules, masses, and ground glass opacifications or as a pattern of diffuse interstitial lung disease. Hilar or mediastinal lymphadenopathy might also be present [4,5].\nPET-CT is useful for staging, and most lesions demonstrate increased FDG avidity.\nPulmonary MALT lymphoma can only be reliably diagnosed by pathology. Transbronchial or CT-guided transthoracic lung biopsy and surgical resection can be used to obtain samples for pathologic diagnosis [6].\nOutcome\nPatients usually have a favourable outcome, with a 5-year overall survival of >85% and a median survival time of over 10 years [7]. Nevertheless, systemic dissemination and transformation into high-grade B-cell lymphoma may occur.\nTherapeutic strategies and guidelines remain under debate, mainly due to the limited availability and heterogeneity of the data reported in the literature. Wait-and-watch approach might be considered in asymptomatic patients. Treatment options include surgery, radiotherapy, chemotherapy, immunotherapy, and or a combination of these options [6].\nTake Home Message / Teaching Points\nPrimary pulmonary MALT lymphoma is a rare low-grade B-cell non-Hodgkin\u2019s lymphoma with an indolent course.\nThe radiographic findings are nonspecific and include a solitary nodule, multiple ill-defined nodules, or consolidated masses with air bronchogram signs. It can easily be misdiagnosed as other lung pathologies like infection or lung cancer.\nBiopsy is required for diagnosis.",
    "differential_diagnosis": "Organizing, pneumonia, Eosinophilic, lung, disease, Sarcoidosis, Primary, pulmonary, MALT, lymphoma, Pulmonary, vasculitis, (granulomatosis, with, polyangiitis,, polyarteritis, nodosa, or, Churg-Strauss, syndrome), Pulmonary, infection, (tuberculosis, or, fungal, infection), Neoplastic, (invasive, adenocarcinoma, of, the, lung), or, lymphoproliferative",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-11/Figure%201_small.png?itok=achmVyye",
            "caption": "X-ray shows bilateral airspace consolidations."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-11//18388_2_1.png?itok=qjg7BtCw",
            "caption": "CT shows well-delineated soft-tissue masses with air bronchogram and halo sign and multiple lung cysts."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-11//18388_3_1.png?itok=vafBRPIW",
            "caption": "PET-CT shows pulmonary consolidation areas with 18FDG uptake in both lungs (SUVmax: 9.9)."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-11//18388_4_1.png?itok=2feNDR6x",
            "caption": "Histopathological findings of the lung biopsy, compatible with a pulmonary MALT lymphoma. Abnormal lymphocyte infiltration in HE staining (\u00d710 magnification) (A). Immunohistochemical staining (\u00d72 magnification) for CD20 (B), Bcl2 (C) and CD79 (D)."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Haematologic",
      "Lung"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT",
      "PET-CT"
    ],
    "link": "https://www.eurorad.org/case/18388",
    "time": "21.11.2023"
  },
  "18403": {
    "case_id": 18403,
    "title": "Tracheobronchopathia osteochondroplastica: Radiological and endoscopic correlation",
    "section": "Chest imaging",
    "age": "66",
    "gender": "male",
    "diagnosis": "Tracheobronchopathia osteochondroplastica",
    "history": "A sixty-six-year-old male was referred to the pulmonology consultation by his medical assistant with a history of two months odynophagia, exacerbated with swallowing and no other symptoms. A nasopharyngolaringoscopy was performed, which showed multiple granulomatous lesions in the first tracheal rings. Past medical history was irrelevant.",
    "image_finding": "A chest computed tomography (CT) was performed, which depicted diffuse calcified submucosal nodules of the tracheal cartilage rings projecting into the tracheal lumen, causing a beaded appearance. These changes only affected the anterior and lateral walls of the trachea and main bronchi, sparing its posterior wall. It caused mild luminal narrowing (Figure 1).\nThe bronchoscopy study revealed multiple thick nodules involving all the anterior wall of the trachea, from the subglottic area until the beginning of the main right and left bronchi. Tracheal lumen was 25% narrowed (Figure 2).\nBiopsy of these nodules confirmed the diagnosis of tracheobronchopathia osteochondroplastica (TO).",
    "discussion": "TO is a rare, idiopathic, benign condition which is characterized by the development of osseous and cartilaginous nodules in the submucosa of the trachea, causing tracheal stenosis [1,2]. These sessile, cartilaginous, or bony submucosal nodules are distributed throughout the anterolateral walls of the trachea, over the perichondrium of cartilage rings, projecting into the laryngotracheobronchial lumen [1,2,3]. It tends to affect the lower two-thirds of the trachea, but all the trachea and the beginning of the mainstem bronchi may be affected as well, such as in our case [1,2,3].\nPathogenesis of this entity is unclear, with familial cases and others associated with chronic inflammation or trauma [1].\nIt predominantly affects males in the fifth to seventh decades of life [3,4,5]. Most patients are asymptomatic with only minimal progression of the disease [2,3], with TO being incidentally detected in bronchoscopy or autopsy studies [4]. Symptomatic patients may experience dyspnoea, chronic cough with expectoration and rarely, haemoptysis [3,4].\nOn CT, thickened cartilage rings with irregular calcifications and multiple nodules sparing the posterior membranous walls of the trachea are pathognomonic for TO [2]. Tracheomalacia does not occur, although an association with saber-sheath trachea has been described [6]. Atelectasis and pneumonia are possible complications [2].\nBronchoscopy shows the pathognomonic \u201ccobblestone\u201d or \u201crock garden\u201d appearance due to the diffuse cartilaginous nodules protruding into tracheal lumen [3]. When the imaging findings are not definitive, a biopsy may be done for pathological analysis [5].\nAnother entity which spares the posterior membrane of the trachea is relapsing polychondritis (RP), in which there is thickening of the cartilaginous trachea, sometimes with calcifications and associated tracheomalacia [6].\nTracheobronchial amyloidosis consists of concentric calcified nodular or concentric wall thickening without posterior sparing as opposed to TO and RP. Also, amyloidosis may affect the larynx, pharynx, and superior trachea [6].\nThere are other differential diagnoses for TO, such as atrophic polychondritis and sarcoidosis. These conditions involve the whole circumference of the tracheobronchial tree [3].\nThe progression of the disease is benign, with a favourable prognosis for these patients [2,3,6]. Treatment is unspecified and symptomatic with a combination of antitussives, antibiotics and inhaled bronchodilators [3,6].\nCT plays a major role in the evaluation of diffuse tracheal diseases by providing a non-invasive examination of the trachea wall, lumen and surrounding tissues [1,2]. CT findings are pathognomonic and bronchoscopy with tissue biopsy is indicated in equivocal cases [5].\nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Relapsing, polychondritis, Tracheobronchopathia, osteochondroplastica, Tracheobronchial, amyloidosis, Sarcoidosis, Papillomatosis, Scleroderma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-12//18410_1_1.jpg?itok=L1NItVUU",
            "caption": "Axial CT reconstruction in mediastinal window (a) and virtual bronchoscopy image (b) at the same level, showing irregular thickening of the anterolateral tracheal submucosa with multiple nodules, sparing the posterior membrane with luminal narrowing."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-12//18410_1_2.jpg?itok=3bDSF-uB",
            "caption": "Axial CT reconstruction in mediastinal window (a) and virtual bronchoscopy image (b) at the same level, showing irregular thickening of the anterolateral tracheal submucosa with multiple nodules, sparing the posterior membrane with luminal narrowing."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-12//18410_2_1.jpg?itok=oY5MPdiB",
            "caption": "Axial CT reconstruction in mediastinal window (a) and virtual bronchoscopy image (b), showing irregular thickening at the bifurcation of the tracheal submucosa and at the beginning of the main bronchi."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-12//18410_2_2.jpg?itok=H37gZ52k",
            "caption": "Axial CT reconstruction in mediastinal window (a) and virtual bronchoscopy image (b), showing irregular thickening at the bifurcation of the tracheal submucosa and at the beginning of the main bronchi."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-12//18410_3_1.jpg?itok=-yA0kEjg",
            "caption": "Coronal CT reconstruction in mediastinal window showing diffuse irregular thickening of the tracheal submucosa."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-12//18410_4_1.jpg?itok=M8TqjE-W",
            "caption": "Sagittal CT reconstruction in mediastinal window showing diffuse irregular thickening of the anterior wall of the trachea since the subglottic region."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-12//18410_5_1.jpg?itok=ecFWIa5m",
            "caption": "Axial CT reconstruction in bone window depicting the calcified matrix in the nodular lesions."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-12//18410_6_1.jpg?itok=nmPYzm5Z",
            "caption": "Bronchoscopy study revealing multiple cartilaginous nodules in the submucosa protruding into the subglottic lumen of the trachea."
          }
        ]
      },
      {
        "number": "Figure 7",
        "subfigures": [
          {
            "number": "Figure 7",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-12//18410_7_1.jpg?itok=jykd0wQn",
            "caption": "Bronchoscopy study showing multiple nodules in the anterior and lateral tracheal submucosal wall with the characteristic \u201ccobblestone\u201d appearance. The posterior wall is spared."
          }
        ]
      },
      {
        "number": "Figure 8",
        "subfigures": [
          {
            "number": "Figure 8",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-12//18410_8_1.jpg?itok=EzGmB-vb",
            "caption": "Bronchoscopy study showing extension of the lesions till the carina and main bronchi."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Respiratory system",
      "Thorax"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/18403",
    "time": "07.12.2023"
  },
  "18404": {
    "case_id": 18404,
    "title": "Pulmonary arteriovenous malformation: Multimodality chest imaging",
    "section": "Chest imaging",
    "age": "23",
    "gender": "female",
    "diagnosis": "Pulmonary arteriovenous malformation",
    "history": "A 23-year-old female presented with a complaint of intermittent dyspnea (New York Heart Association NYHA grade, II), which aggravates on exertion and mild chest pain. No past significant medical and surgical history was given by the patient. On clinical examination, bruit was heard on auscultation in the left mid-zone.",
    "image_finding": "Chest X-ray (Figure 1) shows a well-circumscribed homogenous soft pulmonary nodular opacity in mid-zone of left lung (arrow) and a tubular structure arising from its medial margin and directed towards the hilum (arrowhead).\nCTPA with Axial MIP image (Figure 2) shows a left lower lobe high-density, contrast-enhancing tortuous nodular opacity (arrow) with tubular structure arising from the superomedial aspect of the lesion and directed towards the left hilum (arrowhead). This is the feeding artery branch of main left pulmonary artery.\nCTPA with coronal MIP image (Figure 3) shows left lobe pulmonary arterio-venous malformation demonstrating the angioarchitecture of a PAVM with a single feeding artery (down arrowhead) from the left main pulmonary artery and single vein (up arrowhead) draining into the left atrium via an inferior pulmonary vein, both connected to the tortuous contrast enhancing aneurysmal sac (nidus).\nVolume rendering multiplanar reformatted image (Figure 4) confirmed the suspected diagnosis of pulmonary arterio-venous malformation by establishing vascular communications of the lesion with the origin and termination of the pulmonary arteriovenous malformation (PAVM).",
    "discussion": "Background\nPulmonary arteriovenous malformations (PAVMs) are rare, abnormal low resistance, high flow vascular structure. It is a fistulous communication between the pulmonary artery and vein bypassing the capillary bed and resulting in the intrapulmonary right to left shunt. PAVMs are often unilateral with their propensity towards the lower lobes. According to various literature, its incidence is 2\u20133 per 100,000 population [1]. Mostly PAVMs are associated with Hereditary Hemorrhagic Telangiectasia (HHT1 > HHT2) / Osler-Weber Rendu syndrome. It can be congenital or acquired [2]. Usually, till the second decade, it remains asymptomatic, but in puberty and pregnancy, it may show some symptoms like chest pain and dyspnea hemoptysis because of the gradual enlargement of PAVMs with age.\nClinical perspective\nThere are 4 variants of PAVMs:\n\nSimple: the commonest, comprises a single artery feeding the malformation; the feeding segmental artery may have multiple subsegmental branches [2].\nComplex: have multiple segmental arteries feeding the malformation [2].\nDiffuse: rare, it is a combination of simple and complex variants [1].\nTelangiectatic: these are typically seen in children more common in patients with telangiectasia [2].\n\nThe diagnosis of PAVMs is confirmed only if the nodule is connected with the artery and vein.\nImaging perspective\nRadiologically, the condition is an important differential diagnosis of the pulmonary nodule. In our case, PAVMs are detected on Multimodality chest imaging: Roentography, Contrast-enhanced computed tomography (CECT) and Computed tomography pulmonary angiography [2].\nOn chest radiography, typically, PAVMs appear as well-defined homogeneous soft tissue lesions and are associated with dilated pulmonary vessels. CECT is the modality of choice for the characterization of PAVMs. A homogenous, well-circumscribed, high density, non-calcified enhancing nodule or serpiginous mass lesion connected with blood vessels, showing aneurysmal connection along with the feeding artery and draining vein related to PAVMs [3].\n3D spiral CT is useful in the pre-therapeutic evaluation of the number and orientation of the feeding arteries.\nCT pulmonary angiography is the gold standard modality required when further intervention is planned.\nMultiplanar reformatted images confirmed the diagnosis of PAVMs by establishing the vascular communication with the lesion, with the origin and termination of PAVMs [8].\nOutcome\nStudies have shown that CT is the best noninvasive modality for the evaluation of pulmonary AVMs. Surgery and transcatheter embolotherapy is recommended for treatment of symptomatic patients or those AVMs having a diameter of more than 3mm. Transcatheter embolotherapy with stainless steel coils or detachable balloons is most commonly performed by interventionists [6].\nTeaching points\nPulmonary AVMs are a rare clinical entity. It is usually associated with Hereditary Hemorrhagic Telangiectasia / Osler Weber Rendu syndrome. CECT chest is the best and noninvasive modality to know the description of PAVMs. After transcatheter embolotherapy, significant decrease in the size of the nodule is usually seen.",
    "differential_diagnosis": "Pulmonary, arteriovenous, malformation, Pulmonary, nodule, Pulmonary, varix, Vascular, pulmonary, mass, Bronchocele, Mucocele",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-12//18411_1_1.jpg?itok=A3Xu276C",
            "caption": "Chest X-ray"
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-12//18411_2_1.png?itok=IMmcXS-w",
            "caption": "CTPA with axial MIP image"
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-12//18411_3_1.png?itok=RjfaNIdu",
            "caption": "CTPA with coronal MIP image"
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2023-12//18411_4_1.png?itok=Z0Ozbx-d",
            "caption": "Volume rendering multiplanar reformatted image"
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Pulmonary vessels"
    ],
    "imaging_technique": [],
    "link": "https://www.eurorad.org/case/18404",
    "time": "07.12.2023"
  },
  "18414": {
    "case_id": 18414,
    "title": "A case of diffuse pneumonic-type lung adenocarcinom",
    "section": "Chest imaging",
    "age": "54",
    "gender": "male",
    "diagnosis": "Pneumonic-type lung adenocarcinoma",
    "history": "A 54-year-old man presented to our hospital with complaints of fever, cough and shortness of breath associated with chronic weight loss and generalized weakness. He was diagnosed as sputum-positive pulmonary tuberculosis outside and was on anti-tubercular drugs since past 2 months.",
    "image_finding": "Chest radiograph PA view showed large areas of confluent consolidation in both lungs with few lucent areas seen within the consolidation in right midzone.\nNon-contrast CT scan of thorax showed extensive consolidation in both lungs, with intervening ground glass opacities, septal thickening and multiple small cystic/cavitating areas. Some of the consolidations showed internal low-density areas (attenuation values ranging from 15\u201325 HU). There was no associated pleural effusion or significant mediastinal lymphadenopathy.\nPatient\u2019s total leucocyte counts and inflammatory markers like C-reactive protein and procalcitonin were within normal limits.\nNo infective pathogen was identified on microbiological examination, and bronchoalveolar lavage was negative for malignancy. CT-guided biopsy from the left upper lobe consolidation was done, which revealed mucinous adenocarcinoma with lepidic growth. Immunohistochemistry was positive for cytokeratin 7 (CK 7) and was negative for TTF1, CK20, Napsin A, CDX2 and synaptophysin.",
    "discussion": "Lung adenocarcinoma is the most common type of lung cancer [1]. It has a wide variety of imaging appearances on CT scans, and can sometimes present as localized or diffuse lung consolidation, which can be misdiagnosed as pneumonia [2].\nClinically, it is difficult to differentiate pneumonic-type lung adenocarcinoma (PLAC) and infectious pneumonia, as both can present with cough and sputum production [3]. However, infectious pneumonia are frequently associated with fever and elevated inflammatory markers [4].\nSeveral studies have assessed the CT imaging features of pneumonic-type adenocarcinoma [5,6]. Some of the proposed features that can help in differentiating it from infection include irregular air bronchogram sign, bulging interlobular fissure, pseudocavitation, presence of low attenuation areas within the consolidation and CT angiogram sign (seen on contrast-enhanced scans). Irregular air bronchogram sign is seen secondary to lepidic growth or tumour invasion into the bronchi [6,7]. Bulging interlobular fissure sign is seen as result of increased lung volume secondary to mucus production by the tumour cells [8]. Pseudocavitation occurs due to invasion of the tumour cells into bronchial lumen, forming a one-way valve resulting in cyst formation within the consolidation [9]. Consolidation in PLAC tends to have lower attenuation values due to increased mucus production by the tumour cells [7,10].\nDiagnosing PLAC requires high degree of suspicion, and it should be kept as one of the imaging differentials in cases with chronic non-healing consolidation. Histopathological correlation is needed to confirm the diagnosis.\nWritten informed consent for publication has been obtained.",
    "differential_diagnosis": "Pneumonic-type, lung, adenocarcinoma, Atypical, lung, infection, like, fungal, infection, Cryptogenic, organizing, pneumonia",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-01/Figure%201a_small_0.jpg?itok=kLpPuZ9U",
            "caption": "Chest X-ray PA view showing bilateral lung consolidation (black arrows) with multiple cystic lucencies seen in the right mid zone (red arrow)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-01/Figure%202a_small_0.jpg?itok=4DMsnvmv",
            "caption": "Non-contrast CT chest, lung window, showing extensive bilateral lung consolidation with multiple cystic areas suggesting pseudocavitation (black arrows in Figures 2a and 2b) and bulging interlobular fissure sign (red arrows in Figure 2c)."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-01/Figure%202b_small_0.jpg?itok=EEMpHs4d",
            "caption": "Non-contrast CT chest, lung window, showing extensive bilateral lung consolidation with multiple cystic areas suggesting pseudocavitation (black arrows in Figures 2a and 2b) and bulging interlobular fissure sign (red arrows in Figure 2c)."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-01/Figure%202c_small_0.jpg?itok=e81-xLwJ",
            "caption": "Non-contrast CT chest, lung window, showing extensive bilateral lung consolidation with multiple cystic areas suggesting pseudocavitation (black arrows in Figures 2a and 2b) and bulging interlobular fissure sign (red arrows in Figure 2c)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-01/Figure%203a_small_0.jpg?itok=15da0Vh3",
            "caption": "Non-contrast CT chest, mediastinal window, axial images showing low-density areas within the consolidation (black arrows) in right upper lobe (3a) and left lung base (3b)."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-01/Figure%203b_small_0.jpg?itok=718NES9Z",
            "caption": "Non-contrast CT chest, mediastinal window, axial images showing low-density areas within the consolidation (black arrows) in right upper lobe (3a) and left lung base (3b)."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-01/Figure%204a_small.jpg?itok=2br6DRtM",
            "caption": "CT chest, bone window, showing the tip of biopsy needle in left upper lobe consolidation."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-01/Figure%205a_small.jpg?itok=_XuHfMjY",
            "caption": "Histopathological images showing tumour cells growing along the surface of alveolar septa (white arrows). The tumour cells' nuclei showed loss of polarity, overlapping, pleomorphism, along with atypical mitosis (black arrow). Features suggesting mucinous adenocarcinoma with lepidic growth."
          },
          {
            "number": "Figure 5b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-01/Figure%205b_small.jpg?itok=0sFWGZJu",
            "caption": "Histopathological images showing tumour cells growing along the surface of alveolar septa (white arrows). The tumour cells' nuclei showed loss of polarity, overlapping, pleomorphism, along with atypical mitosis (black arrow). Features suggesting mucinous adenocarcinoma with lepidic growth."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Oncology"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/18414",
    "time": "03.01.2024"
  },
  "18415": {
    "case_id": 18415,
    "title": "Traqueal Diverticulum: An unusual presentation of an underecognized condition",
    "section": "Chest imaging",
    "age": "56",
    "gender": "female",
    "diagnosis": "Tracheal Diverticulum",
    "history": "The patient presented with a chronic cough, dysphagia, and heartburn. It was referred for an oesophagus contrast-barium study to investigate and exclude gastric reflux disease.",
    "image_finding": "The contrast study showed the esophagus, in the upper third near the thoracic inlet, deviated to the left by a hyperlucent oval area, which was surrounded by thin walls, suggesting a cyst with gas content. Although there was oesophagal deviation, this lesion did not cause significant oesophagal stenosis or delay in contrast progression.\nA CT was performed to characterise this lesion, which revealed a right posterior paratracheal air cyst at the thoracic inlet. Communication with the tracheal lumen was seen, making the diagnosis of a Tracheal Diverticulum.",
    "discussion": "The tracheal wall comprises mucosa, submucosa, cartilage or muscle, and adventitia. Horseshoe-shaped bands of hyaline cartilage support the anterior and lateral tracheal walls [1]. The posterior tracheal wall lacks cartilage and is supported by the trachealis muscle, forming the posterior tracheal membrane. The right side of the trachea is relatively weaker, while the left side is more resistant because of the support provided by both the oesophagus and the aortic arch [2]. Chronic cough or obstructive lung diseases, increase intratracheal pressure, making it more susceptible to the formation of a tracheal diverticulum (TD), preferentially on the right posterior side near the thoracic inlet [3].\nThey are classified as congenital or acquired based on their anatomical location. Congenital TD, often smaller and located below the vocal cords or above the carina, results from developmental defects. Acquired TD, larger and resulting from increased expiratory pressures or tracheomalacia, lacks a muscular layer and cartilage, appearing as pseudo-diverticula [4].\nTD is relatively common, found in approximately 3.7% \u2013 5.7% of the population [2,3]. It is often asymptomatic, discovered incidentally during Computed Tomography (CT) scans for investigating pulmonary symptoms. Some patients may experience chronic cough, dyspnea, stridor, or recurrent tracheobronchitis [2]. Although TD is related to increased intratracheal pressure, which is usual in obstructive lung diseases, previous studies show no significant association between emphysema and TD [2,3].\nImaging, particularly CT, is crucial for diagnosing TD. It evaluates its localization, size, and wall thickness. TD typically appears as a paratracheal thin-walled air cyst, with or without communication to the tracheal lumen, located most commonly near the thoracic inlet at the level between the T1 and T3 vertebrae [1]. Bronchoscopy, although invasive, can aid in diagnosis, but cases with a very narrow opening or fibrous tract may not be revealed [4].\nTreatment is not necessary in asymptomatic patients. However, surgical resection is often the treatment of choice in symptomatic cases, especially for young patients with long-term accumulated mucous in the lesion [2,4]. Careful surgical resection is crucial to avoid injury to the laryngeal nerve and oesophagus. Infections can occur in TD, progressing to a paratracheal abscess [4].\nRadiologists should recognize and describe right-sided paratracheal air cysts as a common finding, avoiding confusion with pneumomediastinum. While clinical importance may be limited, understanding TD characteristics aids in proper diagnosis and treatment decisions, especially in symptomatic cases [2,4].",
    "differential_diagnosis": "Laryngocele, Tracheal, Diverticulum, Zenker\u2019s, Diverticulum, Lung, bullae",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-01//18422_1_1.png?itok=O7Pqcs7T",
            "caption": "Radiographs showing a thin wall air cyst located right posterolateral to the trachea, at the level of the thoracic inlet. Contrast study of the oesophagus showing deviation by the tracheal diverticulum."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-01//18422_2_1.png?itok=d-XZh7xX",
            "caption": "CT images (lung window and MinIp) showing a right posterolateral paratracheal air cyst, with thin walls and gas content. Note the communication of the cyst with the trachea (arrow), making the diagnosis of tracheal diverticulum."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT",
      "Fluoroscopy"
    ],
    "link": "https://www.eurorad.org/case/18415",
    "time": "04.01.2024"
  },
  "18471": {
    "case_id": 18471,
    "title": "Pulmonary nocardiosis mimicking a lung neoplasm in an immunocompetent patient",
    "section": "Chest imaging",
    "age": "78",
    "gender": "female",
    "diagnosis": "Pulmonary nocardiosis",
    "history": "After a chest X-ray, an immunocompetent 78-year-old non-smoker woman, presenting cough, dyspnoea and leucocytosis arrived at the lung cancer diagnosis program. Assessment was completed with a CT scan and a PET scan. Subsequently, a BAL and an EBUS were performed. Samples were negative for malignancy, but culture turned out positive.",
    "image_finding": "Posterior-anterior (PA) and lateral X-rays showed a right hilar mass and associated partial atelectasis of the right upper lobe (Figures 1a and 1b).\nCT scan revealed a hypodense mass in the right hilar region, likely necrotic, accompanied by a distal consolidation in the anterior segment of the upper lobe (Figures 2a, 2b and 2c). Lung neoplasia was the suspected diagnosis with these findings.\nPET scan denoted hypermetabolism over the right hilar mass, the distal atelectasis/consolidation, and the mediastinal lymph nodes (Figure 3).\nFollow-up imaging controls were performed by sequential radiography and CT. Under treatment with meropenem, progressive reduction of the lung mass and lymphadenopathies, as well as diminution of the consolidation, was seen. Residual atelectatic tracts with traction bronchiectasis and bronchial thickening in the right upper lobe remained two months after the initial CT (Figures 4a, 4b and 5).",
    "discussion": "Pulmonary nocardiosis (PN) is a rare opportunistic infection recognised in the past years, which is becoming more common due to the increased number of patients with depressed cellular immunity in our population and the improved diagnosis techniques developed [1,2]. Despite Nocardia spp. being usually reported in people suffering from HIV/AIDS, transplant recipients and patients under corticosteroid therapy, it can also affect immunocompetent individuals, mainly those with bronchiectasis, as in our case [3,4].\nThe clinical presentation of PN can vary widely and can mimic other lung conditions, such as pulmonary tuberculosis. It can occur as an acute, subacute or chronic disease [4]. Symptoms may include persistent cough, dyspnoea, fever, chest pain, unexplained weight loss or weakness.\nThe diagnosis typically includes a blend of clinical evaluation, laboratory tests and imaging studies. Concerning the last ones, chest radiography and CT are keys to diagnosis and follow-up [5].\nMultiple radiographic patterns have been reported. Multilobar consolidation is probably the predominant manifestation. Foci of low attenuation areas with a rim enhancement on contrast-enhanced CT may reflect abscess formation. Cavitation might be associated in approximately 30% of the patients. Likewise, reticulonodular infiltrates may be demonstrated. It should be noted lymphadenopathies are not characteristic of this condition [4].\nEndobronchial spread involves small centrilobular nodules, often associated with bronchial wall thickening and endobronchial debris. Disseminated PN consists on numerous different-sized nodules.\u00a0Other accompanying, non-specific features include pleural thickening, pleural effusion or empyema necessitatis [4,5]. As in our patient, a solitary mass or nodule with central low attenuation and/or cavitation can be found.\nConsidering most of the patterns, an infectious process may be suspected. However, as concerning in our case, when PN is manifested as a solitary mass, a lung neoplasm might be presumed. Therefore, microbiological studies, in addition to cytological ones, are important when assessing solitary necrotic pulmonary lesions in immunocompromised patients.\nWhen PN is clinically not suspected, the radiological presumption may guide blood culture, bronchial lavage, pleuropulmonary aspirates or even lung biopsies in order to isolate the bacteria and confirm the diagnosis [5].\nFirst-line treatment is based on high-dose sulphonamide therapy. Empyema and chest wall abscesses may require surgical debridement or percutaneous drainage. Mortality rates are high. Time-to-diagnosis and an appropriate treatment are determining prognostic factors [6]. Recurrences after treatment are reported [4].\nTake Home Message\nInflammatory-infectious processes can radiologically manifest similarly to lung neoplasms. Thus, the differential diagnosis of necrotic solitary pulmonary masses should be expanded.\nAll patient data have been completely anonymized throughout the entire manuscript and related files.",
    "differential_diagnosis": "Lung, cancer, (squamous, cell, carcinoma, with, cavitation), Pulmonary, nocardiosis, Pulmonary, tuberculosis, Lung, abscess, (non-nocardial, origin), Actinomycosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-03/Figure%201a_small.jpg?itok=XpxFWvbQ",
            "caption": "Chest X-ray in PA projection (1a) shows a right hilar mass with surrounding opacity and peripheral tracts. Lateral projection (1b) denotes a mass location in the upper right lobe and a minimal pleural effusion."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-03/Figure%201b_small.jpg?itok=cP-6h-le",
            "caption": "Chest X-ray in PA projection (1a) shows a right hilar mass with surrounding opacity and peripheral tracts. Lateral projection (1b) denotes a mass location in the upper right lobe and a minimal pleural effusion."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-03//18497_2_1.png?itok=4yABnq6L",
            "caption": "Contrast-enhanced CT in axial, coronal and sagittal projections, reveals a hypodense mass in the right hilar region, likely necrotic, accompanied by a distal consolidation in the anterior segment of the upper lobe. Paratracheal lymph nodes, sized over 10 millimetres in short-axis diameter."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-03//18497_2_2.png?itok=MVUMb-6d",
            "caption": "Contrast-enhanced CT in axial, coronal and sagittal projections, reveals a hypodense mass in the right hilar region, likely necrotic, accompanied by a distal consolidation in the anterior segment of the upper lobe. Paratracheal lymph nodes, sized over 10 millimetres in short-axis diameter."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-03//18497_2_3.png?itok=GtaMvEOh",
            "caption": "Contrast-enhanced CT in axial, coronal and sagittal projections, reveals a hypodense mass in the right hilar region, likely necrotic, accompanied by a distal consolidation in the anterior segment of the upper lobe. Paratracheal lymph nodes, sized over 10 millimetres in short-axis diameter."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-03//18497_3_1.JPG?itok=wkzEvYIf",
            "caption": "Caption from the PET-scan demonstrating a hypermetabolic uptake of the hilar lesion, the distal consolidation/atelectasis and mediastinal lymph nodes."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-03//18497_4_1.png?itok=NZ2Do9LF",
            "caption": "Follow-up chest X-rays in PA (4a) and lateral (4b) projections display reduction of the lung mass and remaining atelectatic tracts in the area."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-03//18497_4_2.png?itok=fZ8vM7kz",
            "caption": "Follow-up chest X-rays in PA (4a) and lateral (4b) projections display reduction of the lung mass and remaining atelectatic tracts in the area."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-03/Figure%205_edit.jpg?itok=mmE31Afw",
            "caption": "Follow-up thoracic CT confirms reduction of the upper right lobe lung mass and distal consolidation. Bronchial thickening and traction bronchiectasis in the limit with the mid lobe can be found. Residual atelectatic tracts remain. No radiologically significant lymph nodes were observed anymore."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "CT",
      "Digital radiography"
    ],
    "link": "https://www.eurorad.org/case/18471",
    "time": "06.03.2024"
  },
  "18479": {
    "case_id": 18479,
    "title": "Dissemination of cholangiocarcinoma as pulmonary tumour embolism",
    "section": "Chest imaging",
    "age": "65",
    "gender": "male",
    "diagnosis": "Pulmonary tumour embolism",
    "history": "A 65-year-old man with stable non-small cell lung cancer presented a hepatic mass during the follow-up. The biopsy revealed cholangiocarcinoma. In the following controls, the patient presented filling defects in pulmonary artery branches and pulmonary thromboembolism was diagnosed, the patient being asymptomatic. The patient received chemotherapy and anticoagulation. In subsequent controls, the lesions in the pulmonary arteries increased and changed morphology.",
    "image_finding": "The first CT scan revealed filling hypodense defects in arterial branches of the middle lobe (ML) and left upper lobe (LUL), especially in lingula, that were compatible with bilateral pulmonary thromboembolism (Figures 2a and 2b).\nIn the LUL, some new hypodense nodules that were not visible in the previous scans appeared, the largest measuring 8 mm, and several of them were very close to each other. Two other nodules appeared in the left lower lobe (LLL).\nIn addition, a lesion localized in the left hepatic lobe with peripheral enhancement and a hypodense central area was revealed, with other smaller lesions suggestive of metastasis (Figure 1a). A filling defect of the portal vein and intrahepatic vena cava was seen, which was compatible with thrombosis (Figures 1b and 1c).\nThe following CT scan done 5 months later revealed an increase in the size of the nodular lesions with a beaded appearance, where hypodense images suggestive of thrombosis were previously described, and which, given the current context, suggested intravascular tumour progression of cholangiocarcinoma (Figures 2c and 2d).\nFurthermore, a significant increase in the size of the multiple bilateral nodules was seen, predominantly in the left lung, and new ones appeared, the largest forming a 30 mm conglomerate in the LUL.",
    "discussion": "Tumour pulmonary embolism (TPE) represents a diagnostic challenge in oncology patients. The reason for this is that both radiological findings and clinical features often resemble those of pulmonary embolism (PE) and the vast majority of PE in this context are of thrombotic origin [1,2]. This is why TPE must be taken into account in the differential diagnosis when subacute dyspnoea appears in oncology patients [3]. It is observed in just a few autopsies [3,4], especially in solid tumours that infiltrate systemic veins such as hepatocellular carcinoma, kidney, breast, chondrosarcoma or lung [2,4,5]. TPE can be macroscopic or microscopic [1,2]. Macroscopic TPE, as the case we presented, can affect the main, lobar or segmentary pulmonary arteries [1], and can produce an acute pulmonary hypertension syndrome due to occlusion of proximal branches [6].\nClinical features are similar to PE of thrombotic origin and include pleuritic chest pain, cough, haemoptysis, and weight loss. It rarely presents with severe shock due to acute massive tumour embolism. Physical examination reveals tachypnoea, tachycardia, fever, signs of right heart failure, cyanosis, and auscultation of superimposed respiratory sounds is unusual [7].\nThe radiological findings of TPE are dilatation, beaded, lobulated and heterogeneous appearance of the pulmonary arteries, tumour enhancement in the arterial filling defect, transmural extension, the presence in the thrombus of some specific component of the tumour and the lack of resolution after anticoagulant treatment [2,3,5]. Lymphadenopathy and lymphangitic carcinomatosis may also suggest the diagnosis of TPE [6].\nPET/CT can be useful for differentiating from thromboembolism [2]. In any case, the final diagnosis will be made by biopsy \u2013 being something exceptional \u2013 which is indicated in cases with therapeutic options [6].\nGiven the infrequent presentation of tumour embolism in oncological patients and subtle but characteristic radiological findings, the description of this case is considered essential to make an adequate approach to the differential diagnosis of pulmonary thromboembolism with a lack of response to anticoagulant treatment in these patients.\nAll patient data have been completely anonymised throughout the entire manuscript and related files.",
    "differential_diagnosis": "Pulmonary, tumour, embolism, Thromboembolism, Septic, embolism, Fat, embolism",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-03//18505_1_1.png?itok=FjCIF6jO",
            "caption": "Axial CT image showing an infiltrative hypodense lesion in the right hepatic lobe."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-03//18505_1_2.png?itok=sgnyKAcy",
            "caption": "Coronal CT image showing thrombosis of the portal branches."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-03//18505_1_3.png?itok=XSlrjEwZ",
            "caption": "Coronal CT image showing thrombosis of the vena cava."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-03//18505_2_1.png?itok=Lf0KYceG",
            "caption": "Axial and coronal CT images showing hypodense images inside pulmonary artery branches suggestive of thrombosis."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-03/Figure%202B_small_0.png?itok=mqhoRlqe",
            "caption": "Axial and coronal CT images showing hypodense images inside pulmonary artery branches suggestive of thrombosis."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-03//18505_2_3.png?itok=hdPskkU4",
            "caption": "Axial and coronal CT image showing increase in the size of previously described hypodense lesions, currently presenting a nodular beaded appearance, and which, given the context, suggest intravascular tumour progression of cholangiocarcinoma."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-03//18505_2_4.png?itok=OXlYKhO4",
            "caption": "Axial and coronal CT image showing increase in the size of previously described hypodense lesions, currently presenting a nodular beaded appearance, and which, given the context, suggest intravascular tumour progression of cholangiocarcinoma."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Pulmonary vessels"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/18479",
    "time": "11.03.2024"
  },
  "18496": {
    "case_id": 18496,
    "title": "Inflammatory myofibroblastic tumour of the lung in a young male",
    "section": "Chest imaging",
    "age": "36",
    "gender": "male",
    "diagnosis": "Inflammatory myofibroblastic tumour",
    "history": "A 36-year-old male patient, a former smoker, with a history of left radical orchidectomy for seminoma, performed a chest radiograph during a routine follow-up. The radiograph showed a well-circumscribed nodule in the left lower lobe (Figure 1). A computed tomography (CT), a PET-CT and a biopsy were later performed for better characterisation.",
    "image_finding": "A computed tomography without contrast was performed, identifying a well-circumscribed 17 mm solid nodule in the left lower lobe (Figure 2). There was no evidence of macroscopic fat, and no intra-lesional calcifications were noted. A subsequent [18F]-FDG-PET-CT was performed, showing a nodule in the left lower lobe, which was mildly FDG-avid. There were no other pulmonary lesions nor evidence of thoracic adenopathies or distant metastasis. Consequently, a thoracic biopsy was performed, and the histological results were suggestive of an inflammatory myofibroblastic tumour (IMT). Left lower lobectomy was proposed to the patient. In the pathological examination, a mesenchymal neoplasm was identified, confirming the diagnosis of IMT (Figures 3 to 6). One year after the surgery, chest CT did not reveal new nodules or other relevant changes, and the patient is asymptomatic.",
    "discussion": "Background\nFirst described by Brunn in 1937, inflammatory myofibroblastic tumours (IMTs) are a rare group of neoplasms composed of a mixture of spindle-shaped myofibroblasts and inflammatory cells. One of the most frequently affected organs is the lung [1,2]. Although it is the most common lung tumour in children, it is rarely seen in adults, with equal male and female incidence rates [3]. The pathogenesis is still unclear, although different aetiologies have been proposed, such as chronic infections, autoimmune diseases, and trauma [1,4]. In some cases, IMTs are also related to previous lung surgery, and they can arise in surgical lung scars [2].\nClinical Perspective\nPatients can be asymptomatic or present with unspecific respiratory symptoms, such as cough, dyspnoea, fever and malaise [1\u20134].\nImaging Perspective\nThe radiological presentation of lung IMTs is non-specific, and they are often misdiagnosed as malignant neoplasms. They usually appear as solitary, well-circumscribed peripheral lung masses, with predominance for the lower lobes. They may also involve the pleura, showing pleural retraction in these cases [4]. Calcification of the masses is unusual and more common in children than in adults, while cavitation and lymphadenopathy are rare [1,2]. Although uncommon, they can also be multiple. On chest radiograph, they are normally single, well-defined, oval lesions and on contrast-enhanced CT, they show variable enhancement on delayed acquisitions due to the presence of fibrosis. On MRI, a notable feature is its hyperintensity on T2-weighted images due to the myxoid stroma. Although FDG-PET/CT shows variable FDG uptake by IMT in the lung, this modality may be best suited for the evaluation of local recurrence and distant metastases [1\u20133]. Nevertheless, histopathologic examination of the resected specimen is the only reliable method to confirm the diagnosis. Positive immunohistochemical staining of ALK is seen as a prognostic factor of aggressiveness, and it is present in approximately 40\u2013100% of IMTs [4].\nOutcome\nSurgical resection is both diagnostic and curative in most cases of solitary pulmonary IMT, with an excellent prognosis after complete resection. Cases of spontaneous regression or resolution after treatment with corticosteroids have been reported. In case of incomplete resection or non-operable patients, radiotherapy is an alternative treatment. The prognosis after complete surgical resection is excellent, with a low rate of recurrence [2,3].\nTake Home Message / Teaching Points\nLung inflammatory myofibroblastic tumours are a rare group of neoplasms, and their radiological presentation is non-specific. They usually appear as solitary, well-circumscribed peripheral lung masses, with predominance for the lower lobes. Surgical resection is both diagnostic and curative, and the prognosis after complete resection is excellent [1\u20134].",
    "differential_diagnosis": "Inflammatory, myofibroblastic, tumour, Lung, cancer, Metastasis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-03//18522_1_1.png?itok=9dWgVXyK",
            "caption": "Chest radiograph \u2013 an oval opacity, with irregular borders, is seen in the left lower lobe."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-03//18522_2_1.png?itok=P3_e_XVU",
            "caption": "Chest CT, axial plane, lung window \u2013 a solid nodule measuring 17 mm (yellow circle) is seen in the left lower lobe, causing pleural retraction (white arrow)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-03//18522_3_1.png?itok=kYNDju0g",
            "caption": "Macroscopy \u2013 the pleural surface is smooth and shiny, with an area of retraction (red arrow). Underlying the area of retraction, a nodular lesion is identified, with ill-defined borders, and with yellowish (star) and reddish areas (white arrow)."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-03/Picture%204_small.png?itok=drQ8Vush",
            "caption": "Microscopy \u2013 mesenchymal neoplasm (yellow circle) with infiltrative borders is observed, consisting of fusiform cells, with a fascicular and sometimes \u201cstoriform\u201d arrangement, without evidence of marked atypia. Lymphoplasmacytic inflammatory infiltrate is observed within the neoplasm. No areas of necrosis or vascular invasion are identified. An area of pleural retraction is seen (yellow arrow)."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-03//18522_5_1.jpg?itok=unmjgICs",
            "caption": "Microscopy \u2013 mesenchymal neoplasm consisting of fusiform cells, with a fascicular and sometimes \u201cstoriform\u201d arrangement, without evidence of marked atypia. Lymphoplasmacytic inflammatory infiltrate is observed within the neoplasm. No areas of necrosis or vascular invasion are observed."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-03//18522_6_1.jpg?itok=jZojlg7V",
            "caption": "Microscopy \u2013 mesenchymal neoplasm ALK-positive."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/18496",
    "time": "19.03.2024"
  },
  "18505": {
    "case_id": 18505,
    "title": "Chronic eosinophilic pneumoni",
    "section": "Chest imaging",
    "age": "63",
    "gender": "male",
    "diagnosis": "Chronic eosinophilic pneumonia",
    "history": "A 63-year-old male with a medical background of allergic rhinitis reported a deteriorating productive cough characterised by the presence of mucus in the sputum. The cough was accompanied by fatigue and muscle pain. He also reported a 5 kg weight loss within the past 6 months. Blood tests revealed an increase in eosinophils in the peripheral blood and an elevation in C-reactive protein (CRP) levels. An increase in bronchoalveolar lavage (BAL) fluid eosinophils (44%) was also found. The physician ordered a chest x-ray, followed by a chest CT scan.",
    "image_finding": "Chest x-ray showed bilateral upper-lobe consolidations, as well as a peripheral consolidation in the middle third of the right lung.\nChest CT revealed bilateral upper lobe consolidations with air bronchogram surrounded by ground-glass opacities. A peripheral area of consolidation was also found on the lateral segment of the middle lobe.",
    "discussion": "Eosinophilic pulmonary diseases are rare entities characterised by alveolar and interstitial eosinophilic infiltration. These diseases include acute eosinophilic pneumonia (AEP) and chronic eosinophilic pneumonia (CEP) [1].\nAEP is associated with an acute hypersensitivity reaction to an inhaled agent. Tobacco smoke and dust/smoke inhalation are the most common precipitants. Patients are typically around 20 years old and have no history of allergic disease. Clinically, patients typically present with an acute-onset dyspnoea, a non-productive cough, and fever, starting days after the inhalation episode. Severe hypoxemia, respiratory failure, and acute respiratory distress syndrome (ARDS) can also occur. Blood tests show leukocytosis and an elevated CRP. Peripheral eosinophilia is an uncommon finding [2]. Diagnosis is made after a BAL showing eosinophilia, typically >40%. Bilateral ground grass opacities accompanied by areas of consolidation are the most common chest radiography findings. Chest CT often shows an upper lobe predominant pattern of bilateral ground-glass opacities and interlobular septal thickening. Areas of consolidation, centrilobular nodules, and bilateral pleural effusion are also common findings [3]. Treatment involves systemic corticotherapy and respiratory support. If smoking is discontinued, recurrence is rare, and there is rarely a lasting impairment in pulmonary function tests (PFTs).\nCEP typically occurs in 30- to 50-year-old patients with a history of allergic disease. There is no association with tobacco use. Dyspnoea, productive cough, wheezing, weight loss, and chest pain typically develop over several months. Peripheral eosinophilia is a common finding, associated with an elevation in IgE and CRP. Unlike AEP, the BLA may not be necessary for diagnosis as long as peripheral eosinophilia above 1000/mm3 is present. PFTs may show a restrictive (more common) or obstructive pattern. Bilateral peripheral consolidations in a\u00a0\u201creverse batwing\u201d pattern may be found in chest radiography. On chest CT, the most common findings include bilateral peripheral ground-glass opacities, often associated with areas of consolidation. Despite there not being formal diagnostic criteria, diagnosis is often made based on clinical symptoms, eosinophilia (peripheral and/or BAL), and suggestive imaging findings. Corticosteroids are the treatment of choice. More than half of patients relapse, especially after treatment discontinuation. PFTs often remain altered long after treatment [4,5].\nThe distinction between AEP and CEP should be made by correlating the epidemiological and clinical settings with imaging and laboratory findings, given that there are no formal diagnostic criteria for either. Despite having similar treatment, these diseases have a significantly different prognosis.\nIn this case, given that the patient had an allergic background, no history of tobacco use or dust/smoke inhalation, peripheral eosinophilia, a later-found elevated bronchoalveolar lavage eosinophil count (44%), and the above-mentioned imaging findings, the final diagnosis of chronic eosinophilic pneumonia was achieved.",
    "differential_diagnosis": "Acute, eosinophilic, pneumonia, Chronic, eosinophilic, pneumonia, Eosinophilic, granulomatosis, with, polyangiitis, Cryptogenic, organizing, pneumonia",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-03//18531_1_1.png?itok=vrG2uOxc",
            "caption": "PA chest x-ray. Bilateral upper-lobe consolidations, as well as a peripheral consolidation in the middle third of the right lung."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-03//18531_2_1.png?itok=iBQxa55n",
            "caption": "Axial (a and b), coronal (c) and sagittal (d) non-enhanced CT images in lung window. Bilateral upper lobe consolidations with air bronchogram surrounded by ground-glass opacities. A peripheral area of consolidation was also found on the lateral segment of the middle lobe."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-03//18531_2_2.png?itok=N2eMVTOQ",
            "caption": "Axial (a and b), coronal (c) and sagittal (d) non-enhanced CT images in lung window. Bilateral upper lobe consolidations with air bronchogram surrounded by ground-glass opacities. A peripheral area of consolidation was also found on the lateral segment of the middle lobe."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-03//18531_2_3.png?itok=qd5sDcSp",
            "caption": "Axial (a and b), coronal (c) and sagittal (d) non-enhanced CT images in lung window. Bilateral upper lobe consolidations with air bronchogram surrounded by ground-glass opacities. A peripheral area of consolidation was also found on the lateral segment of the middle lobe."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-03//18531_2_4.png?itok=hUFQnqWh",
            "caption": "Axial (a and b), coronal (c) and sagittal (d) non-enhanced CT images in lung window. Bilateral upper lobe consolidations with air bronchogram surrounded by ground-glass opacities. A peripheral area of consolidation was also found on the lateral segment of the middle lobe."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Thorax"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/18505",
    "time": "27.03.2024"
  },
  "18538": {
    "case_id": 18538,
    "title": "Birt\u2013Hogg\u2013Dub\u00e9 syndrome presenting as recurrent pneumothoraces",
    "section": "Chest imaging",
    "age": "61",
    "gender": "male",
    "diagnosis": "Birt\u2013Hogg\u2013Dub\u00e9 syndrome (BHDS)",
    "history": "A 61-year-old gentleman presented to A&E with shortness of breath and cough for 1 month, with no history of chest pain or trauma. CXR done showed left-sided pneumothorax. Past medical history revealed that the patient presented with similar complaints in 2016. Skin examination revealed multiple skin-coloured papules on the face, neck and trunk.",
    "image_finding": "A chest X-ray (CXR) was performed which revealed left-sided moderate pneumothorax. The patient underwent non-contrast CT thorax. CT revealed multiple thin-walled elliptical para-mediastinal air-filled cysts without internal structure in a basilar distribution, with preserved lung volume and no evidence of interstitial lung disease, and a left-sided pneumothorax (Figures 1a, 1b, 1c, 1d, 1e and 1f). Previous records were checked, and the patient had undergone CXR and CT in 2016, which showed similar findings.\nFamily history revealed a sibling with similar complaints and early onset renal cell carcinoma (RCC). MRI kidney done for this patient was normal, and no evidence of RCC was found. Biopsy from the skin lesions (Figures 2a, 2b and 2c) had been performed in the past and was consistent with fibrofolliculomas.",
    "discussion": "Background \nBirt\u2013Hogg\u2013Dub\u00e9 syndrome (BHDS) is a rare, inherited syndrome known to involve the skin, lungs and kidneys [1]. It is an autosomal dominant disorder caused by constitutional mutations in the FLCN gene [2\u20134]. Folliculin (FLCN) gene is currently the only known causative gene for BHDS and has been mapped to chromosome 17p11; over 200 types of mutations have been identified affecting this gene locus in BHDS patients. These mutations are often inherited but can also arise de novo.\nSkin-related clinical features in BHDS encompass fibrofolliculomas, trichodiscomas and acrochordons, primarily manifesting on the facial region, neck and upper torso [1,5]. A distinctive hallmark of lung involvement in BHDS is the presence of cysts, which heightens the risk for spontaneous pneumothorax [6,7]. The syndrome\u2019s most severe manifestation lies in its association with a predisposition to RCC [8].\nClinical Perspective\nBHDS usually manifests in the 3rd\u20134th decade of life. The phenotype of families affected by BHDS can be quite diverse, and not all patients exhibit the classical triad of lung, skin and renal findings, making the diagnosis of BHDS challenging. All patients suspected of having BHDS should undergo CT chest to look for lung involvement and MR/CT kidneys to look for RCC. Patients complicated by pneumothorax should undergo early pleurodesis to reduce the risk of recurrence. Nephron-sparing surgery is recommended for RCCs bigger than 3cm. Patients without any RCC should undergo routine screening MRI kidneys throughout their lifetime (done every 3\u20134 years).\nAccurate diagnosis not only plays a crucial role in patient management but also helps identify undiagnosed family members. In this case, one family member was diagnosed with unilateral RCC. Due to its rarity, BHDS is unknown to many physicians and is likely to be under-diagnosed.\nImaging Perspective\nThe diagnostic criteria for Birt\u2013Hogg\u2013Dub\u00e9 syndrome (BHDS) include:\n\nOne major criterion: (A) Presence of five adult-onset fibrofolliculomas; (B) Proven pathogenic FLCN germline mutation.\nTwo minor criteria: (A) Typical lung cysts with no alternative reasonable explanation; (B) Multifocal or bilateral RCC, or early onset (before age 50) RCC, or RCC showing mixed chromophobe-oncocytic histology; (C) A first-degree relative with BHDS.\n\nThe lung cysts in BHDS are lower lobe predominant, located in paramediastinal and subpleural locations and usually have oblong shape (floppy cysts) [9]. Lung involvement in BHDS does not lead to respiratory insufficiency, in contrast to other cystic lung diseases (LAM or PLCH).\nOutcome\nPatient was conservatively managed and discharged with an appointment for outpatient follow-up after 6 weeks. The patient will have surveillance renal MRI every 3 years to rule out RCC. Recurrent pneumothorax may need to be treated with pleurodesis.\nTake Home Message / Teaching Points\n\nPatients with lung cysts and recurring pneumothoraces should raise suspicion of BHDS.\nBHDS patients need to be monitored routinely for pneumothorax and RCC development.\nThere can be quite diverse clinical presentations, even within a family with BHDS.\nDiagnosing BHDS is of paramount importance not only for patient management but also for identification of previously undiagnosed family members.\n\nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Lymphangioleiomyomatosis, (LAM), Pulmonary, Langerhans, cell, histiocytosis, (LCH), Lymphocytic, interstitial, pneumonia, (LIP), Birt\u2013Hogg\u2013Dub\u00e9, syndrome, (BHDS)",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-04/Figure%201A_small.png?itok=NXh6H0Q2",
            "caption": "CT and CXR findings of pulmonary cysts and pneumothorax. Axial and coronal CT images (1a, 1b, 1c, 1d) showing the typical paramediastinal cysts with lower lobe predominance. CXR (1e) with a drainage tube in situ from 2016. Present CXR (1f) showing recurrent pneumothorax."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-04/Figure%201B_small.png?itok=ektvn9fg",
            "caption": "CT and CXR findings of pulmonary cysts and pneumothorax. Axial and coronal CT images (1a, 1b, 1c, 1d) showing the typical paramediastinal cysts with lower lobe predominance. CXR (1e) with a drainage tube in situ from 2016. Present CXR (1f) showing recurrent pneumothorax."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-04//18567_1_3.PNG?itok=jR4EV3zy",
            "caption": "CT and CXR findings of pulmonary cysts and pneumothorax. Axial and coronal CT images (1a, 1b, 1c, 1d) showing the typical paramediastinal cysts with lower lobe predominance. CXR (1e) with a drainage tube in situ from 2016. Present CXR (1f) showing recurrent pneumothorax."
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-04/Figure%201D_small.png?itok=m_4Vybxr",
            "caption": "CT and CXR findings of pulmonary cysts and pneumothorax. Axial and coronal CT images (1a, 1b, 1c, 1d) showing the typical paramediastinal cysts with lower lobe predominance. CXR (1e) with a drainage tube in situ from 2016. Present CXR (1f) showing recurrent pneumothorax."
          },
          {
            "number": "Figure 1e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-04/Figure%201E_small.png?itok=b-XPgzQa",
            "caption": "CT and CXR findings of pulmonary cysts and pneumothorax. Axial and coronal CT images (1a, 1b, 1c, 1d) showing the typical paramediastinal cysts with lower lobe predominance. CXR (1e) with a drainage tube in situ from 2016. Present CXR (1f) showing recurrent pneumothorax."
          },
          {
            "number": "Figure 1f",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-04/Figure%201F_small.png?itok=1rHO-ihT",
            "caption": "CT and CXR findings of pulmonary cysts and pneumothorax. Axial and coronal CT images (1a, 1b, 1c, 1d) showing the typical paramediastinal cysts with lower lobe predominance. CXR (1e) with a drainage tube in situ from 2016. Present CXR (1f) showing recurrent pneumothorax."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-04/Figure%202A_small.png?itok=AhIrB3Yq",
            "caption": "Skin changes, with fibrofolliculomas on chest and back."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-04/Figure%202B_small.png?itok=vcehNlZc",
            "caption": "Skin changes, with fibrofolliculomas on chest and back."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-04/Figure%202C_small.png?itok=lXAB6VW_",
            "caption": "Skin changes, with fibrofolliculomas on chest and back."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Thorax"
    ],
    "imaging_technique": [
      "CT",
      "CT-High Resolution"
    ],
    "link": "https://www.eurorad.org/case/18538",
    "time": "23.04.2024"
  },
  "18539": {
    "case_id": 18539,
    "title": "Pseudomyxoma pleuri \u2013 A rare manifestation of pseudomyxoma peritonei",
    "section": "Chest imaging",
    "age": "52",
    "gender": "female",
    "diagnosis": "Pseudomyxoma peritonei with pseudomyxoma pleuri",
    "history": "A 52-year-old female with a known case of carcinoma caecum who underwent right hemicolectomy and chemotherapy for mucinous adenocarcinoma of the caecum, presented with complaints of difficulty in breathing and cough for 1 month. Reduced breath sounds in the right lung field were found during the respiratory system evaluation. Standard lab tests were within normal limits.",
    "image_finding": "Chest radiograph (X-ray) showed near total opacification of the right thorax and mild cardiomediastinal shift to the left (Figure 1).\nAbdominal and thoracic ultrasonography (USG) showed multiloculated pleural effusion and loculated non-mobile echogenic ascites with scalloping of the hepatic margins (Figures 2a and 2b).\nThoracic contrast-enhanced computed tomography (CT) showed massive multiloculated peripherally enhancing collections with few specks of calcification in the right hemithorax with a near complete collapse of the right lung and cardiomediastinal shift to the left (Figures 4a, 4b and 4c).\nAbdominal contrast-enhanced CT showed few loculated hypodense collections with few specks of calcifications in the right subhepatic region with extension along falciform ligament, causing scalloping of the liver surface.\nT2-weighted magnetic resonance imaging (MRI) showed multiloculated hyperintense collections in the right hemithorax with mild cardiomediastinal shift to the left (Figures 5a, 5b and 5c). T1 contrast MRI showed multiloculated peripherally enhancing collections and few loculated hyperintense collections in the subhepatic region (Figures 6a and 6b). The pleural extension appeared as a thickened pleura with multiple lobulated masses.\nPeritoneal and pleural aspiration showed abundant mucinous material. Cytological examination of the fluid showed mucus with cohesive aggregates of muco-producing epithelial cells (Figure 7).",
    "discussion": "According to an American study published in 2000, the intrathoracic spread of pseudomyxoma peritonei is a rare condition, occurring in only 5.4% of cases [1]. Diffuse collections of gelatinous fluid and mucinous implants on the peritoneal surface, omentum, and pleura are characteristic of pseudomyxoma peritonei, pleuri. The primary tumour in our case is mucinous adenocarcinoma of caecum that perforates and spreads mucus-producing cells throughout the abdomen and pleura [2,3]. Imaging plays a major role in the diagnosis of pseudomyxoma pleuri and peritonei.\nIatrogenic perforation of the diaphragm, occurring during sub-diaphragmatic peritonectomy, is the most frequent mechanism for intrathoracic extension [1,4]. Congenital pleuroperitoneal communications, direct invasion of the diaphragm, and haematogenous dissemination can also lead to pleural extension [1]. The synchronous pleural involvement of pseudomyxoma peritonei, in our case, resulted from the massive mucinous tumour invading the diaphragm and extending into the pleural space.\nIt has to be differentiated from mesothelium carcinomatosis, where diffuse or nodular thickening of the peritoneal serosa with infiltration of the greater omentum, mesenteric masses, and pleural plaques is noted [7].\nThe current course of treatment for pseudomyxoma pleuri and peritonei involves multiple surgical debulking and cytoreductive surgery with hot intraoperative intraperitoneal chemotherapy [1]. Bicavitary hyperthermic chemoperfusion is a treatment for pleural involvement [1,5].",
    "differential_diagnosis": "Pseudomyxoma, peritonei, with, pseudomyxoma, pleuri, Soft, tissue, neoplasms, with, myxoid, changes, Mesothelium, carcinomatosis, Peritoneal, carcinomatosis, Cystic, lymphangioma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-04/Figure%201-xray_small.jpg?itok=gamv2q6z",
            "caption": "X-ray showed near total opacification of the right thorax and mild cardiomediastinal shift to the left."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-04/Figure%202a-usg_small.jpg?itok=cfr-AsXA",
            "caption": "Ultrasonography showed multiloculated pleural effusion and loculated non-mobile echogenic ascites with scalloping of the hepatic margins."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-04//18568_2_2.jpg?itok=6ijvBt_Z",
            "caption": "Ultrasonography showed multiloculated pleural effusion and loculated non-mobile echogenic ascites with scalloping of the hepatic margins."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-04/Figure%203a-axial%20plain%20CT_small.jpg?itok=NmMsUGCM",
            "caption": "Axial plain CT images showed massive multiloculated collections with specks of calcification in the right hemithorax with a near complete collapse of the right lung and cardiomediastinal shift to the left."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-04/Figure%203b%20coronal%20plain_small.jpg?itok=q5tmhLHd",
            "caption": "Coronal and sagittal plain CT images showed massive multiloculated collections with specks of calcification in the right hemithorax with a near complete collapse of the right lung and cardiomediastinal shift to the left with extension along falciform ligament, causing scalloping of the liver surface."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-04/Figure%203c%20sagittal%20plain_small.jpg?itok=2-s-_qh1",
            "caption": "Coronal and sagittal plain CT images showed massive multiloculated collections with specks of calcification in the right hemithorax with a near complete collapse of the right lung and cardiomediastinal shift to the left with extension along falciform ligament, causing scalloping of the liver surface."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-04/figure%204a%20axial%20contrast_small.jpg?itok=a9qDHEvM",
            "caption": "Axial thoracic and upper abdominal contrast-enhanced CT showed peripherally enhancing a few loculated hypodense lesions."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-04/Figure%204b%20coronal%20contrast_small.jpg?itok=LbOuRNdK",
            "caption": "Coronal and sagittal thoracic and upper abdominal contrast-enhanced CT showed a few peripherally enhancing loculated hypodense lesions with few specks of calcification in the right subhepatic region with extension along falciform ligament, causing scalloping of the liver surface."
          },
          {
            "number": "Figure 4c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-04//18568_4_3.jpg?itok=iaxE88ZY",
            "caption": "Coronal and sagittal thoracic and upper abdominal contrast-enhanced CT showed a few peripherally enhancing loculated hypodense lesions with few specks of calcification in the right subhepatic region with extension along falciform ligament, causing scalloping of the liver surface."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-04/Figure%205a%20axial%20T2_small.jpg?itok=TUIWico3",
            "caption": "Axial, coronal and sagittal T2-weighted MRI showed multiloculated collection in the right hemithorax with cardiomediastinal shift to the left."
          },
          {
            "number": "Figure 5b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-04/Figure%205b%20coronal%20T2_small.jpg?itok=IvoysLL9",
            "caption": "Axial, coronal and sagittal T2-weighted MRI showed multiloculated collection in the right hemithorax with cardiomediastinal shift to the left."
          },
          {
            "number": "Figure 5c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-04/Figure%205c%20sagittal_small.jpg?itok=SXDSDt5z",
            "caption": "Axial, coronal and sagittal T2-weighted MRI showed multiloculated collection in the right hemithorax with cardiomediastinal shift to the left."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-04/Figure%206a%20axial%20T1c_small.jpg?itok=w0fy6emS",
            "caption": "Axial and coronal T1 contrast MRI showed peripherally enhancing multiloculated collection in the right hemithorax with cardiomediastinal shift to the left."
          },
          {
            "number": "Figure 6b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-04/Figure%206b%20coronal%20T1c_small.jpg?itok=zX4_Z2jW",
            "caption": "Axial and coronal T1 contrast MRI showed peripherally enhancing multiloculated collection in the right hemithorax with cardiomediastinal shift to the left."
          }
        ]
      },
      {
        "number": "Figure 7",
        "subfigures": [
          {
            "number": "Figure 7",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-04//18568_7_1.jpg?itok=h45hyV3v",
            "caption": "Peritoneal and pleural aspiration showed abundant mucinous material. Cytological examination of the fluid showed mucus with cohesive aggregates of muco-producing epithelial cells."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Abdomen",
      "Oncology",
      "Thorax"
    ],
    "imaging_technique": [
      "CT",
      "MR",
      "Ultrasound"
    ],
    "link": "https://www.eurorad.org/case/18539",
    "time": "24.04.2024"
  },
  "18562": {
    "case_id": 18562,
    "title": "Congenital stridor en route Swyer\u2013James syndrome",
    "section": "Chest imaging",
    "age": "11",
    "gender": "male",
    "diagnosis": "Congenital lobar overinflation\n                    \n\n                        Unilateral absence of main pulmonary artery\n                    \n\n                        Bullous emphysema\n                    \n\n                        Hypogenetic lung syndrome\n                    \n\n                        Swyer\u2013James\u2013MacLeod syndrome\n                    \n\n                        Poland syndrome",
    "history": "An 11-year-old male child came with a 4-day history of fever, vomiting, abdominal pain, and a recent bout of cough with expectoration. A past\u00a0history of congenital stridor, which was subsequently diagnosed as laryngomalacia, was managed conservatively. Since then, the child has had frequent hospitalisations due to recurrent lung infections.",
    "image_finding": "On chest radiograph, unilateral (right) hyperlucent hemithorax with paucity of vessels/oligemia and mild bronchiectasis in the right lower zone. Bilateral costophrenic angles are blunt (Figure 1).\nHRCT axial and coronal images show a decrease in right lung volume with diffuse decreased attenuation and diminished vascular markings. Collapse of posterior and anterior segments of right upper lobe associated with traction bronchiectasis involving the right middle lobe and basal segments of the right lower lobe. A thin, smooth-walled air-containing cyst is seen in the superior segment of the right lower lobe. Mild to moderate right pleural effusion. The left lung appears normal (Figures 2a and 2b).\nPast investigation: In view of congenital stridor, laryngoscopy revealed laryngomalacia. 99 Technetium gastro-oesophageal reflux scintigraphy done at 1 year of his age indicated a moderate degree of gastroesophageal reflux.",
    "discussion": "The condition known as \u201cunilateral hyperlucent lung\u201d is characterised radiographically by one lung/lobe having a strikingly lower density compared to the other; caused due to hypoperfusion. Owing to potential causes, like technical (most common) and pathological factors. Swyer\u2013James\u2013MacLeod syndrome (SJS) represents a very rare cause of a hyperlucent unilateral hemithorax with a prevalence rate of 0.01% [1]. It is linked to the long-term sequelae of postinfectious bronchiolitis obliterans in childhood, characterised by pulmonary artery hypoplasia and/or agenesis leading to pulmonary parenchyma hypoperfusion, showing a characteristic pattern of hyperlucent unilateral lung [3]. Due to repetitive infection, lung parenchyma shows an obstructive pattern in the bronchioles, leading to structural changes in the form of permanent dilatation and damage to alveolar structures, air-trapping, and lung hypoperfusion [4].\nSJS is typically associated with lower respiratory tract infections, which may be viral or non-viral aetiologies such as mycoplasma pneumonia, tuberculosis, and pertussis. Other causes can be inhalation of toxic substances or aspiration of foreign bodies [4]. This disease, if symptomatic, can be detected in early childhood, which presents with repeated lower respiratory tract infections, hemoptysis, or dyspnea, but can be asymptomatic and may go unnoticed until adulthood [2].\nThe criteria for diagnosis of Swyer\u2013James syndrome include one of the following: lung volume loss in the form of radiolucency on a chest X-ray; ipsilateral reduction in pulmonary vasculature on a CT chest; and ipsilateral loss of perfusion on lung scintigraphy using Tc 99m [6]. In our case, the aetiology was found to be laryngomalacia with gastroesophageal reflux disease leading to recurrent pneumonitis. The patient was diagnosed after a decade, incidentally on a chest X-ray, followed up with an HRCT thorax, which showed the classical picture of SJS and thus fulfilled the criteria. SJS leads to complications such as bronchiectasis (78%), lung abscesses, and spontaneous pneumothorax [8]. Therapeutic options include\u00a0conservative and supportive management that points to improved airway clearance and anticipation of diseases by administration of pneumococcal vaccine, inhalation of low-dose steroids, and chest physiotherapy for bronchial drainage. Surgical treatment is saved for patients with refractory diseases [9]. Early intervention has a direct impact on prognosis, wherein radiological imaging forms the mainstay of diagnosis for SJS. Hence, it is important to know and frame the predisposing factors for infective bronchiolitis and their severity in posing the complication of unilateral lung hyperlucency. Finally, we conclude that laryngomalacia with GERD is a potential risk factor for infective bronchiolitis that may lead to SJS in older children and adults.",
    "differential_diagnosis": "Congenital, lobar, overinflation, Unilateral, absence, of, main, pulmonary, artery, Bullous, emphysema, Hypogenetic, lung, syndrome, Swyer\u2013James\u2013MacLeod, syndrome, Poland, syndrome",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-05//18594_1_1.PNG?itok=Nvv7ETv_",
            "caption": "Chest radiograph PA view showing unilateral (right) hyperlucent hemithorax with paucity of vessels/oligemia and mild bronchiectasis in the right lower zone. The right hilum appears relatively smaller sized. Pleural tenting in the right lower zone. Bilateral costophrenic angles are blunt. No mediastinal shift."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-05//18594_2_1.png?itok=56guuEkL",
            "caption": "HRCT axial and coronal images show a decrease in right lung volume with diffuse decreased attenuation and diminished vascular markings. Collapse of posterior and anterior segments of right upper lobe associated with traction bronchiectasis involving the right middle lobe and basal segments of right lower lobe. A thin, smooth-walled air-containing cyst is seen in the superior segment of the right lower lobe. Mild to moderate right pleural effusion. The left lung appears normal."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-05//18594_2_2.PNG?itok=woHal_w6",
            "caption": "HRCT axial and coronal images show a decrease in right lung volume with diffuse decreased attenuation and diminished vascular markings. Collapse of posterior and anterior segments of right upper lobe associated with traction bronchiectasis involving the right middle lobe and basal segments of right lower lobe. A thin, smooth-walled air-containing cyst is seen in the superior segment of the right lower lobe. Mild to moderate right pleural effusion. The left lung appears normal."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/18562",
    "time": "24.05.2024"
  },
  "18574": {
    "case_id": 18574,
    "title": "Caplan syndrome",
    "section": "Chest imaging",
    "age": "65",
    "gender": "male",
    "diagnosis": "Caplan syndrome",
    "history": "A 65-year-old male with a medical history of severe seropositive rheumatoid arthritis (RA) and a cumulative exposure of 40 pack years. The patient is a former construction worker, with repeated occupational exposures to both asbestos and silica. He has no respiratory symptoms, and pulmonary clinical evaluation is normal.",
    "image_finding": "A high-resolution computed tomography (HRCT) of the lungs revealed multiple well-defined lung nodules with an apical and peripheral predilection and relatively spared lung bases (Figures 1 and 2). The nodules exhibited variable diameters ranging from some millimetres to approximately one centimetre and showed sporadic calcifications (Figure 3). In the upper lobes, these nodules showed a tendency to coalesce, without cavitation. There is also mild parastatal emphysema with apical predilection, as well as diffuse bronchial wall thickening.",
    "discussion": "Background\nCaplan syndrome, also termed rheumatoid pneumoconiosis, manifests as the development of lung nodules in individuals with seropositive RA and a history of exposure to inhaled inorganic dust particles, predominantly coal and silica. Histologically akin to rheumatoid nodules, these lung nodules, or Caplan nodules, also exhibit concentric rings of dust particles and an outer zone of active inflammation. It is a rare disease with a reported incidence of 1 in every 100,000 people, with a decline in incidence due to further decrease in exposure to coal, asbestos and silica [1].\nClinical Perspective\nCaplan syndrome usually manifests with cough and shortness of breath alongside rheumatoid arthritis symptoms like inflammatory joint pain and morning stiffness. However, symptoms are often non-specific or absent, as in our case. Onset typically occurs suddenly, with subsequent disease varying from complete regression to further progression [1]. Physical examination typically shows tender, swollen metacarpophalangeal joints and rheumatoid nodules. Chest auscultation may detect persistent diffuse crackles.\nImaging Perspective\nOn imaging, these Caplan nodules present as multiple lung nodules ranging from approximately 5 millimetres to several centimetres, which are distributed throughout the lungs, with a predilection for peripheral zones and upper lobes. Often clustered in crops, these nodules may merge to form larger, confluent masses, and occasionally cavitate or calcify. They may become coalescent as in progressive massive fibrosis (PMF), but do not express the associated scarring, retraction or central migration characteristic of PMF. Solitary cavitating lung nodules may mimic cancer or infection radiologically, especially upon growth. Furthermore, rheumatoid nodules in individuals with pneumoconiosis may resemble silicosis nodules, often necessitating correlation with clinical history, symptoms, and histological examination for accurate diagnosis [1,2].\nOutcome\nManagement of RA should adhere to current guidelines, regardless of the presence of Caplan syndrome [1]. The Caplan nodules necessitate treatment upon complication, such as rupture. In our case, no treatment was initiated because of the newly discovered pulmonary manifestations.\nTake Home Message / Teaching Points\nCaplan syndrome, the combination of seropositive rheumatoid arthritis and pneumoconiosis, is an important differential diagnosis in patients with RA, a history of exposure to inhaled inorganic dust particles and multiple lung nodules.\nAll patient data have been completely anonymised throughout the entire manuscript and related files.",
    "differential_diagnosis": "Caplan, syndrome, Pneumoconiosis, Sarcoidosis, Lung, metastases, Massive, pulmonary, fibrosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-06//18606_1_1.png?itok=h4m0W-pf",
            "caption": "Coronal CT with multiplanar reconstruction (10mm thickness) showing numerous well-defined lung nodules with an apical and peripheral predilection, ranging in size from a few millimetres to one centimetre."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-06/Caplan_2_small.png?itok=nymipa0r",
            "caption": "Coronal CT showing lung nodules in the upper lobes, with a tendency to coalesce (arrow)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-06/Caplan_3_small.png?itok=Wqg_wQzW",
            "caption": "Axial CT showing lung nodules with sporadic intralesional calcification (arrow)."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/18574",
    "time": "03.06.2024"
  },
  "18578": {
    "case_id": 18578,
    "title": "A case of Beh\u00e7et\u2019s disease with multiple pulmonary artery aneurysms",
    "section": "Chest imaging",
    "age": "20",
    "gender": "male",
    "diagnosis": "Pulmonary artery aneurysms in patient with previously undiagnosed Beh\u00e7et\u2019s disease",
    "history": "A 20-year-old male with recurrent oral and genital ulcers since adolescence, suggestive of Beh\u00e7et\u2019s disease but not meeting diagnostic criteria, presented to the emergency department with pleuritic chest pain, dry cough, and a four-day history of fever. He had no ongoing treatment.",
    "image_finding": "An emergency chest radiograph was initially performed, revealing well-defined bilateral nodular opacities with a predominant perihilar distribution (Figure 1a). These findings were not present in the chest X-ray taken 8 months earlier (Figure 1b).\nSubsequently, a contrast-enhanced computed tomography of the chest was carried out. This showed that the masses communicated with the pulmonary arteries with a short neck, centrally filling with the density of the arterial pool (Figure 2). In the periphery of these nodules, a non-enhancing hypodense area was visualised (Figure 3). There were no other pulmonary findings, namely suggestive of bleeding. These findings are compatible with multiple saccular aneurysms of the pulmonary arteries with mural thrombosis.",
    "discussion": "Beh\u00e7et\u2019s disease is a chronic, idiopathic multisystemic vasculitis that predominantly afflicts young men. Traditionally, it manifests through the clinical triad of recurrent oral and genital ulcers, in addition to uveitis, but it can manifest with various systemic symptoms [1,2]. While both veins and arteries can be affected, impacting approximately 20%\u201340% of patients, venous involvement is prominent, often leading to lower-extremity deep vein thrombosis [2].\nChest radiographs frequently serve as the initial imaging modality in the emergency department. In patients suspected of Beh\u00e7et\u2019s disease, the presence of well-defined, perihilar nodular opacities should prompt suspicion of pulmonary artery aneurysms. Performing thoracic CT allows for a more precise evaluation of pulmonary lesions, the assessment of their relationship with pulmonary arteries, and the exclusion of active bleeding. Furthermore, it provides comprehensive information regarding lung parenchyma, pleura, and mediastinal structures [2,3].\nThese pulmonary artery aneurysms are often associated with thrombosis and surrounding inflammation. Although some of the aneurysms may regress with immunosuppressive medication, embolisation is frequently required to prevent life-threatening haemoptysis [3].\nPulmonary artery aneurysms are exceedingly rare; however, their association with Beh\u00e7et\u2019s disease is well-established. It is imperative to entertain the suspicion of pulmonary artery aneurysms upon encountering characteristic pulmonary lesions in the radiography or CT scans of Beh\u00e7et\u2019s patients. Detecting these lesions allows for the optimisation of medical therapy or consideration of embolisation, which can potentially enhance the prognosis for these individuals.",
    "differential_diagnosis": "Infectious, pulmonary, arterial, aneurysm, Traumatic, pulmonary, arterial, aneurysm, Autoimmune, pulmonary, arterial, aneurysm, (including, Beh\u00e7et\u2019s, disease), Pulmonary, artery, aneurysms, in, patient, with, previously, undiagnosed, Beh\u00e7et\u2019s, disease, Idiopathic, pulmonary, arterial, aneurysm, Congenital, pulmonary, arterial, aneurysm",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-06//18610_1_1.png?itok=zc059sJr",
            "caption": "Posteroanterior chest X-ray displays sizable bilateral opacities, predominantly located in the perihilar region."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-06//18610_1_2.png?itok=MAPK182O",
            "caption": "Chest radiograph performed 8 months before, showing no significant findings."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-06/fig%202_small.png?itok=5r0j59nj",
            "caption": "Axial reconstruction from a contrast-enhanced computed tomography scan, showing a pulmonary mass centrally filling with a short neck connecting it to the artery (arrow)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-06/figura%203_small.png?itok=wONDXOqP",
            "caption": "Axial reconstruction from a contrast-enhanced computed tomography scan, showing the largest saccular aneurysmal lesions in the pulmonary arteries. On the right, the aneurysm is located anteriorly (arrow), originating from a segmental branch of the middle lobe artery. On the left, the aneurysm is located posteriorly (arrowhead), with its origin in the interlobar descending artery. Both aneurysms display extensive mural thrombosis (*)."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Emergency",
      "Lung",
      "Pulmonary vessels"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/18578",
    "time": "20.06.2024"
  },
  "18583": {
    "case_id": 18583,
    "title": "Traumatic pneumothorax, pneumomediastinum and subcutaneous emphysem",
    "section": "Chest imaging",
    "age": "75",
    "gender": "female",
    "diagnosis": "Pneumothorax, pneumomediastinum and massive subcutaneous emphysema following rib fractures",
    "history": "A 75-year-old woman, who had fallen down the stairs about 12 hours earlier, was brought to our emergency department in the morning. According to her husband, she was fine after the fall. However, when she woke up in the morning, she was unresponsive and completely swollen.",
    "image_finding": "The CT scan showed a compound fracture of three ribs of the left hemithorax associated with an ipsilateral pneumothorax with pneumomediastinum and mediastinal shift. There was also massive bilateral subcutaneous emphysema (SE) sparing only the lower limbs. Subsequent bronchoscopy was negative for rupture or injury, as was a contrast-enhanced upper gastrointestinal radiograph (diatrizoic acid).",
    "discussion": "Pneumomediastinum and SE are the accumulation of gas around the mediastinal structures and the spread of gas along the subcutaneous tissue through a gap, respectively. Chest pain and dyspnoea are the most common presenting symptoms.\nUsually (95%), pneumomediastinum is associated with SE or results from alveolar rupture. Both can be complications of ARDS or COVID-19 [1\u20133]. In the latter case, which occurs mainly in primary lung trauma or during positive pressure mechanical ventilation, the gas spreads along the pulmonary interstitium and peribronchovascular sheaths to reach the mediastinum, a pathophysiological mechanism first described by Macklin in 1939 (Macklin effect) [4,5]. Lesions of the trachea, bronchi or oesophagus cause pneumomediastinum in the remaining cases.\nSE is most commonly associated with trauma, especially rib fractures, and sometimes pneumothorax; but it can also be a complication of pathological conditions (diverticulitis, Fournier\u2019s gangrene, etc.) [6,7] or medical procedures (anaesthesia, colonoscopy, tonsillectomy, dental extractions, catheterisation, etc.) [8\u201312]. Rarely, it can be mistaken for an allergic reaction or angioedema. However, angioedema has a low incidence [13]. It could potentially extend to any area, such as the head and neck, upper limbs, abdomen, scrotum or vulva, as in our case, and could lead to a worse prognosis even in modest cases where drainage is not considered necessary [14].\nDepending on the cause, the definitive treatment of SE is different. If it is non-traumatic, it is usually treated conservatively, but due to the severity of the clinical picture and the onset of complications (respiratory failure, pacemaker dysfunction, airway compromise and tension phenomena) [15,16], several treatments can be adopted, such as infraclavicular incisions, tracheostomy, placement of additional chest tubes either in the intrapleural space or subcutaneously, large-bore subcutaneous drains with or without suction, in addition to compressive massage [4,15\u201318].",
    "differential_diagnosis": "Pneumothorax,, pneumomediastinum, and, massive, subcutaneous, emphysema, following, rib, fractures, Boerhaave\u2019s, syndrome, Tracheal, injury, Angioedema, Severe, allergic, reaction",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-06//18615_1_1.jpg?itok=xx919xzF",
            "caption": "Scout images that allow to grasp at a glance the extent of the massive subcutaneous emphysema."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-06//18615_1_2.jpg?itok=HaEAiiHr",
            "caption": "Scout images that allow to grasp at a glance the extent of the massive subcutaneous emphysema."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-06//18615_2_1.jpg?itok=9unsb5DR",
            "caption": "Axial (2a) and CT-MPR (2b and 2c) showing pneumomediastinum, pneumoperitoneum and massive subcutaneous emphysema. In the axial scan, it can also be visible compound complete rib fracture and the communication between the upper left lobe and subcutaneous thoracic wall tissues (white arrow)."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-06//18615_2_2.jpg?itok=pPr6yv2U",
            "caption": "Axial (2a) and CT-MPR (2b and 2c) showing pneumomediastinum, pneumoperitoneum and massive subcutaneous emphysema. In the axial scan, it can also be visible compound complete rib fracture and the communication between the upper left lobe and subcutaneous thoracic wall tissues (white arrow)."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-06//18615_2_3.jpg?itok=rWDU9YnQ",
            "caption": "Axial (2a) and CT-MPR (2b and 2c) showing pneumomediastinum, pneumoperitoneum and massive subcutaneous emphysema. In the axial scan, it can also be visible compound complete rib fracture and the communication between the upper left lobe and subcutaneous thoracic wall tissues (white arrow)."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Mediastinum",
      "Soft tissues / Skin"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/18583",
    "time": "25.06.2024"
  },
  "18592": {
    "case_id": 18592,
    "title": "Haemothorax induced by rib spur in a paediatric patient",
    "section": "Chest imaging",
    "age": "14",
    "gender": "male",
    "diagnosis": "Haemothorax caused by rib spur of unknown cause",
    "history": "A 14-year-old child was brought to the emergency department with complaints of left-sided chest pain persisting for four days, radiating to the shoulder. Additionally, the patient reported experiencing one episode of fever spike accompanied by vomiting. There was no history of trauma, weight loss or increased susceptibility to bleeding.",
    "image_finding": "A chest x-ray revealed moderate collection in the left pleural cavity (Figure 1). A bedside US was obtained, which was positive for left-sided pleural effusion with dependent echogenic contents (Figure 2), following which the patient was subjected to contrast-enhanced computed tomography (CECT), which showed moderate fluid in the left pleural cavity with dependent non-enhancing hyperdense contents (Figures 3a and 3b). Correlative MRI showed T2 and STIR hyperintense fluid with dependent contents showing diffusion restriction. These imaging findings were suggestive of haemorrhagic effusion, which was confirmed on pleural tapping (Figures 4a, 4b and 4c). There was no evidence of enhancing pleural-based lesions or vascular malformations. On bone windowing, there was evidence of two rib spurs arising from the inner aspect of the left 6th rib with sharp tips, each measuring about 6 mm and 3.5 mm in length, which was the likely cause of haemothorax (Figures 5a, 5b and 5c).\nThe child was treated by thoracentesis, following which the patient clinically improved. As the parents did not agree to surgery, the child was kept in regular follow-up for symptoms recurrence.",
    "discussion": "Rib spurs causing haemothorax in paediatric populations is rare as most of these are asymptomatic. The rib spurs can be osteochondromas or osteophytes.\nOsteochondromas are the most common benign bone tumour occurring in children. These osteochondromas can be classified as multiple, associated with syndromes, or isolated lesions. Multiple lesions occur in the form of an autosomal dominant syndrome called hereditary multiple osteochondromas. They account for about 20\u201350% of all benign bone tumours [1]. Most osteochondromas are slow-growing and asymptomatic. However, osteochondromas occurring in adolescence or in adults have a tendency to grow and cause symptoms due to mechanical irritation of the adjacent tissue or peripheral nerves and cause complications like haemothorax, pneumothorax, cardiac symptoms, diaphragmatic rupture, and spinal injury. And can also undergo malignant transformation.\nThe pathogenesis of osteochondromas due to developmental growth defect of the perichondrium, which is covering the epiphyseal plate, which result in lateral inward growth from the rib. Osteochondromas are often diagnosed using radiographic evidence, particularly computed tomography with 3D reconstruction.\nIn asymptomatic children, surgical removal of osteochondromas is usually not indicated. However, surgical resection becomes necessary in adolescents or adults who present with increased size, pain and mechanical complications such as haemothorax [2]. There are various surgical techniques used for removal, with the preferred one being video-assisted thoracoscopic surgery (VATS), which is a minimally invasive procedure. A study done by Simansky et al. [3], which includes 8 cases of rib osteochondromas, showed that in five patients, haemothorax occurred due to injury of the parietal pleura and in three cases due to injury to the diaphragm. Among them, three cases were managed by thoracotomy, two cases by video-assisted thoracoscopy, and the remaining were treated by drainage.\nIn patients with spontaneous haemothorax, imaging plays a key role, particularly computed tomography. Osteochondromas being a rare cause for haemothorax, it can be easily identified, and assess the severity, multiplicity and disease extent with possible mechanism of injury and guide the clinician in appropriate intervention.",
    "differential_diagnosis": "Haemothorax, secondary, to, coagulopathy, Haemothorax, secondary, to, arteriovenous, malformation, Haemothorax, secondary, to, intrathoracic, malignancy, Haemothorax, caused, by, rib, spur, of, unknown, cause",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-06//18624_1_1.png?itok=QNPIqKYp",
            "caption": "Chest x-ray showing gross fluid collection in the left pleural cavity."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-06//18624_2_1.png?itok=jn147Gf4",
            "caption": "Ultrasound chest showing gross fluid in the left pleural cavity with dependent hyperechoic cots."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-06//18624_3_1.png?itok=3kjFDigH",
            "caption": "CECT chest showing gross fluid in the left pleural cavity with non-enhancing hyperdense contents (arrow)."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-06//18624_3_2.png?itok=MIoTCcjE",
            "caption": "CECT chest showing gross fluid in the left pleural cavity with non-enhancing hyperdense contents (arrow)."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-06/fig%204a_small.png?itok=kXi0V7SF",
            "caption": "Coronal T2 (4a) image showing hyperintense fluid in the right pleural cavity with dependent contents, which shows diffusion restriction appearing hyperintense on DWI (4b) with corresponding hypointensity on ADC (4c)."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-06/fig%204b_small.png?itok=sIBFMm-U",
            "caption": "Coronal T2 (4a) image showing hyperintense fluid in the right pleural cavity with dependent contents, which shows diffusion restriction appearing hyperintense on DWI (4b) with corresponding hypointensity on ADC (4c)."
          },
          {
            "number": "Figure 4c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-06//18624_4_3.png?itok=LMZ1BvYQ",
            "caption": "Coronal T2 (4a) image showing hyperintense fluid in the right pleural cavity with dependent contents, which shows diffusion restriction appearing hyperintense on DWI (4b) with corresponding hypointensity on ADC (4c)."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-06//18624_5_1.png?itok=IdNoJl4_",
            "caption": "CT bone window (5a), VRT (5B) and zoomed image (5c) showing rib spur arising from the inner aspect of the left 6th rib."
          },
          {
            "number": "Figure 5b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-06//18624_5_2.png?itok=BxO_GX3A",
            "caption": "CT bone window (5a), VRT (5B) and zoomed image (5c) showing rib spur arising from the inner aspect of the left 6th rib."
          },
          {
            "number": "Figure 5c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-06/fig%205c_small.png?itok=5Z2okGdU",
            "caption": "CT bone window (5a), VRT (5B) and zoomed image (5c) showing rib spur arising from the inner aspect of the left 6th rib."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "CT",
      "MR"
    ],
    "link": "https://www.eurorad.org/case/18592",
    "time": "27.06.2024"
  },
  "18602": {
    "case_id": 18602,
    "title": "Chronic pulmonary consolidations: Discriminating invasive mucinous adenocarcinom",
    "section": "Chest imaging",
    "age": "61",
    "gender": "female",
    "diagnosis": "Invasive mucinous adenocarcinoma",
    "history": "A 61-year-old woman, active smoker, diagnosed with SARS-CoV-2 infection three months ago. Since then, she has been experiencing symptoms of dyspnoea, productive cough and chest pain. Chest X-ray shows persistent bilateral infiltrates that have worsened despite antibiotic treatment.",
    "image_finding": "A non-contrast chest CT scan was performed, revealing a large consolidation involving almost the entire right lower lobe (Figure 1), with poorly defined borders, extending towards the pulmonary hilum, encompassing and narrowing the bronchi of the right lower lobe (Figure 2). Additionally, smaller consolidations are seen in the left lower lobe and lingula, accompanied by a ground-glass halo (Figure 3). Multiple subcentimeter pulmonary nodules are noted bilaterally (Figure 4). Smooth septal thickening and centrilobular emphysema, predominantly in the upper lobes, are also observed. No pleural effusion is noted, but there is a layer of pericardial effusion. Despite being a non-contrast study, slightly enlarged mediastinal lymph nodes are visualised (Figure 5).",
    "discussion": "Invasive mucinous adenocarcinoma, also referred to as pneumonic-type adenocarcinoma, is a primary lung neoplasm that often manifests in a multicentric, extensively and bilaterally affected manner. This presentation is likely influenced by tumoural dissemination through the airway [1].\nIts consolidative form may be indistinguishable from a bronchopneumonic process. Key diagnostic points include the\u00a0patient\u2019s clinical presentation: absence of fever, antibiotic refractoriness, and in some cases, a disconnect between the\u00a0patient\u2019s limited or absent infectious symptoms and extensive lung involvement [2]. In the case of infectious pneumonia, patients will often associate analytical alterations such as leukocytosis, elevated c-reactive protein or elevated procalcitonin.\nThe radiological presentation of mucinous adenocarcinoma includes single or multiple nodules, consolidations, and a combination of nodules, ground-glass opacities, and consolidations, with a predilection for the lower lobes in all forms.\nAnother characteristic is the arrangement of bronchi within the tumour lesions\u2014narrowed, with an increased angle of branching and distally truncated (the\u00a0\u201ctree-in-bud\u201d sign) [3]. These alterations can help differentiate these consolidations from pneumonia.\nAcinar nodules are a distinctive feature of this tumour type, characterised by their density and relatively well-defined borders, reflecting acinar and alveolar occupation by mucus and mucin-laden tumour cells.\nMucinous adenocarcinoma manifests as a consolidation affecting more than half of a lobe and is more frequently accompanied by fissure bulging, consolidation hypodensity, airspace lesions, CT angiogram sign, other coexisting nodules, pleural effusion, and adenopathy. On the other hand, other adenocarcinoma variants with a pneumonic appearance, especially the acinar-predominant type, affect less than 50% of a lobe and are accompanied by fissural retraction [4].\nIn pneumonic-type adenocarcinomas with a localised pattern of involvement, the TNM classification will be applied in the same way as for other lung cancer subtypes. In case of a more diffuse pattern of involvement, T and M categories are assigned according to the extent of the affected areas (T3 for involvement confined to one lobe, T4 for unilateral involvement of more than one lobe, and M1a in case of bilateral involvement) [6].\nIt should be noted that non-mucinous adenocarcinomas may also present as pseudopneumonic consolidations.\nThe main differential diagnosis should be established with infectious processes, inflammatory conditions (cryptogenic organised pneumonia), and neoplasms (lymphoma)[5].\nTake Home Message\nIn patients with chronic consolidative processes who exhibit subtle symptoms and lack of response to antibiotic therapy or other treatments, it is crucial to consider the possibility of pulmonary adenocarcinoma as a potential diagnosis.\nInformed consent for publication has been obtained.",
    "differential_diagnosis": "Bronchopneumonia, Invasive, mucinous, adenocarcinoma, Lymphoma, Alveolar, sarcoidosis, Cryptogenic, organising, pneumonia, (COP), Alveolar, proteinosis, Eosinophilic, pneumonia",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-07//18634_1_1.png?itok=dIceLwG0",
            "caption": "Non-contrast axial CT scan in lung parenchyma window: Extensive consolidation occupying almost the entire right lower lobe."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-07//18634_2_1.jpg?itok=uDyN9U7_",
            "caption": "Non-contrast axial CT scan in lung parenchyma window: Extensive consolidation extending towards the pulmonary hilum, encompassing and narrowing the bronchi of the right lower lobe."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-07//18634_3_1.jpg?itok=6y2rHgDm",
            "caption": "Non-contrast axial CT scan in lung parenchyma window: Consolidations in the left lower lobe and lingula accompanied by a ground-glass halo."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-07//18634_4_1.jpg?itok=lsIknLWA",
            "caption": "Non-contrast axial CT scan in lung parenchyma window: Bilateral subcentimeter pulmonary nodules."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-07//18634_5_1.png?itok=FfySo-NX",
            "caption": "Non-contrast axial CT scan in soft tissue window: Mediastinal adenopathies."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/18602",
    "time": "03.07.2024"
  },
  "18607": {
    "case_id": 18607,
    "title": "Pulmonary vein thrombosis with pulmonary infarction in child with APLA syndrome",
    "section": "Chest imaging",
    "age": "8",
    "gender": "male",
    "diagnosis": "Pulmonary vein thrombosis with pulmonary infarct",
    "history": "An 8-year-old boy presented with high-grade fever, non-productive cough and exertional breathlessness for seven days. On examination, the child was tachypnoeic with absent air entry on the left. Initial sputum studies revealed no pathogenic organism. He had TLC of 14,000 cells/cubic millimetre, prompting repeat-induced sputum analysis, which was positive for cotrimoxazole-sensitive Acinetobacter species. Anti-phospholipid and anti-cardiolipin IgM returned positive.",
    "image_finding": "Frontal chest radiograph showed near-complete opacification of the left hemithorax. The pleural line was visible with peripheral absence of broncho-vascular markings suggestive of pleural effusion. There was no mediastinal shift, suggesting concomitant underlying lung collapse (Figure 1).\nMultiplanar HRCT chest with contrast, done three days later, showed wedge-shaped non-enhancing parenchyma of the left upper lobe without air bronchograms suggestive of pulmonary infarct. There was consolidation in the lingular segment of the left upper lobe with subsegmental collapse of the left lower lobe (Figures 2 and 3). There was moderate pleural effusion on the left with smooth enhancement of the pleura. There was thrombosis of the left superior pulmonary vein, with the thrombus extending into the tributaries and into the left atrium (Figures 4, 5, 6, 8 and 9). Pulmonary arteries were normal.",
    "discussion": "Background\nPulmonary vein thrombosis (PVT) is a rare disease entity with limited aetiologies, most commonly open or VATS-assisted pulmonary surgery, lung malignancy and RFA for atrial fibrillation. Other aetiologies include congenital narrowing of pulmonary veins, sclerosing mediastinitis or left atrial clots [1]. Few case reports suggested the possibility of procoagulant states like polycythaemia vera [2]. In post-surgical cases, it is likely secondary to direct injury. In malignancy, it can be caused by direct extension, hypercoagulable state, or extrinsic compression [3].\nClinical Perspective\nClinical presentation can be divided into acute and chronic spectrum. Acute onset pathology presents with features of pulmonary infarction like cough, pleuritic chest pain and haemoptysis. Chronic disease process presents with repeated bouts of pulmonary infections, progressing to lung fibrosis or cardiac failure [4].\nImaging Perspective\nImaging is the mainstay of diagnosis as the clinical history and examination findings can be non-specific. The key imaging modalities are CT pulmonary angiography (CTPA) and trans-oesophageal echocardiography (TEE). CTPA allows direct visualisation of the pulmonary venous clot and evaluation of aetiological factors and complications in the pulmonary parenchyma. Drawbacks of CTPA are the possibility of overlooking a potential clot due to slow flowing contrast and cardiac motion artefacts [6]. TEE, on the other hand, provides indirect evidence of thrombosis from the flow velocities in the pulmonary veins and extent into the left atrium. Drawbacks of TEE are that it is limited to proximal PVT and it is an invasive modality [5]. Primary evaluation of pulmonary veins and detection of thrombus is challenging unless there is a high degree of suspicion. However, in patients with atrial clots and pulmonary infarction, PVT must be evaluated and appears as filling defects within the pulmonary veins juxtaposed to the left atrium. In our case, the HRCT suggestive of pulmonary infarct with likely secondary infection causing necrotising pneumonia raised suspicion for a vascular thrombo-embolic cause.\nOutcome\nAll patients with PVT are to be treated with anticoagulation in the form of parenteral LMWH with or without oral warfarin [5]. Additional therapeutic options include mechanical thrombectomy in post-surgical patients, antibiotic prophylaxis and pulmonary resection in cases of large infarcted or gangrenous lungs.\nTeaching Points\nPVT is a rare disease entity and is usually missed on imaging due to a primary focus on the pulmonary arteries in cases of lung infarction. Imaging-centric diagnosis is essential to guide the line of clinical work-up. Timely diagnosis can prevent devastating complications secondary to embolism or infarction.\nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Pulmonary, vein, thrombosis, with, pulmonary, infarct, Segmental, lobar, collapse, Pulmonary, thrombo-embolism, Typical, lobar, pneumonia",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-07/FIG%201_small.jpg?itok=_tYhJuvw",
            "caption": "Frontal chest radiograph shows near-complete opacification of the left hemithorax. The pleural line is visible with peripheral absence of broncho-vascular markings suggestive of mild pleural effusion. There is no mediastinal shift, suggesting concomitant underlying lung collapse."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-07//18639_2_1.jpg?itok=Y3W6XyS2",
            "caption": "The coronal section of HRCT chest with contrast shows wedge-shaped non-enhancing parenchyma of the left upper lobe without air bronchograms suggestive of pulmonary infarct. There is consolidation in the lingular segment of the left upper lobe with subsegmental collapse of the left lower lobe. Pleural effusion seen along left costal convexity."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-07//18639_3_1.jpg?itok=dPt7dEP-",
            "caption": "The coronal section of HRCT chest shows lobar consolidation without signs of mediastinal shift."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-07//18639_4_1.jpg?itok=LWOq1IV1",
            "caption": "The axial section of HRCT chest with contrast shows thrombosis of the left superior pulmonary vein (green arrow), with the thrombus extending into the tributaries and into the left atrium. Pulmonary arteries are normal."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-07//18639_5_1.jpg?itok=HxahpDQ_",
            "caption": "The axial section of HRCT chest with contrast shows thrombosis of the left superior pulmonary vein (green arrow), with the thrombus extending into the tributaries and into the left atrium. Pulmonary arteries are normal."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-07//18639_6_1.jpg?itok=s5SSCHbZ",
            "caption": "The axial section of HRCT chest with contrast shows thrombosis of the left superior pulmonary vein (green arrow), with the thrombus extending into the tributaries and into the left atrium. Pulmonary arteries are normal."
          }
        ]
      },
      {
        "number": "Figure 7",
        "subfigures": [
          {
            "number": "Figure 7",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_video/2024-07/FIG%207_frame%20at%200m0s.jpg?itok=pQzLsA3O",
            "caption": "The axial section of HRCT chest with contrast shows thrombosis of the left superior pulmonary vein (green arrow), with the thrombus extending into the tributaries and into the left atrium. Pulmonary arteries are normal."
          }
        ]
      },
      {
        "number": "Figure 8",
        "subfigures": [
          {
            "number": "Figure 8",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-07//18639_8_1.jpg?itok=2SktF67p",
            "caption": "The oblique axial section of soft tissue window of the contrast-enhanced CT chest at the level of the great vessels shows the filling defect in the left superior pulmonary vein (green arrow)."
          }
        ]
      },
      {
        "number": "Figure 9",
        "subfigures": [
          {
            "number": "Figure 9",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-07//18639_9_1.jpg?itok=u1OUwNcK",
            "caption": "The oblique axial section of soft tissue window of the contrast-enhanced CT chest at the level of the four-chamber heart shows the filling defect in the left superior pulmonary vein draining the corresponding non-viable lung parenchyma, suggesting pulmonary vein thrombus with lung infarct (green arrow)."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Cardiovascular system",
      "Lung"
    ],
    "imaging_technique": [
      "CT-High Resolution"
    ],
    "link": "https://www.eurorad.org/case/18607",
    "time": "09.07.2024"
  },
  "18674": {
    "case_id": 18674,
    "title": "Primary cavitary sarcoidosis with \u201cgalaxy sign\u201d",
    "section": "Chest imaging",
    "age": "31",
    "gender": "female",
    "diagnosis": "Primary cavitary sarcoidosis",
    "history": "A 31-year-old female patient presented to the Emergency Unit with recent chest pain, 11 days after being tested positive for COVID-19. The pain was not radiating, pleuritic or reproduced by palpation. Chest auscultation findings disclosed rhonchi and wheezes on the right lung. The rest of the physical examination was normal.",
    "image_finding": "Contrast-enhanced CT excluded pulmonary embolism. However, it showed some bilateral retractile peribronchovascular nodular opacities surrounded by multiple perilymphatic micronodules, giving the appearance of the \u201cgalaxy sign\u201d (Figures 3a and 3b), accompanied by a mosaic attenuation pattern and tracheobronchial abnormalities. A sarcoid galaxy sign with central cavitation was noted in the left upper lobe (Figure 2).\nBilateral symmetric non-calcified mediastino-hilar lymphadenopathies, showing no mass effect, were observed (Figure 1). No typical viral pneumonia findings, including COVID-19 abnormalities, were found.\nA bronchoscopy was performed with bronchoalveolar lavage, transbronchial biopsies and electronavigation of the main cavitary lesion. All samples returned pathogen-free and showed non-caseating granulomatosis inflammation, consistent with pulmonary sarcoidosis.\nTo complete the workup and rule out cardiac involvement, an [18F]FDG PET-CT scan was performed and revealed a multisystemic hypermetabolic involvement, including multiple thoracic-abdominal-pelvic lymphadenopathies, as well as hepatic and lytic bone lesions.\nA surgical biopsy of a hypermetabolic inguinal adenopathy was also consistent with the diagnosis of sarcoidosis.",
    "discussion": "Typical high-resolution computed tomography (HRCT) pulmonary manifestations of sarcoidosis are well described in the literature [1\u20136]. This includes nodules and micronodules with a peri-lymphatic distribution, predominantly in the middle and upper lung zones [5,7,8].\nOur patient presented with acute multisystemic sarcoidosis, including lung involvement with typical abnormalities and a cavitary nodule in the upper left lobe with the \u201cgalaxy sign\u201d. \u00a0This type of nodule is formed by the confluence of many small-sized nodules surrounded by satellites tiny nodules creating the \u201cgalaxy sign\u201d. \u00a0This infrequent aspect of lung sarcoidosis was first described in 2002 [4] and is also observed in other granulomatous diseases such as tuberculosis [4,9,10], hypersensitivity pneumonitis and coal workers\u2019  disease [4].\nIn addition, primary cavitary sarcoidosis (PCS) is a rare presentation of lung sarcoidosis. In a recent systematic review [11], they reported a prevalence between 0.56% and 11%. However, in the two main case series collected in their paper [12,13], only 1.3\u20132.2% of patients with sarcoidosis presented with PCS. The mechanism of cavitation in lung sarcoidosis is not yet clear, although various hypotheses have been put forward, including ischemic necrosis [5,11]. Cystic bronchiectasis or large bullae can mimic cavitation; however, these lesions may appear in a chronic stage of the disease with irreversible and fibrotic changes [6] and can be potentially occupied by mycetomas.\nPrimary cavitation is not associated with specific symptoms and can rarely be accompanied by haemoptysis. Solitary or multiple, irregular or smoothly marginated, all cavitations usually resolve when establishing corticotherapy [6], like in our case (Figure 4).\nIf a biopsy has identified non-necrotising granulomas and other potential causes have been reasonably excluded, the diagnosis of sarcoidosis can be established [10,11], especially when clinical symptoms and imaging findings are concordant. In our case, this patient was recently diagnosed with infection by SARS-COV-2, had no story of malignancy, and no pneumoconiosis was suspected.\nAll patient data have been completely anonymised throughout the entire manuscript and related files.",
    "differential_diagnosis": "Fungal, infection, Mycobacterial, infection, Rheumatoid, nodules, Granulomatosis, with, polyangiitis, Primary, cavitary, sarcoidosis, Cystic, bronchiectasis, Large, bullae, Neoplasm, Pneumoconiosis, Necrotizing, sarcoid, granulomatosis, (NSG)",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-08//18706_1_1.PNG?itok=ByPBBp_W",
            "caption": "CT pulmonary angiogram demonstrating multiple bilateral symmetric non-calcified mediastino-hilar lymphadenopathies showing no mass effect on adjacent structures."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-08//18706_2_1.PNG?itok=DMvw1DH1",
            "caption": "Axial reconstruction high-resolution CT showing the \u201csarcoid galaxy sign\u201d with central cavitation in the left upper lobe."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-08//18706_3_1.PNG?itok=kLlGM9_D",
            "caption": "Coronal reconstruction high-resolution CT showing the multiple nodular opacities surrounded by multiple perilymphatic micronodules giving the appearance of a \u201cgalaxy sign\u201d."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-08//18706_3_2.PNG?itok=30eAXgJU",
            "caption": "Coronal MIP reconstruction highlights the \u201cgalaxy sign\u201d pattern."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-08/Sarcoidose%20images%204_s.PNG?itok=bYN5RVzL",
            "caption": "Non-contrast CT nine months after therapy demonstrating regression of the nodular opacities and the size of the cavitation in the left upper lobe."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT-Angiography"
    ],
    "link": "https://www.eurorad.org/case/18674",
    "time": "30.08.2024"
  },
  "18680": {
    "case_id": 18680,
    "title": "xercise-induced pulmonary haemorrhage",
    "section": "Chest imaging",
    "age": "35",
    "gender": "male",
    "diagnosis": "Exercise-induced pulmonary haemorrhage (EIPH)",
    "history": "A 35-year-old male, post-ironman, presented with severe dyspnoea, 80% O2 saturation, haemoptysis, and tachypnoea. Developed nausea and vomiting during cycling and walked the last 20 km of the marathon due to fatigue. Mild COVID-19 three weeks prior. He was admitted to the ICU with severe respiratory distress.",
    "image_finding": "Initial chest X-ray indicated bilateral diffuse alveolar infiltrates, suggesting pneumonia (Figure 1).\nA follow-up CT scan ruled out pulmonary embolism but revealed an enlarged heart with a dilated right ventricle, indicating pulmonary resistance. The lungs exhibited diffuse infiltrative changes in all lobes, consistent with pulmonary oedema and potential infection. Ground-glass opacities progressing to consolidation suggested alveolar damage and microbleeds, raising the possibility of acute respiratory distress syndrome (ARDS) (Figures 2a and 2b).\nOn day 2, a subsequent chest X-ray revealed more consolidated infiltrates in the left lung and right upper lobe, further supporting the diagnosis of diffuse alveolar damage and microbleeds, with ARDS suspicion (Figure 3).\nBy day 4, the final chest X-ray demonstrated significant resolution of the infiltrates, correlating with the patient\u2019s clinical recovery (Figures 4a and 4b).\nAfter a 6-day admission, the patient was discharged in an almost habitual condition.\nThe imaging sequence effectively documented the patient's progression from severe lung distress to gradual recovery.",
    "discussion": "Background\nExercise-induced pulmonary haemorrhage (EIPH) involves pulmonary capillary disruption during intense exercise, leading to lung bleeding. This condition is well-documented in thoroughbred horses, with post-race bronchoscopy revealing visible airway blood in approximately 70% of cases, and all training horses showing hemosiderin-laden macrophages in tracheal washings due to high pulmonary vascular pressures [1,2].\nThough EIPH is rare in humans, similar conditions have been observed, particularly in elite athletes, military trainees, and sedentary individuals subjected to maximal aerobic effort [3]. There is only little understanding of the pathogenesis, but the phenomenon is hypothesised to occur when the low-pressure pulmonary capillaries, which are extremely thin in humans to allow efficient gas exchange, are subject to a high increase in hydrostatic pressure during exercise, disrupting the blood gas barrier and causing the vessels to leak [1,4].\nClinical Perspective\nEIPH diagnosis is challenging due to its rarity and being a diagnosis of exclusion. In humans, it presents as haemoptysis, which, while uncommon, may indicate severe pulmonary stress during intense exercise, or sudden severe dyspnoea during or after intense exercise. Comprehensive history, physical exams, and diagnostic imaging are critical. Clinicians must rule out other life-threatening conditions [4,5].\nImaging Perspective\nImaging, including chest X-ray and CT-thorax, are pivotal in the differentiation process. Typical findings are bilateral ground-glass opacities and peribronchial cuffing without cardiomegaly on chest X-rays. Contrast-enhanced chest CT is useful for further evaluation, particularly to rule out pulmonary embolism. CT findings typically show panlobular ground-glass opacities and diffuse thickening of interlobular septa and bronchial walls, also without cardiomegaly or pleural effusion.\nThe final diagnosis of EIPH is made based on the combination of clinical presentation, imaging findings, and exclusion of other causes [5].\nOutcome\nTherapeutic options for EIPH are mainly supportive, focusing on oxygen therapy and rest. The prognosis is generally good, with most patients recovering rapidly without long-term complications [2\u20135].\nIn our case, the patient received high-flow oxygen therapy, which had a positive effect on them.\nTake Home Message\n\nExercise-induced pulmonary haemorrhage is a rare but important exercise-related condition, that should be considered in young, otherwise healthy individuals presenting with haemoptysis and/or dyspnoea.\nThorough evaluation and imaging are essential for accurate diagnosis and effective management.\n\nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Pulmonary, embolism, Cardiogenic, pulmonary, oedema, Pneumonia, Exercise-induced, pulmonary, haemorrhage, (EIPH), Acute, respiratory, distress, syndrome, (ARDS)",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-09/Figure%201_small_0.jpg?itok=QsSL9Ncq",
            "caption": "Initial chest X-ray. Bilateral diffusely distributed consolidations in the lung parenchyma. No obvious dilatation of the pulmonary vessels. No obvious pleural effusion."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-09/Figure%202a_small.jpg?itok=l_H4HNX7",
            "caption": "Follow-up CT scan. Axial view still image (2a) and lung window axial view (2b) show no pulmonary embolism and an enlarged heart with a dilated right ventricle, indicating pulmonary resistance. The diffusely spread ground-glass opacities and consolidation are clearly illustrated in 2a. Diffuse lung infiltrates are consistent with pulmonary oedema and possible infection. Ground-glass opacities and consolidation suggest alveolar damage and microbleeds, raising acute respiratory distress syndrome (ARDS) possibility."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_video/2024-09/Figure%202b%20-%20frame%20at%200m0s.jpg?itok=b_91Yu58",
            "caption": "Follow-up CT scan. Axial view still image (2a) and lung window axial view (2b) show no pulmonary embolism and an enlarged heart with a dilated right ventricle, indicating pulmonary resistance. The diffusely spread ground-glass opacities and consolidation are clearly illustrated in 2a. Diffuse lung infiltrates are consistent with pulmonary oedema and possible infection. Ground-glass opacities and consolidation suggest alveolar damage and microbleeds, raising acute respiratory distress syndrome (ARDS) possibility."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-09/Figure%203_small.jpg?itok=81Ip3izO",
            "caption": "Chest X-ray with consolidated infiltrates in the left lung and right upper lobe, supporting diffuse alveolar damage and microbleeds, with suspicion of acute respiratory distress syndrome (ARDS)."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-09/Figure%204a_small.jpg?itok=E61g4hwM",
            "caption": "Final chest X-ray. PA view (4a) and lateral view (4b) demonstrated significant resolution of the infiltrates, correlating with the patient\u2019s clinical recovery and readiness for discharge."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-09/Figure%204b_small.jpg?itok=8xD7KgAM",
            "caption": "Final chest X-ray. PA view (4a) and lateral view (4b) demonstrated significant resolution of the infiltrates, correlating with the patient\u2019s clinical recovery and readiness for discharge."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT"
    ],
    "link": "https://www.eurorad.org/case/18680",
    "time": "04.09.2024"
  },
  "18696": {
    "case_id": 18696,
    "title": "Pulmonary glue embolism as a complication of retrograde spermatic vein sclerotherapy",
    "section": "Chest imaging",
    "age": "40",
    "gender": "male",
    "diagnosis": "Pulmonary glue (N-butyl-2-cyanoacrylate) embolism",
    "history": "A 40-year-old male patient underwent retrograde sclerotherapy of the left spermatic vein using a Histoacryl\u00ae\u2013Lipiodol\u00ae mixture as a treatment for varicocele and subfertility.",
    "image_finding": "Dual subtraction angiography (DSA) of the left pulmonary artery showed delayed filling of the subsegmental branch of the left lower lobe without occlusion (Figure 1). Heparin was administered. No further retrieval of the glue embolism was performed, given the risk of more distal embolisation and the risk of complete occlusion. Dual-energy computed tomography pulmonary angiography (DE-CTPA) confirmed the pulmonary glue embolism as a focal hyperdensity (>600 HU) in a slightly dilated proximal subsegmental artery in the lateral lower segment of the left lower lobe (Figures 2a and 2b), being spontaneously hyperdense on the virtual non-contrast reconstruction (Figure 2c). Iodine maps showed a wedge-shaped perfusion defect in the respective region in the left lower lobe (Figure 2d). No parenchymal abnormalities, such as mosaic perfusion or pulmonary infarction, were apparent (Figure 2e).",
    "discussion": "Varicocele represents a prevalent condition in males, typically manifesting during adolescence and acknowledged as a primary contributor to male infertility. Treatment indications include pain, infertility, and testicular hypotrophy, with the two primary therapeutic options being surgery or endovascular scleroembolisation, the latter being the most commonly used technique. It involves selective catheterisation of the spermatic vein followed by injection of a sclerosing agent into its distal segment [1]. The advantage of sclerotherapy is the lower risk of hydrocele and testicular atrophy, which are associated with lymphatic and arterial damage. Possible disadvantages are the risk of venous or pulmonary embolism, thrombophlebitis and (allergic) reaction [1].\nPulmonary glue embolism is also described as secondary to endoscopic sclerotherapy for gastric variceal bleeding. Risk factors for pulmonary glue embolism in this setting are large volumes of sclerosant (in a large variceal vein), injection rate and the glue component ratio (excess of lipiodol) [2].\nClinical Perspective\nPatients with pulmonary glue emboli can be asymptomatic or manifest with a variety of clinical signs and symptoms like dyspnoea, cough, pleuritic chest pain, tachycardia, hypoxemia, and in worse cases, even cardiorespiratory arrest or sudden death [2].\nSometimes a chest X-ray is performed to confirm the diagnosis. However, more information is obtained when performing a DE-CTPA because it can confirm the diagnosis, evaluate the extension and the parenchymal complications, and might guide further treatment.\nImaging Perspective\nThis case demonstrates pulmonary glue embolism as a complication of retrograde sclerotherapy in varicocele treatment in an asymptomatic patient. Through DE-CTPA, the Histoacryl\u00ae-embolus could be clearly depicted as a hyperdense filling defect in the pulmonary artery, with an associated typical wedge-shaped perfusion defect on the iodine map, while excluding lung infarction on the parenchymal window. Since the presence of hyperdense glue emboli in the pulmonary arteries may be masked by the intravenous contrast medium, both adjusting the window settings and the use of iodine maps helped in detecting the dissemination of the disease.\nOutcome\nTreatment is based on extension, clinical impact and complications of the pulmonary glue embolism. In this asymptomatic patient, no further treatment was installed after the initial heparin administration.\nTake Home Message\nPulmonary glue embolism is a possible complication of retrograde sclerotherapy of the internal spermatic vein in varicocele treatment in which DE-CTPA with iodine perfusion maps can confirm the diagnosis, evaluate the extension and further complications on the lung parenchyma, and guide further treatment.\nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Pulmonary, cement, (polymethyl, methacrylate,, PMMA), embolism, Pulmonary, glue, (N-butyl-2-cyanoacrylate), embolism, Chronic, pulmonary, thromboembolism, Pulmonary, artery, atherosclerosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-09//18729_1_1.JPG?h=e0dd3e83&itok=yazxyJbP",
            "caption": "Dual subtraction angiography (DSA) of the left pulmonary artery showed delayed filling of the subsegmental branch of the left lower lobe without occlusion."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-09//18729_2_1.JPG?itok=F8m0XMHj",
            "caption": "Confirmation of the pulmonary glue embolism as a focal hyperdensity (>600 HU) in a slightly dilated proximal subsegmental artery in the lateral lower segment of the left lower lobe."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-09//18729_2_2.JPG?itok=C3PugLwO",
            "caption": "Confirmation of the pulmonary glue embolism as a focal hyperdensity (>600 HU) in a slightly dilated proximal subsegmental artery in the lateral lower segment of the left lower lobe."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-09//18729_2_3.JPG?itok=8Hu95DV-",
            "caption": "The glue embolism is spontaneously hyperdense on the virtual non-contrast reconstruction."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-09//18729_2_6.JPG?itok=VGfSFFV8",
            "caption": "Iodine maps showed a wedge-shaped perfusion defect in the respective region in the left lower lobe."
          },
          {
            "number": "Figure 2e",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-09//18729_2_7.JPG?itok=G73GS8B4",
            "caption": "No parenchymal abnormalities, such as mosaic perfusion or pulmonary infarction, were apparent."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung",
      "Vascular"
    ],
    "imaging_technique": [
      "Catheter arteriography",
      "CT-Angiography"
    ],
    "link": "https://www.eurorad.org/case/18696",
    "time": "17.09.2024"
  },
  "18715": {
    "case_id": 18715,
    "title": "Is cystic interstitial lung disease rare in systemic lupus erythematosus?",
    "section": "Chest imaging",
    "age": "48",
    "gender": "female",
    "diagnosis": "Cystic interstitial lung disease in systemic lupus erythematosus",
    "history": "A 48-year-old woman with systemic lupus erythematosus (SLE), complicated by interstitial lung disease since 2006 and desquamative interstitial pneumonia diagnosed in 2017, was treated with cyclophosphamide for severe disease progression, undergoing high-resolution CT control scans forward to 2024.",
    "image_finding": "High-resolution CT (HRCT) scans from 2007 to 2011 show slight changes with ground-glass opacifications (GGO) and small cysts developed during this period (Figure 1).\nHRCT scans in 2016 and 2017 show alternating lung changes with added pneumonitis, interlobar septal thickening, and pleural accumulation on the left side. The last picture has persistent GGO and localised slight fibrosis (Figure 2).\nHRCT from 2018 to 2023 show increasing localized fibrosis with cyst development, sometimes added interstitial infectious changes, cyst wall thickening, and bronchiectasis (Figure 3).\nHRCT scans from 2023 and 2024 show a tendency towards repeated infections and further development of cysts with alternating wall thickening. The last scan with the infection at rest, shows established parenchymatous cysts. Volume measurement revealed the beginning shrinkage of the parenchyma (Figure 4).",
    "discussion": "Systemic lupus erythematosus (SLE) is an autoimmune disease known for its multiorgan involvement, including the lungs, joints (arthritis), skin (photosensitive rashes), kidneys (glomerulonephritis), and blood (cytopenia). It is predominantly affecting women, with hormonal influences contributing to its onset [1].\nPulmonary involvement occurs in up to 50% of patients, including pleuritis, pleural effusion, pneumonitis, diffuse alveolar haemorrhage, vasculitis, pulmonary hypertension, and rarely cavitary lesions [2]. The infrequent occurrence of lung cavitations in SLE contributes to a limited understanding of their pathogenesis, though they are often linked to infectious aetiologies, vasculitis, or necrotic infarctions [3].\nDesquamative interstitial pneumonia is a rare interstitial lung disease (ILD). It is characterised by the accumulation of alveolar macrophages and emphysema, with minimal fibrosis or neutrophilic inflammation [4]. ILD is a rare manifestation of SLE and typically presents as nonspecific interstitial pneumonia.\nPulmonary involvement in SLE is associated with a high expression of type I interferon (IFN)-regulated genes, termed\u00a0\u201cIFN signature\u201d,  which promotes autoantibody synthesis and disrupts immune tolerance in the lungs [5]. While pulmonary involvement in SLE is frequent, pulmonary symptoms manifest in only 4%\u20135%. These can vary from an asymptomatic to persistent exertional dyspnoea, pleuritic chest pain, nonproductive cough, and decreased exercise tolerance.\nDiagnosis of interstitial lung disease relies on clinical, radiological, and pathological data. A high-resolution-computed tomography (HRCT) reveals abnormalities such as thickened interlobular septa, bronchiectasis, and bronchial wall thickening [1].\u202fPulmonary function tests typically show a restrictive pattern with decreased forced vital capacity and diffusing capacity for carbon monoxide. Surgical lung biopsy remains the most sensitive method for obtaining an accurate pathological diagnosis [5,6]. Desquamative interstitial pneumonia may manifest with ground glass opacities on HRCT, resembling nonspecific interstitial pneumonia, making the finding nonspecific. Therefore, biopsy consideration is crucial [7].\nManagement of pulmonary complications in active SLE involves systemic corticosteroids as a primary treatment, often combined with cyclophosphamide or mycophenolate mofetil, followed by either rituximab or intravenous immunoglobulins. Despite limited evidence, systemic corticosteroids can improve some patients' inspiratory vital capacity and diffusing capacity for carbon monoxide [4,8].\nIn our case, the endpoint of lung changes is the cysts and bronchiectasis in both lung areas, irreversible changes with a high impact on lung function, and a high risk for intercurrent infection, spontaneous pneumothorax, pulmonary hypertension, and lung shrinking syndrome.\nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Cystic, interstitial, lung, disease, in, systemic, lupus, erythematosus, Wegener\u2019s, granulomatosis, Infection, Tuberculosis, Cancer, Sarcoidosis",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-10//18751_1_1.jpg?itok=gN0Tyxdw",
            "caption": "HRCT shows slight changes with ground-glass opacifications (blue arrows) and small cysts (yellow arrow) developed from 2007 to 2011."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-10//18751_2_1.jpg?itok=0r4jQtsU",
            "caption": "HRCT shows alternating lung changes with added pneumonitis, interlobar septal thickening (yellow arrow) and pleural accumulation on the left side (blue arrow). The last picture with persistent ground-glass opacifications and localised slight fibrosis (arrowhead)."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-10//18751_3_1.jpg?itok=8IoTIEkb",
            "caption": "HRCT from 2018 to 2023 show increasing localised fibrosis with cyst development, sometimes added interstitial infectious changes (arrowhead), cyst wall thickening (blue arrow) and bronchiectasis (yellow arrow)."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-10//18751_4_1.jpg?itok=u2nccCM8",
            "caption": "HRCT scans from 2023 and 2024 show a tendency towards repeated infections and further development of cysts with alternating wall thickening; the last scan, with the infection at rest, shows established parenchymatous cysts. Volume measurement revealed a beginning shrinkage of the parenchyma."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "CT-High Resolution"
    ],
    "link": "https://www.eurorad.org/case/18715",
    "time": "02.10.2024"
  },
  "18717": {
    "case_id": 18717,
    "title": "Oesophageal gastrointestinal stromal tumour (GIST)",
    "section": "Chest imaging",
    "age": "74",
    "gender": "female",
    "diagnosis": "Oesophageal gastrointestinal stromal tumour (GIST)",
    "history": "An asymptomatic 74-year-old woman with a history of ankylosing spondylitis and breast cancer underwent a thoracoabdominopelvic computed tomography (CT) for oncologic follow-up. This was her first CT scan at our institution and we did not have access to previous exams.",
    "image_finding": "The thoracoabdominopelvic CT scan demonstrated a round, well-circumscribed, heterogeneous mass in the lower third of the oesophagus, isoattenuating to skeletal muscle and moderately enhancing after intravenous contrast administration. It measured 48mm in its greatest diameter and caused compression\u2014but not obstruction\u2014of the oesophageal lumen. There was no mediastinal lymphadenopathy or other signs of metastatic disease. The patient underwent endoscopic ultrasonography with fine needle aspiration (EUS-FNA), and the diagnosis of oesophageal gastrointestinal stromal tumours (GIST) was made. Following discussion in the oncologic multidisciplinary meeting, the patient is currently on the waiting list for surgery.",
    "discussion": "Background\nGastrointestinal stromal tumours (GISTs) account for less than 1% of gastrointestinal tumours and are mainly localised in the stomach (60%\u201370%) and small bowel (20%\u201330%) [1]. Oesophageal GISTs are exceedingly rare, corresponding to only 0.7%\u20135% of all GISTs [1\u20134]. They occur mainly in the distal third of the oesophagus (around 80% of cases), where there is a higher number of interstitial cells of Cajal, from which they originate [1\u20134]. Given their low incidence, specialised literature, namely radiological literature, is very scarce.\nClinical Perspective\nOesophageal GISTs are more frequently observed in younger patients compared to gastric and intestinal GISTs, with a slight male predilection [1\u20133]. In 50% of cases, they are asymptomatic and are incidentally diagnosed during endoscopic or radiological procedures [1]. When symptomatic, the most common manifestation is dysphagia (23%\u201350% of cases), followed by chest pain and gastrointestinal bleeding [1].\nImaging Perspective\nThe imaging features of oesophageal GISTs are similar to those of GISTs in the other most typical locations [4]. On CT, they appear as round, well-defined, bulky, frequently heterogeneous masses in the posterior mediastinum, inseparable from the oesophagus. They present a predominantly exoenteric growth pattern, without obstructing the oesophageal lumen or invading adjacent mediastinal structures [4]. They are isoattenuating to skeletal muscle and enhance moderately after intravenous contrast administration [1\u20134]. Internal coarse calcifications are a rare finding [4].\nIt is difficult to distinguish oesophageal GISTs from other submucosal tumours by imaging alone [3]. GISTs and leiomyomas appear similar on CT and endoscopic ultrasonography (EUS) [3]. On magnetic resonance imaging, diffusion-weighted imaging (DWI) with apparent diffusion coefficient (ADC) may be useful as an emerging modality in the differential diagnosis of oesophageal submucosal tumours [3].\nEUS-FNA with pathological analysis and gene expression profiling enables definitive diagnosis and determines eligibility for adjuvant treatment with tyrosine-kinase inhibitors \u00a0[1\u20134].\nOutcome\nGISTs have malignant potential, and surgery without dissection of clinically negative lymph nodes is the mainstay of treatment [1]. Surgical tumour enucleation should be considered for low to intermediate malignancy risk GISTs, while esophagectomy is indicated in the remaining cases [1\u20134]. Neoadjuvant and/or adjuvant therapy with tyrosine-kinase inhibitors may play a role in the treatment of these tumours [1\u20133].\nTake Home Message / Teaching Points\nOesophageal GISTs are rare, with limited evidence on their imaging features and management options. Nonetheless, they must be taken into account in the differential diagnosis of an intramural oesophageal mass. Endoscopic ultrasonography with fine needle aspiration (EUS-FNA) enables definitive diagnosis. Surgery with or without tyrosine-kinase inhibitors therapy is the current mainstay of treatment.\nAll patient data have been completely anonymised throughout the entire manuscript and related files.",
    "differential_diagnosis": "Oesophageal, gastrointestinal, stromal, tumour, (GIST), Leiomyoma, Leiomyosarcoma, Schwannoma, Metastatic, disease",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-10/Figure%201a.jpg?itok=0d4u6TTN",
            "caption": "Unenhanced (1a) and contrast-enhanced (1b, late arterial phase; 1c, portal venous phase) CT shows a round, well-circumscribed, isoattenuating to skeletal muscle, moderately enhancing mass in the lower oesophagus (arrows), compressing but not obstructing the oesophageal lumen. Pericardial effusion is also seen."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-10/figure_1b.jpg?itok=FwQFudQM",
            "caption": "Unenhanced (1a) and contrast-enhanced (1b, late arterial phase; 1c, portal venous phase) CT shows a round, well-circumscribed, isoattenuating to skeletal muscle, moderately enhancing mass in the lower oesophagus (arrows), compressing but not obstructing the oesophageal lumen. Pericardial effusion is also seen."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-10/figure_1c.jpg?itok=brZSrmQw",
            "caption": "Unenhanced (1a) and contrast-enhanced (1b, late arterial phase; 1c, portal venous phase) CT shows a round, well-circumscribed, isoattenuating to skeletal muscle, moderately enhancing mass in the lower oesophagus (arrows), compressing but not obstructing the oesophageal lumen. Pericardial effusion is also seen."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-10/Figure%202a.jpg?itok=w3yqfgbp",
            "caption": "Contrast-enhanced CT portal venous phase (2a, coronal reconstruction; 2b, sagittal reconstruction) shows the lesion to better advantage (arrows)."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-10/figure_2b.jpg?itok=fh2v0K1u",
            "caption": "Contrast-enhanced CT portal venous phase (2a, coronal reconstruction; 2b, sagittal reconstruction) shows the lesion to better advantage (arrows)."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Gastrointestinal tract",
      "Stomach (incl. Oesophagus)"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/18717",
    "time": "02.10.2024"
  },
  "18741": {
    "case_id": 18741,
    "title": "Inverted chest wall hernia mimicking metastasis",
    "section": "Chest imaging",
    "age": "34",
    "gender": "female",
    "diagnosis": "Inverted chest wall hernia",
    "history": "A 34-year-old woman with a history of solitary fibrous tumour (SFT) of the thigh undergoes a follow-up CT.",
    "image_finding": "The CT scan revealed a nodular lesion on the left posterior parietal pleura between the 9th and 10th ribs, visible only in non-contrast sequences (Figures 1a, 1b, 1c and 1d). At the same level, in the scans following the administration of contrast medium, the suspected lesion was no longer visible (Figures 2a and 2b).",
    "discussion": "Background\nAn inverted chest wall hernia is an exceedingly rare condition (to our knowledge, fewer than 10 cases have been documented in the literature) where a portion of the thoracic wall herniates into the thoracic cavity [1,2]. This condition is usually a consequence of trauma, surgery, or congenital weakness [3,4], but spontaneous cases are extremely rare, particularly in patients with no prior history of chest surgery or trauma.\nClinical Perspective\nClinically, an inverted chest wall hernia can be asymptomatic or present with non-specific symptoms such as chest discomfort or respiratory issues. Its rarity and non-specific presentation can lead to misdiagnosis, particularly in oncological patients where new thoracic lesions are often presumed to be metastatic. Awareness and careful analysis are crucial for proper diagnosis to avoid unnecessary treatments and anxiety for the patient.\nImaging Perspective\nOn imaging, an inverted chest wall hernia may appear as a nodular lesion. In this case, the lesion was visible in baseline CT sequences but not in contrast-enhanced sequences, suggesting a non-neoplastic nature. Key imaging features include the location, shape, and particularly the behaviour during different respiratory phases. The \u201cparietal junction sign\u201d can help differentiate between pleural and lung parenchymal lesions; hernias typically show obtuse angles of connection to the chest wall and smooth interfaces.\nOutcome\nThe final diagnosis of an inverted chest wall hernia in this patient, who had no history of chest trauma or surgery, was made based on imaging findings. The lesion\u2019s disappearance in contrast-enhanced scans and its behaviour during deep inspiration indicated a reversible and non-permanent condition. Recognising this rare entity prevented a misdiagnosis of metastatic disease and guided appropriate patient management without unnecessary interventions.\nTake Home Message\nInverted chest wall hernia, though rare, should be considered in the differential diagnosis of new thoracic lesions in oncological patients. Radiologists should be aware of its imaging characteristics to avoid misdiagnosis, particularly in the context of follow-up for potential metastatic disease.\nAll patient data have been completely anonymised throughout the entire manuscript and related files.",
    "differential_diagnosis": "Metastasis, Pleural, tumour, Pulmonary, nodule, Chest, wall, neoplasm, Inverted, chest, wall, hernia",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-10//18777_1_1.jpg?itok=FlwhHlKP",
            "caption": "Non-contrast CT axial views with lung window (1a) and mediastinal window (1b), and sagittal views with lung window (1c) and mediastinal window (1d), demonstrate the inverted chest wall hernia located at the left posterior parietal pleura (white arrow)."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-10//18777_1_2.jpg?itok=NSEDABa-",
            "caption": "Non-contrast CT axial views with lung window (1a) and mediastinal window (1b), and sagittal views with lung window (1c) and mediastinal window (1d), demonstrate the inverted chest wall hernia located at the left posterior parietal pleura (white arrow)."
          },
          {
            "number": "Figure 1c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-10//18777_1_3.jpg?itok=BlHiiK9o",
            "caption": "Non-contrast CT axial views with lung window (1a) and mediastinal window (1b), and sagittal views with lung window (1c) and mediastinal window (1d), demonstrate the inverted chest wall hernia located at the left posterior parietal pleura (white arrow)."
          },
          {
            "number": "Figure 1d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-10//18777_1_4.jpg?itok=lhivUhDx",
            "caption": "Non-contrast CT axial views with lung window (1a) and mediastinal window (1b), and sagittal views with lung window (1c) and mediastinal window (1d), demonstrate the inverted chest wall hernia located at the left posterior parietal pleura (white arrow)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-10//18777_2_1.png?itok=GX7jGZwI",
            "caption": "Contrast-enhanced CT axial views with lung window (2a) and mediastinal window (2b) do not visualise the hernia identified in the non-contrast CT."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-10//18777_2_2.jpg?itok=1yiC2EOO",
            "caption": "Contrast-enhanced CT axial views with lung window (2a) and mediastinal window (2b) do not visualise the hernia identified in the non-contrast CT."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Anatomy",
      "Lung",
      "Oncology",
      "Respiratory system"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/18741",
    "time": "22.10.2024"
  },
  "18742": {
    "case_id": 18742,
    "title": "Primary Sj\u00f6gren\u2019s syndrome with interstitial lung disease",
    "section": "Chest imaging",
    "age": "40",
    "gender": "female",
    "diagnosis": "Primary Sj\u00f6gren\u2019s syndrome with interstitial lung disease",
    "history": "A 40-year-old female presented with an 8-month history of dry mouth, dry eyes, joint pain, and recurrent oral ulcers, along with a 4-month history of dry cough and dyspnoea. Laboratory tests showed positive anti-Ro/SSA and anti-La/SSB antibodies. Imaging was performed to assess the involvement of salivary glands and lungs.",
    "image_finding": "Ultrasonography of the salivary glands revealed multiple calculi in the superficial lobe of the right parotid gland, measuring up to 5 mm (Figure 1). Bilateral parotid glands were heterogeneous with multiple hypoechoic areas, indicating chronic sialadenitis (Figure 2). Additionally, ductal dilation was observed bilaterally. Doppler ultrasonography displayed increased vascularity, typical of active inflammation associated with Sj\u00f6gren\u2019s syndrome (SS) (Figure 3).\nThe high-resolution CT (HRCT) thorax demonstrated a usual interstitial pneumonia (UIP) pattern with diffuse reticular opacities, traction bronchiectasis, and honeycombing, predominantly in the subpleural and basal regions (Figures 4, 5a and 5b). This is characteristic of SS-associated interstitial lung disease (ILD). Patchy ground-glass opacities were also present, indicating ongoing inflammation. No lymphadenopathy or pleural effusion was noted. These imaging features correlate with advanced fibrotic lung disease secondary to SS, emphasising the systemic nature of this autoimmune condition.",
    "discussion": "Background\nSj\u00f6gren\u2019s syndrome (SS) is a chronic autoimmune disease affecting the exocrine glands, predominantly the salivary and lacrimal glands. It affects 0.1\u20130.6% of the population, with women being more frequently affected [1]. In SS, lymphocytic infiltration of glandular tissue leads to decreased glandular secretion, causing dryness (Figure 1). Primary SS occurs without other autoimmune diseases, while secondary SS coexists with conditions like rheumatoid arthritis or lupus [2]. Pulmonary involvement, such as interstitial lung disease (ILD), occurs in up to 20% of SS patients, often presenting with insidious respiratory symptoms (Figure 4) [3].\nClinical Perspective\nPatients with SS commonly present with xerostomia, xerophthalmia, joint pain, and recurrent oral ulcers. Renal involvement in primary Sj\u00f6gren\u2019s syndrome can present as interstitial nephritis or glomerulonephritis [3]. When SS extends to the lungs, symptoms may include chronic cough, dyspnoea, and reduced exercise tolerance [4]. Imaging is crucial in identifying glandular and pulmonary involvement, aiding early diagnosis and treatment, especially since ILD can significantly impact morbidity and mortality. Radiologists play a key role in identifying SS-associated complications, which guides multidisciplinary management [5].\nImaging Perspective\nUltrasonography (USG) is a valuable tool for assessing salivary gland involvement in SS, being non-invasive, cost-effective, and widely available. The presence of hypoechoic areas, gland heterogeneity, ductal dilation, and increased vascularity are characteristic findings (Figures 1, 2 and 3). These features align with chronic inflammation and fibrosis in SS, making USG a critical diagnostic adjunct [6]. HRCT is the gold standard for evaluating lung involvement, with the UIP pattern being indicative of fibrotic ILD in SS. The combination of subpleural honeycombing, traction bronchiectasis, and ground-glass opacities enhances diagnostic accuracy (Figure 4). These HRCT findings distinguish SS-associated ILD from other autoimmune lung diseases, aiding in the differential diagnosis [7].\nOutcome\nManagement of SS includes symptomatic relief with artificial tears and saliva substitutes, alongside immunosuppressive therapy, such as hydroxychloroquine or corticosteroids. In cases of ILD, corticosteroids, antifibrotic agents, or immunosuppressants like mycophenolate mofetil may be required [8]. Regular imaging follow-up is essential to monitor disease progression and treatment response, especially in cases with systemic manifestations like ILD, which significantly affect prognosis.\nTake-Home Message / Teaching Points\n\nUltrasonography effectively evaluates salivary gland involvement in SS, while HRCT is essential for diagnosing and monitoring ILD.\nRecognising imaging patterns helps differentiate SS-associated ILD from other autoimmune conditions.\nRadiologists play a vital role in early diagnosis, guiding management, and improving outcomes in SS with systemic involvement.\n\nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Primary, Sj\u00f6gren\u2019s, syndrome, with, interstitial, lung, disease, Rheumatoid, arthritis-associated, interstitial, lung, disease, Sarcoidosis, Chronic, sialadenitis, Mikulicz\u2019s, disease",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-10/Figure%201_small_1.jpg?itok=eyyZhEPq",
            "caption": "The superficial lobe of the right parotid gland shows multiple calculi (arrows), indicating obstructive sialadenitis. The calculi appear as highly echogenic structures with posterior acoustic shadowing, typical in chronic salivary gland inflammation."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-10/Figure%202_small_2.jpg?itok=6kelkJgr",
            "caption": "Bilateral parotid glands appear heterogeneous with multiple hypoechoic areas (arrow), suggestive of chronic sialadenitis. The heterogeneity and hypoechoic regions correspond to glandular inflammation and fibrosis."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-10//18778_3_1.jpg?itok=92Df5Zyn",
            "caption": "Doppler ultrasonography shows increased vascularity within the right parotid gland (indicated by colour flow signals), consistent with active inflammatory changes. The increased blood flow suggests an ongoing inflammatory process."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-10//18778_4_1.jpg?itok=Ojr58lhL",
            "caption": "High-resolution CT (HRCT) of the thorax shows a usual interstitial pneumonia pattern, characterised by subpleural honeycombing, traction bronchiectasis, and reticular opacities. These features demonstrate advanced fibrotic changes in the lung parenchyma."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-10//18778_5_1.jpg?itok=8Gh8HkB9",
            "caption": "Coronal and sagittal reformatted high-resolution CT (HRCT) images of the thorax demonstrate a usual interstitial pneumonia pattern, evidenced by subpleural honeycombing, traction bronchiectasis, and reticular opacities. These findings involve the posterior, lateral, and medial bronchopulmonary segments of the right lower lobe, and the posterior, lateral, and anteromedial bronchopulmonary segments of the left lower lobe."
          },
          {
            "number": "Figure 5b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-10//18778_5_2.jpg?itok=_Rv1MaBd",
            "caption": "Coronal and sagittal reformatted high-resolution CT (HRCT) images of the thorax demonstrate a usual interstitial pneumonia pattern, evidenced by subpleural honeycombing, traction bronchiectasis, and reticular opacities. These findings involve the posterior, lateral, and medial bronchopulmonary segments of the right lower lobe, and the posterior, lateral, and anteromedial bronchopulmonary segments of the left lower lobe."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Kidney",
      "Salivary glands",
      "Thorax"
    ],
    "imaging_technique": [
      "CT",
      "Ultrasound"
    ],
    "link": "https://www.eurorad.org/case/18742",
    "time": "22.10.2024"
  },
  "18763": {
    "case_id": 18763,
    "title": "Solitary fibrous tumour of the ple",
    "section": "Chest imaging",
    "age": "68",
    "gender": "male",
    "diagnosis": "Solitary fibrous tumour of the pleura",
    "history": "A 68-year-old man with a medical history of chronic myeloid leukaemia was referred to the radiology department for an ultrasound of the abdomen due to aberrant liver values. The patient was asymptomatic.",
    "image_finding": "Ultrasound showed no intra-abdominal abnormalities. However, a large heterogeneous solid and vascularised mass in the right lung base, reaching up to the liver, was noted (Figure 1). Computed tomography (CT) of the chest confirmed a right-sided thoracic mass (15 x 14 x 13 cm) with a broad pleural base, internal vascularisation, and adjacent atelectasis (Figure 2). There was no invasion of osseous structures or other suspicious lung lesions. CT-guided core-needle biopsy of the lesion was performed, which confirmed a solitary fibrous tumour of the pleura.\nThree months later, the chest CT was repeated because of increasing chest pain. This showed a further increase in the volume of the mass, together with the onset of a significant amount of pleural fluid (Figure 3). The patient was referred for surgery, and the mass was resected using a right anterior thoracotomy (Figure 4).",
    "discussion": "The pleura is a two-layered serous membrane from which benign and malignant masses can form. Solitary fibrous tumour (SFT) or pleural fibroma are rare mesenchymal tumours. Their aetiology is still unknown, but they occur most frequently between the 6th and 7th decade of life [1]. The majority of SFTs are benign, slow-growing lesions arising from the visceral pleura, but 20% may be malignant and tend to arise from the parietal pleura [1]. SFTs may metastasise, most commonly affecting the pleura, chest/abdominal wall, lung, peritoneum and liver [2].\nSolitary fibrous tumours are often asymptomatic and an incidental finding on imaging. If symptomatic, they can be accompanied by cough, chest pain, or dyspnoea. More pathognomic for SFT is the presentation of hyperglycaemia due to the production of insulin-like growth factor 2 (Doege\u2013Potter syndrome) or hypertrophic pulmonary osteoarthropathy due to the production of hyaluronic acid (Pierre Marie\u2013Bamberger syndrome) [3].\nCT is the preferred imaging technique, but it is often nonspecific and difficult to differentiate. CT will show a soft tissue pleural-based neoplasm, often with areas of necrosis, haemorrhage and cystic changes, which will enhance heterogeneously post-contrast [2]. The presence of calcifications or wall invasion increases the likelihood of malignancy. Additional MRI can provide further information about the fibrous nature of the tumour. The definitive diagnosis is made histologically.\nThere are no established guidelines for follow-up, but recurrence can occur in around 8% of treated patients [4].\nResection of the lesion is the treatment of choice. In case of malignancy or metastatic disease, therapies such as radiation and chemotherapy may be considered.\nAll patient data have been completely anonymised throughout the entire manuscript and related files.",
    "differential_diagnosis": "Localised, mesothelioma, Metastatic, pleural, disease, Peripheral, lung, cancer, Solitary, fibrous, tumour, of, the, pleura, Primary, pleural, lymphoma, Mass, related, to, chest, wall, or, ribs",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-11//18799_1_1.jpg?itok=xQvxYM9p",
            "caption": "Ultrasound showing a heterogeneous solid mass in the right lung base reaching up to the liver."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-11//18799_2_1.jpg?itok=JaMhfMz8",
            "caption": "Chest CT showing a right-sided thoracic mass with broad pleural base, internal vascularisation and adjacent atelectasis."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-11//18799_3_1.jpg?itok=n41ZpqPI",
            "caption": "Repeated CT, three months after initial presentation, with significant increase in volume of the pleural mass, together with the accumulation of pleural fluid."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-11//18799_4_1.jpg?itok=yuVRcvHG",
            "caption": "Resection of the pleural mass via anterior thoracotomy. A mass of 1516 g was resected and sent for pathology, which confirmed a solitary fibrous tumour."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Thorax"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/18763",
    "time": "06.11.2024"
  },
  "18776": {
    "case_id": 18776,
    "title": "New onset pectus carinatum secondary to osteomalaci",
    "section": "Chest imaging",
    "age": "70",
    "gender": "female",
    "diagnosis": "Osteomalacia secondary to Vitamin D deficiency",
    "history": "A 70-year-old previously healthy female presented to the emergency department (ED) with acute chronic dyspnoea and inability to mobilise after sustaining a fall three weeks prior. The physical exam revealed a new pectus carinatum (PC) deformity with bilateral air entry.",
    "image_finding": "A portable chest radiograph (Figures 1a and 1b) reveals significant compression of her lateral thorax. Diffuse osteopenia is observed in the bones throughout the entire image. Additionally, there is a left lower lobe indistinct opacity that may represent an infection. The trachea is substantially deviated towards the right. Multiple fractures of the thoracic spine can be seen on the lateral radiograph. The superior aspect of the sternum appears protuberant and angulated outwards, while the inferior portion angulates inwards.\nContrast-enhanced CT of the chest revealed multiple fragility fractures at the T5, T6, T8, T10, and T12 levels (Figures 2a and 2b). A kyphotic body habitus is also noted. A sternal fracture and multiple old rib fractures in the thoracic region were also identified. Axial contrast CT images (Figures 3a, 3b and 3c) yield a Haller index of 1.0, indicating extreme PC. Lateral compression of the thoracic ribs gives the sternum an anterior projection.",
    "discussion": "Background\nPectus carinatum (PC) is the second most common chest deformity after pectus excavatum [1]. PC is an anteriorly displaced sternum secondary to costal cartilage overgrowth; however, can also be secondary to abnormal rib morphology [2]. Common symptoms include dyspnoea, chest pain, and reduced exercise tolerance. PC is associated with a wide range of genetic syndromes, connective tissue disorders, scoliosis, and cyanotic heart disease [3\u20135].\nOsteomalacia is a bony disorder characterised by a lack of mineralisation of the bones. The most common cause of osteomalacia is vitamin D deficiency. Common laboratory abnormalities include hypocalcaemia, hypophosphatemia, and elevated alkaline phosphatase and parathyroid hormone levels. Typical radiographic findings include osteopenia and insufficiency fractures, which typically occur in the vertebral bodies, ribs, sternum, femoral neck, and pubic rami [6,7]. Looser zones, also called pseudofractures, are a type of insufficiency fractures that manifest as transverse lucencies in cortical bone accompanied by periosteal thickening. In osteomalacia, they are commonly seen in the proximal femur and ulna, ribs, lateral border of the scapula, and pubic rami [6].\nImaging Perspective\nThe Haller index (HI) is used to measure the severity of both pectus excavatum and pectus carinatum deformities [8]. It is calculated by dividing the maximum transverse diameter of the chest cavity by the distance from the sternum to the vertebral body. A normal chest will have a HI of 2.0 to 2.5, while lower values indicate the start of a PC deformity. The mean HI in patients with PC is 1.8 [9]. The deformity is classified as severe when the HI is 1.2 or lower [10].\nOutcome\nTreatment options include orthotic bracing, typically used in the adolescent population, or surgical correction. The most frequent surgical approach is the Ravitch procedure, where the excess cartilage causing the sternum to protrude forward is removed [11,12]. Little information exists on PC correction in the elderly population.\nOur patient underwent a bone mineral scan which found severe osteoporosis with T-scores of -6.2 on the right femur and -5.5 on the left femur. Laboratory testing revealed extremely low vitamin D levels, while PTH and ALP were both elevated. A diagnosis of osteomalacia secondary to vitamin D deficiency was made, and the patient was started on zoledronic acid, calcium carbonate, and high-dose vitamin D.\nTake Home Message\nMetabolic disorders causing osteomalacia must be considered in elderly patients with a new pectus carinatum deformity.\nWritten informed patient consent for publication has been obtained.",
    "differential_diagnosis": "Osteomalacia, secondary, to, hyperparathyroidism, Osteomalacia, secondary, to, hypophosphatemia, Osteomalacia, secondary, to, proximal, renal, tubular, acidosis, Osteomalacia, secondary, to, Vitamin, D, deficiency, Osteogenesis, imperfecta, Noonan, syndrome",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-11/Figure%201a_edit.png?itok=zznhATuD",
            "caption": "Portable chest radiograph frontal (1a) and lateral (1b) views. There are severe bilateral compression deformities of the chest, with crowding of the vasculature throughout. The trachea is substantially deviated towards the right. The lateral radiograph demonstrates an anteriorly displaced sternum and multiple wedge compression fractures in the thoracic and lumbar spine. The bone mineral density is drastically decreased. Small bilateral pleural effusions and bibasilar atelectasis are noted."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-11/figure_1b_edit.png?itok=ewqEK2Or",
            "caption": "Portable chest radiograph frontal (1a) and lateral (1b) views. There are severe bilateral compression deformities of the chest, with crowding of the vasculature throughout. The trachea is substantially deviated towards the right. The lateral radiograph demonstrates an anteriorly displaced sternum and multiple wedge compression fractures in the thoracic and lumbar spine. The bone mineral density is drastically decreased. Small bilateral pleural effusions and bibasilar atelectasis are noted."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-11/Figure%202a_edit.png?itok=6Xamh_AB",
            "caption": "A chest CT with contrast on bone windows with both frontal (2a) and lateral (2b) views. Multiple compression and wedge fractures are easily visible. Diffuse osteopenia and kyphosis are observed."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-11/figure_2b_edit.png?itok=SCjBbuOY",
            "caption": "A chest CT with contrast on bone windows with both frontal (2a) and lateral (2b) views. Multiple compression and wedge fractures are easily visible. Diffuse osteopenia and kyphosis are observed."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-11//18812_3_1.png?itok=ncWIe-9Q",
            "caption": "A chest CT with contrast axial view with bone windows. The lateral inwards compression of the ribs has caused an outwards protrusion of the chest. Multiple old rib fractures were observed in this CT scan."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-11//18812_3_2.png?itok=1a_TpdOE",
            "caption": "A chest CT with contrast axial view with the Haller index."
          },
          {
            "number": "Figure 3c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-11//18812_3_3.png?itok=ZyhWK45w",
            "caption": "A chest CT with contrast axial view with lung windows."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-11//18812_4_1.png?itok=H9JQ60VL",
            "caption": "Chest radiograph frontal view taken 13 years before."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-11//18812_4_2.png?itok=95y6g7KD",
            "caption": "Chest radiograph sagittal view taken 13 years before."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Bones",
      "Musculoskeletal bone",
      "Thorax"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/18776",
    "time": "14.11.2024"
  },
  "18780": {
    "case_id": 18780,
    "title": "Crack lung. An uncommon disease",
    "section": "Chest imaging",
    "age": "49",
    "gender": "male",
    "diagnosis": "Crack lung",
    "history": "A 49-year-old obese male with sleep apnoea, high smoking history, and occasional cocaine use presented with sudden chest pain, cough, and difficulty breathing. Tests revealed severe respiratory insufficiency, leukocytosis, and ground-glass opacities on computed tomography imaging.",
    "image_finding": "In the X-ray, bilateral pulmonary consolidations, predominantly in the bibasal regions, are observed. Additionally, interstitial opacities with reticular markings are noted at the periphery of the opacities (Figures 1a and 1b), which is manifested on the CT scan as bilateral pulmonary parenchymal involvement in the form of ground-glass opacities, with marked subpleural sparing. Additionally, areas of ground-glass opacities with well-defined margins exhibit a \u201ccrazy paving\u201d pattern, characterised by septal thickening and intralobular reticular lines (Figures 2a, 2b, 2c and 2d).",
    "discussion": "The term \"crack lung\" describes an acute pulmonary syndrome that develops after inhaling freebase cocaine (crack). It is characterised by diffuse alveolar damage and haemorrhagic alveolitis, which typically present within 48 hours after using crack. This syndrome is associated with prolonged inflammatory lung injury and is marked by fever, hypoxemia, haemoptysis, respiratory failure and diffuse alveolar infiltrates [1,2].\nLung tissue samples from affected patients show diffuse alveolar damage and alveolar haemorrhage with interstitial and alveolar cell infiltration rich in eosinophils, along with IgE deposition [2].\nSmoking crack causes various complications, including pulmonary oedema, alveolar haemorrhage, eosinophilic pneumonia, pneumothorax, and thromboembolic disease. The mechanisms include injury to the airways, direct cellular toxicity, induction of inflammatory damage, barotrauma and vasospasm leading to ischemia [1,3].\nImaging studies are crucial for diagnosing crack lung and ruling out other potential causes of the patient\u2019s symptoms, such as infections, diffuse alveolar haemorrhage, and hypersensitivity pneumonitis. They also help in the identification of complications like pneumothorax and pneumomediastinum.\nThe two main imaging modalities used to diagnose crack lung are:\n\nChest X-ray: Useful for detecting complications such as signs of barotrauma (pneumothorax or pneumomediastinum), and for monitoring the resolution of pulmonary involvement after treatment. However, chest X-ray findings are often nonspecific and may show a bilateral alveolar pattern or complete bilateral pulmonary opacification in severe cases.\nComputed tomography (CT): CT is more sensitive than chest X-ray for detecting pulmonary parenchymal changes associated with crack lung. Typical findings include alveolar opacities with air bronchograms and ground-glass opacities, diffusely distributed and more prominent in the subpleural regions. Other findings may include alveolar haemorrhage, eosinophilic pneumonia, crazy-paving pattern, and centrilobular nodules with a tree-in-bud pattern. The presence of lymphadenopathy, pleural effusion, or cavitation, suggests an inflammatory process or concomitant infection [3\u20135].\n\nThe diagnosis of crack lung is based on a combination of:\n\nHistory of cocaine exposure: Obtaining a complete patient history, including drug use, is essential.\nConsistent radiologic findings: The presence of diffuse alveolar opacities on chest X-ray or CT, especially in the context of a history of cocaine use, is suggestive.\nExclusion of other causes: Other causes of the patient\u2019s symptoms, such as infections, diffuse alveolar haemorrhage, and hypersensitivity pneumonitis, should be ruled out through additional tests, such as bronchoalveolar lavage [1,2]. \n\nThe treatment of crack lung is primarily supportive and includes oxygen therapy, and conservative fluid management. Corticosteroids may be beneficial in cases of alveolar haemorrhage or eosinophilic pneumonia [3]. In the absence of complications, symptoms usually resolve spontaneously.\nTeaching Points\n\nCrack lung is a severe respiratory condition caused by inhaling crack cocaine.\nIt is characterised by diffuse alveolar damage and can lead to respiratory failure.\nEarly diagnosis and treatment are crucial for managing crack lung and preventing complications.\n\nAll patient data have been completely anonymised throughout the entire manuscript and related files.",
    "differential_diagnosis": "Pulmonary, oedema, (cardiogenic, or, non-cardiogenic), Diffuse, alveolar, haemorrhage, Hypersensitivity, pneumonitis, Crack, lung, Eosinophilic, pneumonia, Pulmonary, infection, (pneumonia), Pulmonary, infection, (tuberculosis)",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-11/Fig1a.jpeg?itok=IVpabI0Q",
            "caption": "Chest X-ray (AP view). Bilateral pulmonary consolidations predominantly in the bibasal regions (arrow)."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-11//18816_1_2.jpg?itok=L6AqYcC5",
            "caption": "Chest X-ray (PA view). Resolution of pulmonary opacities after 7 days of corticosteroid treatment; however, reticular markings continue to be evident at the lung peripheries."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-11//18816_2_1.jpg?itok=B-TOEUOK",
            "caption": "Chest CT in lung window at basal level (2a), subcarinal (2b), apical (2c) and with MIP reconstruction in basal region (2d). It shows bilateral parenchymal lung involvement consistent with ground-glass opacities (arrows in 2a and 2b) with marked subpleural distribution (arrowheads in 2a and 2b) with an apicobasal gradient. Additionally, in Figure 2a, areas of ground-glass opacities with well-defined margins exhibit a \u201ccrazy paving\u201d pattern, characterised by septal thickening and intralobular reticular lines."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-11//18816_2_2.jpg?itok=Z65WYEuC",
            "caption": "Chest CT in lung window at basal level (2a), subcarinal (2b), apical (2c) and with MIP reconstruction in basal region (2d). It shows bilateral parenchymal lung involvement consistent with ground-glass opacities (arrows in 2a and 2b) with marked subpleural distribution (arrowheads in 2a and 2b) with an apicobasal gradient. Additionally, in Figure 2a, areas of ground-glass opacities with well-defined margins exhibit a \u201ccrazy paving\u201d pattern, characterised by septal thickening and intralobular reticular lines."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-11//18816_2_3.jpg?itok=_gMGoLW2",
            "caption": "Chest CT in lung window at basal level (2a), subcarinal (2b), apical (2c) and with MIP reconstruction in basal region (2d). It shows bilateral parenchymal lung involvement consistent with ground-glass opacities (arrows in 2a and 2b) with marked subpleural distribution (arrowheads in 2a and 2b) with an apicobasal gradient. Additionally, in Figure 2a, areas of ground-glass opacities with well-defined margins exhibit a \u201ccrazy paving\u201d pattern, characterised by septal thickening and intralobular reticular lines."
          },
          {
            "number": "Figure 2d",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-11//18816_2_4.jpg?itok=Ohq4exwN",
            "caption": "Chest CT in lung window at basal level (2a), subcarinal (2b), apical (2c) and with MIP reconstruction in basal region (2d). It shows bilateral parenchymal lung involvement consistent with ground-glass opacities (arrows in 2a and 2b) with marked subpleural distribution (arrowheads in 2a and 2b) with an apicobasal gradient. Additionally, in Figure 2a, areas of ground-glass opacities with well-defined margins exhibit a \u201ccrazy paving\u201d pattern, characterised by septal thickening and intralobular reticular lines."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-11//18816_3_1.jpg?itok=aqDqfGf-",
            "caption": "Chest CT in lung window with coronal reconstruction. It shows bilateral parenchymal lung involvement consistent with ground-glass opacities with an apicobasal gradient."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Emergency"
    ],
    "imaging_technique": [
      "CT"
    ],
    "link": "https://www.eurorad.org/case/18780",
    "time": "15.11.2024"
  },
  "18781": {
    "case_id": 18781,
    "title": "Pulmonary artery sling: An incidental finding",
    "section": "Chest imaging",
    "age": "34",
    "gender": "male",
    "diagnosis": "Pulmonary artery sling",
    "history": "A 34-year-old healthy man presented to the emergency department following a high-impact traumatic event. He had no significant medical history and reported no symptoms before the accident. Trauma protocol was followed, and a thoracoabdominal-pelvic computed tomography (CT) was performed.",
    "image_finding": "Contrast-enhanced axial (Figures 1a and 1b) and sagittal (Figures 2a and 2b) CT planes demonstrated the presence of an aberrant left pulmonary artery, originating from the right pulmonary artery, encircling the trachea and coursing to the hilum of the left lung between the trachea and the oesophagus. The tracheobronchial tree was permeable, with no signs of stenosis. Figures 3a, 3b, 4a, 4b and 4c represent CT reconstructions of the main, right, and left pulmonary arteries and aorta.",
    "discussion": "Pulmonary artery sling (PAS) is a rare vascular anomaly. It accounts for less than 5% of vascular tracheobronchial compression syndromes, with an incidence of 59 per 1,000,000 people [1,2].\nIt occurs when the left pulmonary artery (LPA) abnormally arises extrapericardially from the right pulmonary artery (RPA), encircles the trachea and right mainstem bronchus, and then passes in front of the oesophagus to reach the left hilum [3\u20136]. Embryologically, an aberrant LPA results from the incomplete development of the sixth aortic arch [1,7].\nIt is frequently associated with tracheobronchial anomalies, including intrinsic tracheal stenosis or complete tracheal rings (ring\u2010sling complex, 50\u201380%) and congenital cardiovascular abnormalities (40\u201380%) [2\u20135,7]. Gastrointestinal anomalies may also occur [7].\nMost patients become symptomatic in the first weeks to months of life. Clinical presentation includes respiratory symptoms such as mild respiratory distress, stridor, wheezing, and recurrent respiratory infections due to tracheobronchial compression [1\u20137]. In severe cases, patients may face pulmonary hypertension and severe respiratory failure. Oesophageal compression can cause swallowing difficulties [3,7].\nIn a limited subset of patients, tracheal compression may be absent or minimal, allowing them to reach adulthood without symptoms. In these cases, PAS is often detected incidentally during imaging performed for unrelated reasons [5,8].\nThe diagnostic goal is to identify the LPA arising from the RPA, which runs between the oesophagus and the trachea [1,6]. CT and magnetic resonance imaging (MRI) are the preferred diagnostic methods due to their accuracy and widespread availability [3,6,7].\nAlthough CT can identify complete tracheal rings and narrowing, bronchoscopy is essential to determine full airway involvement. Echocardiography can also aid in diagnosing PAS and identifying congenital heart defects [3,4].\nThe treatment of PAS involves reimplantation of the LPA. When tracheobronchial anomalies are present, tracheoplasty is also necessary [4,5].\nPulmonary sling prognosis depends on associated anomalies, particularly the severity of tracheobronchial disease. Patients without tracheobronchial comorbidity have a 100% survival rate, while those needing both PAS and tracheal repair have a 50\u201390% survival rate. Management is better achieved in specialised centres [3,7,8].\nTake Home Messages\n\nPAS is a condition where the LPA originates from the RPA and passes between the oesophagus and trachea.\nIt is commonly associated with tracheobronchial and cardiac anomalies.\nClinical presentation ranges from no symptoms to severe respiratory distress, typically manifesting early in life.\nSurgery is the standard treatment.\n\nAll patient data have been completely anonymised throughout the entire manuscript and related files.",
    "differential_diagnosis": "Right, aortic, arch, Double, aortic, arch, Pulmonary, artery, sling, Aberrant, right, subclavian, artery",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-11/FIGURE%201A_small.png?itok=ah9mmP2l",
            "caption": "Shows the right pulmonary artery as a direct continuation of the pulmonary trunk (arrowheads)."
          },
          {
            "number": "Figure 1b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-11/FIGURE%201B_small.png?itok=tWSTBHbc",
            "caption": "Shows an aberrant left pulmonary artery (LPA) that arises from the right pulmonary artery instead of originating from the main pulmonary artery. The LPA then encircles the distal trachea, coursing between the trachea and oesophagus to reach the hilum of the left lung (arrow)."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-11/FIGURE%202A_small.png?h=d6b97e0d&itok=02KHzFNU",
            "caption": "Shows an aberrant left pulmonary artery (arrows) encircling the trachea and coursing retro-tracheal in front of the oesophagus."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-11/FIGURE%202B_small.png?itok=fafa6FQO",
            "caption": "Shows an aberrant left pulmonary artery (arrows) encircling the trachea and coursing retro-tracheal in front of the oesophagus."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-11/FIGURE%203A_small.png?itok=jg0uXnd3",
            "caption": "Shows the right pulmonary artery as a direct continuation of the pulmonary trunk, and the aberrant left pulmonary artery arising from the right pulmonary artery."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-11/FIGURE%203B_small.png?itok=GLAHHa0v",
            "caption": "Shows the right pulmonary artery as a direct continuation of the pulmonary trunk, and the aberrant left pulmonary artery arising from the right pulmonary artery."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-11/FIGURE%204A_small.png?itok=ALPec-us",
            "caption": "The anterior view shows the pulmonary trunk (*) ascending posteriorly and to the left of the ascending aorta, but instead of dividing into the two main pulmonary arteries, it continues directly with the right pulmonary artery."
          },
          {
            "number": "Figure 4b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-11/FIGURE%204B_small.png?itok=XcvqysrR",
            "caption": "The lateral view shows the left pulmonary artery arising on the right side and then coursing posteriorly to the hilum of the left lung (**)."
          },
          {
            "number": "Figure 4c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-11/FIGURE%204C_small.png?itok=w5DF1NWs",
            "caption": "The posterior view shows the aberrant left pulmonary artery (**) arising from the right pulmonary artery (***) and then coursing to the left."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Anatomy",
      "Pulmonary vessels",
      "Respiratory system"
    ],
    "imaging_technique": [
      "CT",
      "CT-Angiography"
    ],
    "link": "https://www.eurorad.org/case/18781",
    "time": "15.11.2024"
  },
  "18803": {
    "case_id": 18803,
    "title": "Unusual thoracic presentation: The case of a 17 cm pleural mass",
    "section": "Chest imaging",
    "age": "73",
    "gender": "female",
    "diagnosis": "Ectopic thymoma",
    "history": "A 73-year-old female, a lifelong non-smoker with a previous medical history of hypothyroidism and osteoporosis, was referred to the pulmonology outpatient clinic due to complaints of dyspnoea (mMRC grade 2), orthopnoea, asthenia, and 22% weight loss over the past three months. Physical exam showed no respiratory distress, 97% oxygen saturation, and asymmetric breath sounds with diminished right hemithorax sounds.",
    "image_finding": "Chest x-ray (Figure 1) showed a pulmonary opacity in the right hemithorax causing contralateral deviation of the trachea without other abnormalities. A thoracic contrast CT scan was ordered for better characterisation of the lesion (Figures 2a, 2b and 2c), which revealed, in the right hemithorax, a globular pleural-based mass measuring 172x120x100mm with scattered areas of lower density. No mediastinal lymphadenopathy or other significant abnormalities were noted. A dual-phase 18F-FDG PET-CT scan (figures 3a and 3b) showed hypermetabolic activity in this lesion (SUVmax: 5.8), excluding other sites of abnormal FDG uptake.",
    "discussion": "The patient\u2019s age, symptoms, and clinical course suggested a potential diagnosis of lung cancer. Initial evaluation with x-ray revealed a significant opacification in the right hemithorax, and the CT scan confirmed the presence of a large pleural-based mass. When faced with a large pleural mass, one of the possible diagnoses is a solitary fibrous tumour (SFT) of the pleura. Despite rare, a malignant nature cannot be ruled out, and tru-cut biopsy is associated with a non-negligible potential for seeding, discouraging this approach [1]. However, the homogeneous CT scan appearance was non-expected in a SFT, prompting the lung cancer multidisciplinary team to assess further using an echo-guided fine-needle biopsy.\nThe biopsy revealed an abundant population of lymphocytes with immature T-cells and occasional epithelial cells (Cam 5.2+/p63+). Markers were positive for CD2, CD3, CD5 and TdT, findings consistent with type B1 thymoma.\nPutting aside the main initial diagnostic suspicions, the anatomopathological evaluation led to the diagnosis of an ectopic type B1 thymoma located in the pleura. This is a rare presentation of this neoplasm which typically appears as a mediastinal mass.\nA thymoma is a rare tumour usually located in the anterior thymus. Few cases have been described of this\u00a0tumour\u2019s presence in other locations, such as the neck, thyroid, pleura, and pericardium [2]. When present as a thoracic mass, it typically appears, as in this case, with large dimensions [3\u20135].\nThe clinical case was discussed in a lung cancer multi-disciplinary meeting, during which a total surgical resection of the malignancy was decided. The surgery proceeded without complications, and cancer-free margins were obtained in the pathological evaluation of the surgical specimen, both associated with good long-term prognosis.\nThis is a rare presentation of a type B1 thymoma, highlighting the importance of combining imaging, histological, and immunohistochemical evaluations in establishing the diagnosis of a thoracic mass and recognising the existence of atypical presentations.\nAll patient data have been completely anonymised throughout the entire manuscript and related files.",
    "differential_diagnosis": "Solitary, fibrous, tumour, of, the, pleura, Teratoma, Ectopic, thymoma, Malignant, mesothelioma, Pleural, schwannoma",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-12//18842_1_1.png?itok=S2W8wR6a",
            "caption": "The posteroanterior chest x-ray revealed a pulmonary opacity at the right pleural base, causing the trachea to deviate contralaterally, with no other abnormalities observed."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-12//18842_2_1.png?itok=yU0__ZjT",
            "caption": "Contrast CT thorax showing a nodular mass, 172x120x100 mm antero-inferior right thorax, with soft tissue density. Heterogeneous, areas of necrosis. No adenopathies were identified."
          },
          {
            "number": "Figure 2b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-12//18842_2_2.png?itok=1LWZjVKd",
            "caption": "Profile view of the CT thorax."
          },
          {
            "number": "Figure 2c",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-12//18842_2_3.png?itok=MJe2Bg_P",
            "caption": "Axial image of the CT thorax, illustrating the relationship of the mass with the pre-vascular mediastinum."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3a",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-12//18842_3_1.png?itok=YpkN5IHx",
            "caption": "Dual-phase 18F-FDG PET-CT scan showing a large hypermetabolic mass extensively occupying the right hemithorax. Q.SUVmax: 5.8. Remaining study without foci of anomalous FDG uptake."
          },
          {
            "number": "Figure 3b",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2024-12//18842_3_2.png?itok=ZAS1vK2i",
            "caption": "Profile view of the dual-phase 18F-FDG PET-CT scan."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Lung"
    ],
    "imaging_technique": [
      "Conventional radiography",
      "CT",
      "PET-CT"
    ],
    "link": "https://www.eurorad.org/case/18803",
    "time": "05.12.2024"
  },
  "18822": {
    "case_id": 18822,
    "title": "Incidental but indispensable finding: Persistent left superior vena cav",
    "section": "Chest imaging",
    "age": "73",
    "gender": "female",
    "diagnosis": "Persistent left superior vena cava",
    "history": "A 73-year-old female with chronic cough was admitted to our hospital with complaints of breathlessness for 1 week. The jugular venous pressure was elevated, bilateral pitting pedal oedema was present, and a long systolic murmur was heard in the tricuspid area. A 2D echocardiogram showed dilated right atrium (RA) and right ventricle (RV), severe tricuspid regurgitation/pulmonary arterial hypertension (TR/PAH), and RV dysfunction. ECG showed a right bundle branch block. The patient was referred to our department for a CT pulmonary angiogram.",
    "image_finding": "CT pulmonary angiogram showed a thrombus in the right pulmonary artery (Figure 1) and its branches, and a focal thrombi in the left descending pulmonary artery and its branches.\nIncidentally, we noted variant anatomy in the venous system of the thorax. The right brachiocephalic vein, formed by the union of the right internal jugular vein and right subclavian vein, was seen continuing as superior vena cava. The left brachiocephalic vein was absent (Figure 2). A persistent left superior vena cava (Figures 3, 4, 5 and 6) was noted draining into the right atrium through the coronary sinus (Figures 3 and 4). Features of right heart failure were noted: right atrium and right ventricle were dilated, and there was reflux of contrast into dilated intrahepatic inferior vena cava and hepatic veins.",
    "discussion": "Background and Imaging Perspective\nPersistent left superior vena cava (PLSVC) is a rare but most common anomaly of the venous system of the thorax. Prevalence in general population varies from 0.2 to 3%. In congenital heart disease patients, the prevalence varies from 1.3 to 11% [1].\nSVC develops from the cardinal system of veins, which is one of the three primitive venous systems, along with the umbilical and vitelline systems. There are symmetrical (right and left) pairs of anterior and posterior cardinal veins. Anterior cardinal veins drain the cranial aspect, and posterior cardinal veins drain the caudal aspect of the embryo. These join to form the right and left common cardinal veins, which drain into the ipsilateral horns of the sinus venosus and then to the heart (Figure 7). SVC (Figure 8) develops by forming bridging anastomosis between the right and left anterior cardinal veins. Bridging anastomosis develops into the left brachiocephalic vein (BCV). Then, there is an obliteration of the caudal part of the left anterior cardinal vein, forming the ligament of Marshall. The left sinus venosus and left common cardinal vein form the coronary sinus. The proximal right anterior, right common cardinal vein and right sinus venosus form the normal SVC.\nFailure of regression of the left anterior cardinal vein and adjacent part of the left common cardinal vein results in PLSVC (Figure 9). Various hypotheses have been postulated regarding the development of PLSVC. One of these is the \u201clow left atrial pressure theory\u201d, which states that low pressure in the left atrium, due to other anomalies, fails to compress the coronary sinus and left cardinal vein, leading to the formation of PLSVC [1,2].\nIn 90% of cases, PLSVC is associated with a normal SVC on the right, known as double SVC (DSVC). If SVC does not develop on the right in the presence of a PLSVC, it is called isolated PLSVC (IPLSVC) and is associated with cardiac anomalies and cardiac situs disorders. Single ventricle, atrial and ventricular septal defects, tetralogy of Fallot have been reported as most common associated cardiac anomalies [3\u20135]. Other associations include the right-sided arcus aorta, coarctation of the aorta, and heterotaxy [6].\nClinical Perspective\nAlthough PLSVC is asymptomatic and detected incidentally, there is some clinical significance. Dilated coronary sinus associated with PLSVC can compress the atrioventricular node and the bundle of His and cause arrhythmias. It can complicate mitral valve surgery [7]. PLSVC detection is important before invasive procedures like central venous catheter insertion, cardiac resynchronisation therapy or pacemaker implantation [1,2]. Detection of PLSVC is also important before some cardiac surgeries like venous rerouting procedures, surgeries with cavo-pulmonary anastomosis and transplantation surgeries [1].\nTeaching Points\nPLSVC is usually insignificant and asymptomatic, but it can cause significant problems in a few clinical scenarios. Therefore, its detection is important and should be reported in radiology reports even if detected incidentally.",
    "differential_diagnosis": "Persistent, left, superior, vena, cava, Vertical, vein, Anomalous, left, brachiocephalic, vein, Levoatrialcardinal, vein, Pericardiophrenic, vein, Left, superior, intercostal, vein, Vascular, structures, secondary, to, surgery",
    "figures": [
      {
        "number": "Figure 1",
        "subfigures": [
          {
            "number": "Figure 1",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2025-01//18861_1_1.jpg?itok=-Vs8CeKm",
            "caption": "Thrombus in the right pulmonary artery."
          }
        ]
      },
      {
        "number": "Figure 2",
        "subfigures": [
          {
            "number": "Figure 2",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2025-01//18861_2_1.jpg?itok=3Q4NMWQv",
            "caption": "Absent left brachiocephalic vein."
          }
        ]
      },
      {
        "number": "Figure 3",
        "subfigures": [
          {
            "number": "Figure 3",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2025-01//18861_3_1.jpg?itok=jjR3F3t-",
            "caption": "Persistent left superior vena cava draining into the right atrium through the coronary sinus."
          }
        ]
      },
      {
        "number": "Figure 4",
        "subfigures": [
          {
            "number": "Figure 4",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2025-01//18861_4_1.jpg?itok=ebz-qo2m",
            "caption": "Sagittal image showing persistent left superior vena cava draining into the right atrium."
          }
        ]
      },
      {
        "number": "Figure 5",
        "subfigures": [
          {
            "number": "Figure 5",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2025-01//18861_5_1.jpg?itok=Q8Dn0I_F",
            "caption": "Persistent left superior vena cava."
          }
        ]
      },
      {
        "number": "Figure 6",
        "subfigures": [
          {
            "number": "Figure 6",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2025-01//18861_6_1.jpg?itok=cbK3Bqxh",
            "caption": "Persistent left superior vena cava and superior vena cava draining into the right atrium."
          }
        ]
      },
      {
        "number": "Figure 7",
        "subfigures": [
          {
            "number": "Figure 7",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2025-01/FIGURE%207_small.jpg?itok=LFYFHreQ",
            "caption": "Cardinal system of veins."
          }
        ]
      },
      {
        "number": "Figure 8",
        "subfigures": [
          {
            "number": "Figure 8",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2025-01/FIGURE%208_small.jpg?itok=JnRMXXq-",
            "caption": "Development of normal superior vena cava."
          }
        ]
      },
      {
        "number": "Figure 9",
        "subfigures": [
          {
            "number": "Figure 9",
            "url": "https://www.eurorad.org/sites/default/files/styles/figure_image_teaser_large/public/figure_image/2025-01/FIGURE%209_small.jpg?itok=DDkIB12u",
            "caption": "Development of persistent left superior vena cava."
          }
        ]
      }
    ],
    "area_of_interest": [
      "Anatomy",
      "Cardiac",
      "Cardiovascular system",
      "Pulmonary vessels",
      "Respiratory system"
    ],
    "imaging_technique": [
      "CT-Angiography"
    ],
    "link": "https://www.eurorad.org/case/18822",
    "time": "17.01.2025"
  }
}